Patient expectations and therapeutic alliance as predictors of outcome in group cognitive-behavioral therapy for insomnia

Prognostic models for predicting insomnia treatment outcomes: A systematic review

OBJECTIVE

To identify and critically evaluate models predicting insomnia treatment response in adult populations.

METHODS

Pubmed, EMBASE, and PsychInfo databases were searched from January 2000 to January 2023 to identify studies reporting the development or validation of multivariable models predicting insomnia treatment outcomes in adults. Data were extracted according to CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) guidelines and study quality was assessed using the Prediction model study Risk Of Bias Assessment Tool (PROBAST).

RESULTS

Eleven studies describing 53 prediction models were included and appraised. Treatment response was most frequently assessed using wake after sleep onset (n = 10; 18.9%), insomnia severity index (n = 10; 18.9%), and sleep onset latency (n = 9, 17%). Dysfunctional Beliefs About Sleep (DBAS) score was the most common predictor in final models (n = 33). R2 values ranged from 0.06 to 0.80 for models predicting continuous response and area under the curve (AUC) ranged from 0.73 to 0.87 for classification models. Only two models were internally validated, and none were externally validated. All models were rated as having a high risk of bias according to PROBAST, which was largely driven by the analysis domain.

CONCLUSION

Prediction models may be a useful tool to assist clinicians in selecting the optimal treatment strategy for patients with insomnia. However, no externally validated models currently exist. These results highlight an important gap in the literature and underscore the need for the development and validation of modern, methodologically rigorous models.

Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Prognostic and Treatment-Predictive Factors

Understanding which factors predict the outcome of internet-based cognitive behavioral therapy for insomnia (iCBT-I) may help to tailor this intervention to the patient's needs. We have conducted a secondary analysis of a randomized, controlled trial comparing a multicomponent iCBT-I (MCT) and an online sleep restriction therapy (SRT) for 83 chronic insomnia patients. The difference in the Insomnia Severity Index from pre- to post-treatment and from pre-treatment to follow-up at 6 months after treatment was the dependent variable. Prognostic and treatment-predictive factors assessed at baseline were analyzed with multiple linear regression. The shorter duration of insomnia, female gender, high health-related quality of life, and the higher total number of clicks had prognostic value for a better outcome. Other factors were found to be prognostic for outcome at the follow-up assessment: treatment with benzodiazepines, sleep quality, and personal significance of sleep problems. A high level of dysfunctional beliefs and attitudes about sleep (DBAS) was a moderator for better effects in the MCT at post-treatment assessment. Various prognostic factors (e.g., duration of insomnia, gender, or quality of life) may influence the success of treatment. The DBAS scale may be recommended to select patients for MCT rather than SRT.

Emerging applications of objective sleep assessments towards the improved management of insomnia

Self-reported sleep difficulties are the primary concern associated with diagnosis and treatment of chronic insomnia. This said, in-home sleep monitoring technology in combination with self-reported sleep outcomes may usefully assist with the management of insomnia. The rapid acceleration in consumer sleep technology capabilities together with their growing use by consumers means that the implementation of clinically useful techniques to more precisely diagnose and better treat insomnia are now possible. This review describes emerging techniques which may facilitate better identification and management of insomnia through objective sleep monitoring. Diagnostic techniques covered include insomnia phenotyping, better detection of comorbid sleep disorders, and identification of patients potentially at greatest risk of adverse outcomes. Treatment techniques reviewed include the administration of therapies (e.g., Intensive Sleep Retraining, digital treatment programs), methods to assess and improve treatment adherence, and sleep feedback to address concerns about sleep and sleep loss. Gaps in sleep device capabilities are also discussed, such as the practical assessment of circadian rhythms. Proof-of-concept studies remain needed to test these sleep monitoring-supported techniques in insomnia patient populations, with the goal to progress towards more precise diagnoses and efficacious treatments for individuals with insomnia.

