What Should Be the Focus of Treatment When Insomnia Disorder Is Comorbid with Depression or Anxiety Disorder?

Advances in the research of comorbid insomnia and depression: mechanisms, impacts, and interventions

Insomnia and depression, both significantly impacting public health, are common psychosomatic illnesses that frequently co-occur in the same individual. Not only do these two conditions commonly co-occur, but they also exhibit a bidirectional link, where the existence of one may heighten the risk for the other. Latest research offers compelling evidence of significant overlap in biological, psychological, and sociological aspects in the comorbidity of insomnia and depression. Building on this, we aim to examine the pathophysiology of insomnia and depression, along with their comorbid mechanisms, encompassing biological routes (like genetics, HPA axis, immune-inflammatory activation, neuroendocrine regulation, microbiome alterations, and neural circuits integrating sleep and emotion regulation), as well as psychosocial routes. Consequently, proposing a self-perpetuating and mutually reinforcing "snowball effect" model of comorbid insomnia and depression, and examining corresponding preventative intervention strategies to rectify associated imbalances. Finally, this article encapsulates the challenges in this field of study and the directions for future research. Finally, the paper points out the limitations of current research (cross-sectional data being dominant, and the mechanism of multi-omics dynamics being unknown) and the future direction (longitudinal cohort combined with computational modeling to resolve temporal interactions), which will provide a theoretical basis for precision interventions.

Cognitive-Behavioral Therapists' Experience on