Using network intervention analysis to explore associations between participant expectations of and difficulties with cognitive behavioural therapy for insomnia and clinical outcome: A proof of principle study

BACKGROUND

Research about predictors of response to cognitive behaviour therapy for insomnia (CBT-I) is ongoing. We examined any whether pre-intervention expectations or post-intervention appraisals of difficulties in utilizing face to face (FtF) or digital (dCBT-I) versions of the therapy were associated with outcome.

METHODS

Self-rating data were extracted on 101 adult participants in a recent randomized controlled trial of FtF versus dCBT-I. Network intervention analyses were used to explore any associations between expectations of CBT-I at response at 9 weeks and between post-intervention ratings of difficulties, modality of therapy and response at 9-weeks and at 6-months.

RESULTS

Anticipated and actual difficulties in employing sleep restriction techniques predicted response in all network models. Modality of therapy played a more overt role in the 9-week outcome network, with FtF therapy more robustly associated with response. However, the direct association between FtF therapy and response was not found in the 6-month outcome network. Notable predictors of poor outcome at 9-weeks and 6-month follow-up were difficulties in accommodating CBT-I into work and daily routines and applying the rules of CBT-I.

CONCLUSIONS

This network intervention analysis highlights that self-confidence and ability in undertaking sleep restriction is a key active ingredient of CBT-I. Also, benefits and gains from access to the FtF version of this multi-component therapy were more apparent in the short than the longer term. However, it is important that findings from this proof of principle study are confirmed in further studies.

It takes two to tango: The therapeutic alliance in community brain injury rehabilitation

Objective:

A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.

Method:

This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.

Results:

A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.

Conclusion:

These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

Experience of Treatment and Adherence to Cognitive Behavioral Therapy for Insomnia for Patients with Depression: An Interview Study

OBJECTIVE/BACKGROUND

Research supports the efficacy of Cognitive Behavioral Therapy for Insomnia (CBT-I) for patients suffering from depression and insomnia, but little is known about how they experience treatment and adhere to it. Our objective, therefore, was to explore how patients with depression experience treatment components and how their experiences influence adherence to CBT-I as a full-package treatment.

PARTICIPANTS/METHODS

Twelve patients with depression and comorbid insomnia were interviewed after six sessions of CBT-I, and a conventional qualitative content analysis was conducted.

RESULTS

Two themes were found. The theme "I picked what I needed" showed that participants chose among CBT-I methods. Behavioral methods were considered hard but so effective that they reduced the need to learn other methods. Participants had difficulty learning cognitive methods, such as the restructuring of negative thoughts, owing to lack of energy and cognitive problems aggravated by sleep loss. Sleep hygiene education was regarded as common knowledge. The theme "Staying on track" highlighted factors promoting adherence, such as a preference for non-pharmacological treatment, rapid improvement, and support from relatives and therapists. Factors impeding adherence were: a perceived lack of support from the ongoing group setting, side effects of medication, changes in daily routine, and daytime fatigue influencing cognitive and emotional functioning.

CONCLUSION

The study suggests: focusing on adherence throughout treatment; actively using support from relatives and therapists; preferring individual treatment; and prioritizing behavioral treatment components, with cognitive components introduced later in the treatment course when the negative effects on cognitive functioning due to sleep restriction have diminished.

[Options to enhance the efficacy of cognitive-behavior therapy of insomnia]

Cognitive-behavior therapy of insomnia (CBT-I) is first-line treatment for insomnia, but it produces a clinical significant result only in 60-80% of patients. Addition reason of reduction of CBT-I efficacy is a relatively low adherence: the attrition rate is 10-39%. The authors discuss options to enhance efficacy of the therapy by usage of complex approach, individualized choice of technics, motivating a patient and his relatives, and combination of CBT-I with hypnotics.

Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: An investigation of mediation

Patients' outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., 2011a; Barlow, Sauer-Zavala, et al., in press) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP versus SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance (B = .037, SE = .05, 95% CI [.005, .096]). Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.

Assistive technology to enable sleep function in patients with acquired brain injury: Issues and opportunities

Introduction

Sleep disorders in patients with acquired brain injury are highly burdensome and associated with disability. An assistive technology framework emphasises the need to develop and apply a broad range of devices, strategies, and practices to ameliorate disabilities. We aimed to summarise scientific evidence regarding the utility of assistive technology in managing sleep disorders in patients with various causes of acquired brain injury.

Method

We retrieved articles before January 2016, through database searches of Medline, Embase, PsycINFO, CINAHL, and various bibliographies. The person–environment–occupation framework was used to analyse complex data pertaining to technology application and utility.

Results

We found 21 studies that described seven assistive technologies (continuous positive airway pressure, adaptive servo ventilator, nasotracheal suction mechanical ventilation, positioning devices, cognitive behavioural therapy, light therapy, and acupuncture) utilised in patients with acquired brain injury to manage sleep disorders.

Conclusion

Assistive technologies demonstrated effectiveness in alleviating and/or managing sleep disorders after acquired brain injury. Adherence to using the technology is limited by the level of injury-induced cognitive and physical impairment, technological regime, and environmental support. Development of user-friendly sleep-assistive technologies that take into consideration functional limitations and practice guidelines on structural communication between the occupational therapist, patient, and caregiver may facilitate patients’ self-determination in managing sleep disorders.

Mental health treatment outcome expectancies in Burundi

Best practices in global mental health stress the importance of understanding local values and beliefs. Research demonstrates that expectancies about the effectiveness of a given treatment significantly predicts outcome, beyond the treatment effect itself. To help inform the development of mental health interventions in Burundi, we studied expectancies about the effectiveness of four treatments: spiritual healing, traditional healing, medication, and selected evidence-based psychosocial treatments widely used in the US. Treatment expectancies were assessed for each of three key syndromes identified by previous research: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms) . In individual interviews or written surveys in French or Kirundi with patients ( N = 198) awaiting treatment at the clinic, we described each disorder and the treatments in everyday language, asking standard efficacy expectations questions about each ("Would it work?" "Why or why not?"). Findings indicated uniformly high expectancies about the efficacy of spiritual treatment, relatively high expectancies for western evidence-based treatments (especially cognitive behavior therapy [CBT] for depression-like symptoms), lower expectancies for medicine, and especially low expectancies for traditional healing (except for traditional healing for psychosis-like symptoms). There were significant effects of gender but not of education level. Qualitative analyses of explanations provide insight into the basis of people's beliefs, their explanations about why a given treatment would or would not work varied by type of disorder, and reflected beliefs about underlying causes. Implications for program development and future research are discussed.

Chronotype and Improved Sleep Efficiency Independently Predict Depressive Symptom Reduction after Group Cognitive Behavioral Therapy for Insomnia

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve both sleep and depressive symptoms, but predictors of depression outcome following CBT-I have not been well examined. This study investigated how chronotype (i.e., morningness-eveningness trait) and changes in sleep efficiency (SE) were related to changes in depressive symptoms among recipients of CBT-I.

METHODS

Included were 419 adult insomnia outpatients from a sleep disorders clinic (43.20% males, age mean ± standard deviation = 48.14 ± 14.02). All participants completed the Composite Scale of Morningness and attended at least 4 sessions of a 6-session group CBT-I. SE was extracted from sleep diary; depressive symptoms were assessed using the Beck Depression Inventory (BDI) prior to (Baseline), and at the end (End) of intervention.

RESULTS

Multilevel structural equation modeling revealed that from Baseline to End, SE increased and BDI decreased significantly. Controlling for age, sex, BDI, and SE at Baseline, stronger evening chronotype and less improvement in SE significantly and uniquely predicted less reduction in BDI from Baseline to End. Chronotype did not predict improvement in SE.

CONCLUSIONS

In an insomnia outpatient sample, SE and depressive symptoms improved significantly after a CBT-I group intervention. All chronotypes benefited from sleep improvement, but those with greater eveningness and/or less sleep improvement experienced less reduction in depressive symptom severity. This suggests that evening preference and insomnia symptoms may have distinct relationships with mood, raising the possibility that the effect of CBT-I on depressive symptoms could be enhanced by assessing and addressing circadian factors.

Treating Acute Insomnia: A Randomized Controlled Trial of a "Single-Shot" of Cognitive Behavioral Therapy for Insomnia

STUDY OBJECTIVES

Despite considerable evidence supporting cognitive behavioral therapy for insomnia (CBT-I) for chronic insomnia, it remains untested within the context of acute insomnia. This study examined the efficacy of a single session of CBT-I, with an accompanying self-help pamphlet, for individuals with acute insomnia.

DESIGN

A pragmatic parallel group randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Forty adults (mean age 32.9 ± 13.72 y) with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defined insomnia disorder, except a self-reported duration of less than 3 mo (i.e., acute insomnia), who reported no previous exposure to CBT-I and were not currently taking medication for sleep.

INTERVENTIONS

A single 60- to 70-min session of CBT-I (n = 20), with an accompanying self-help pamphlet, or wait list control group (n = 20). All subjects were offered a full individual course of CBT-I on completion of the study, regardless of group allocation.

MEASUREMENTS AND RESULTS

Subjects completed sleep diaries and the Insomnia Severity Index (ISI) pretreatment and 1 mo following treatment. There were no between-group differences on baseline ISI scores or subjective sleep continuity. The intervention group reported significantly lower ISI scores than controls (t(38) 2.24, P < 0.05) at follow-up. Further, using proposed ISI scores for identifying insomnia caseness (i.e., ≥ 10), 60% of those in the CBT-I group had remitted by 1 mo compared to 15% of those in the control group.

CONCLUSIONS

This single session of cognitive behavioral therapy for insomnia (CBT-I) is sufficiently efficacious for a significant proportion of those with acute insomnia. The results are discussed in terms of integrating this brief form of CBT-I into the "stepped care" model of insomnia.

TRIAL REGISTRATION

Testing the efficacy of an early intervention for acute insomnia (SRCTN05891695) http://www.controlled-trials.com/ISRCTN05891695.

A systematic review and meta-analysis on the efficacy of self-help interventions in tinnitus

This study is a review and meta-analysis on the efficacy of cognitive-behavioural therapy (CBT) self-help interventions for tinnitus. Randomized controlled trials were identified by searching in databases (e.g. ISI Web of Knowledge, PubMed, Cochrane Library, and PSYNDEX) and by manual search. Ten studies with 1188 participants in total were included in the meta-analysis. Participants were 49.2 years old and had tinnitus for 5.2 years. Self-help interventions significantly reduced tinnitus distress (d = 0.48) and depressiveness (d = 0.25) when compared with a passive control (e.g. information only and discussion forums) at post-assessment. There was no difference to the face-to-face controls (group treatment). The presence of therapists and the methodological quality of the studies did not influence the results. Sensitivity analysis revealed that there might be a publication bias regarding the comparison to the face-to-face control. However, the results suggest that CBT self-help interventions are an effective treatment for tinnitus distress. Since few studies were identified, this conclusion must be supported by future meta-analyses.

Cognitive Behavioral Therapy for insomnia with Veterans: evaluation of effectiveness and correlates of treatment outcomes

This paper examines the effectiveness of Cognitive Behavioral Therapy for insomnia (CBT-I) in Veterans and the effects of two process measures on CBT-I outcomes: 1) therapist ratings of patient adherence and 2) patient ratings of therapeutic alliance. Data are from 316 therapists in the Department of Veterans Affairs CBT-I Training Program and 696 patients receiving CBT-I from therapists undergoing training. Mixed effects model results indicate Insomnia Severity Index scores decreased from 20.7 at baseline to 10.9 (d = 2.3) during a typical course of CBT-I. Patients with highest tercile compared to those with lowest tercile adherence achieved, on average, 4.1 points greater reduction in ISI scores (d = 0.95). The effect of therapeutic alliance on change in insomnia severity was not significant after adjusting for adherence to CBT-I. These results support the effectiveness and feasibility of large-scale training in and implementation of CBT-I and indicate that greater focus on patient adherence may lead to enhanced outcomes. The current findings suggest that CBT-I therapists and training programs place greater emphasis on attending to and increasing patient adherence.

Validation and use of the youth and caregiver Treatment Outcome Expectations Scale (TOES) to assess the relationships between expectations, pretreatment characteristics, and outcomes

This study introduces the youth and caregiver versions of the Treatment Outcome Expectations Scale (TOES) and presents the results of comprehensive psychometric analyses in a large sample of clinically-referred youth (N = 291) ages 11-18 and their caregivers (N = 268). This study also examines whether expectations are predictive of early or overall treatment change as measured by changes in youth symptom severity rated by multiple respondents (youth, caregiver, and clinician). Additionally, the relationship between treatment outcome expectations and several background, pretreatment, and clinical variables is explored. Finally, this study investigates the correspondence in outcome expectations between dyads of youth and caregivers. Results demonstrate the TOES is a psychometrically sound measure for use in this population. Findings also indicate that while higher youth outcome expectations significantly relate to higher youth-rated internalizing symptom severity at baseline, they also relate to a faster rate of reduction in internalizing symptom severity. Additionally, caregiver age and youth gender were significant predictors of youth-rated outcome expectations. Results also demonstrate a small, positive correlation between youth and caregiver ratings of outcome expectations. Implications, future directions, and limitations of the study are discussed.

Investigating patient expectations and treatment outcome in a chronic low back pain population

Objective

This study aimed to measure the outcomes that patients consider clinically meaningful across four treatment domains – (1) pain, (2) fatigue, (3) emotional distress, and (4) level of interference – and determine if patients met their own success criteria. Additionally, the role of expectations in treatment outcome was examined. This study also aimed to determine how change in levels of pain, fatigue, disability, and level of interference varied according to the type of treatment delivered to participants.

Patients

Forty-seven chronic low back pain patients were recruited from university-affiliated pain clinics.

Design

The study design was longitudinal, consisting of two randomly assigned treatment conditions. The first treatment condition used opioid medication only and the second used both opioid medication and brief cognitive behavioral therapy. Pre- and post-treatment assessments were conducted, which occurred approximately 3 months after the initiation of treatment.

Outcome measures

A patient-centered outcomes questionnaire was completed by participants at both pre- and post-treatment assessment.

Results

Results suggest that patients did not meet their own success criteria in treatment across any of the four domains. There was a significant main effect of time for level of pain indicating that both treatment groups had a decrease in their level of pain at post-treatment, F(1, 45) = 11.98, P < 0.001. There was a significant main effect of time for level of interference domain indicating that both groups experienced a reduction in the level of pain-related interference with daily activities, F(1, 45) = 5.46, P < 0.05. There were no significant effects of time for emotional distress or fatigue or any significant group by time interactions. Contrary to our hypothesis, no significant correlations were found between pretreatment expectations and usual level ratings at post-treatment across the four domains.

Conclusion

Patients sought larger reductions in pain, fatigue, level of distress, and level of interference than they attained at post-treatment. Enhancing opioid treatment with brief cognitive behavioral therapy did not yield additional improvements for the four domains assessed in patients with chronic low back pain.

Predictors of adherence to a behavioral therapy sleep intervention during breast cancer chemotherapy

BACKGROUND

This study's purpose was twofold: (1) to establish adherence rates to a behavioral therapy (BT) sleep intervention and (2) to identify psychological and physical symptom predictors of adherence to the intervention in women undergoing breast cancer chemotherapy.

METHODS

A randomized controlled trial began 48 h before the first of four chemotherapy treatments. Women with stages I-IIIA breast cancer (n = 113) received a BT sleep intervention composed of stimulus control, modified sleep restriction (MSR), relaxation therapy (RT), and sleep hygiene counseling components. A BT plan was developed by a research nurse and each participant, reinforced on day 8, and repeated for chemotherapy cycles 2, 3, and 4. Adherence to the BT plan was measured daily; total adherence score was computed at each chemotherapy cycle by combining adherence estimates of all BT plan components. Psychological and physical symptoms over the past 7 days were measured 2 days prior to and 7 days after each chemotherapy treatment.

RESULTS

Total adherence rates to the BT plan were 51-52% at all four treatments but adherence varied by component. Sleep disturbance, pain, and anxiety significantly decreased whereas depression significantly increased across chemotherapy. Structural equation modeling revealed a good model fit with decreasing sleep disturbances (0.409) and increasing depression (-0.711) contributing to lower total adherence rates. Increasing depression predicted lower MSR adherence (-0.203) and decreasing sleep disturbances predicted lower RT adherence (1.220).

CONCLUSIONS

Sleep disturbance and depression significantly impacted adherence rates during chemotherapy. Results warrant attention when promoting adherence to BT sleep interventions during chemotherapy treatment.

Cognitive behavioral therapy for sleep disorders

More than 70 million people in the United States experience primary insomnia (PI) at some point in their life, resulting in an estimated $65 billion in health care costs and lost productivity. PI is therefore one of the most common health care problems in the United States. To mollify the negative effects of PI, scholars have sought to evaluate and improve treatments of this costly health care problem. A breadth of research has demonstrated that cognitive behavioral therapy (CBT) is an effective intervention for PI. The goal of this article is to provide an overview of CBT for PI, including evidence regarding treatment efficacy, effectiveness, and practitioner considerations.

The non-specific effects of group-based cognitive--behavioural treatment of chronic pain

Group-based cognitive-behavioural therapy (CBT) for chronic, non-malignant pain is recognized as the treatment of choice for patients with intractable pain problems. The core components of CBT pain treatment have been standardized, and meta-analyses have shown that that this form of intervention is effective. However, the psychotherapy literature points to a range of influences on treatment outcome that arise out of the process of treatment, rather than directly from the active treatment components. These so-called non-specific treatment effects include the composition of the group, the leadership style of the group leader, and the ways in which group dynamics are dealt with. Although CBT pain management programmes are conducted in a group format, and are therefore subject to similar kinds of influences to other forms of group treatment, these issues have not been discussed in detail in any previous literature. The present paper proposes a number of non-specific treatment factors that are likely to be associated with positive outcomes from CBT pain management programmes, and discusses ways in which these factors may be deliberately manipulated in order to maximize treatment effectiveness.

Who is at risk for dropout from group cognitive-behavior therapy for insomnia?

OBJECTIVE

The aim of the present study was to identify characteristics of patients who are at risk for dropout from a seven-session group cognitive-behavior therapy for insomnia (CBT-I) in a clinical setting using the receiver operating characteristic curve (ROC) approach.

METHODS

Two separate ROC analyses were conducted using predictor variables taken from questionnaire packets and sleep diaries collected at baseline including age, gender, Beck Depression Inventory (BDI), Morningness-Eveningness Questionnaire, Beliefs and Attitudes about Sleep, use of sleep medication, sleep onset latency, wake time after sleep onset, and total sleep time (TST).

RESULTS

The first ROC analysis was conducted on the entire sample of 528 patients with treatment completion vs. dropout (noncompletion) as the outcome variable. No significant predictor variables were found in this analysis. The second ROC analysis was conducted on the 211 patients who did not complete treatment with early termination (prior to fourth session) vs. late termination (at or after fourth session) as the outcome variable. The results revealed that patients who reported an average baseline TST <3.65 h were at greatest risk for early termination. Sixty percent of patients in this group terminated early compared to 9.3% of patients with TST > or =3.65 h. Among patients with TST > or =3.65 h, 22% of those with BDI scores > or =16 were early dropouts compared to 4.3% of those who reported BDI <16.

CONCLUSION

These findings indicate that short sleep duration and elevated symptoms of depression at baseline are associated with increased risk of early termination from CBT-I.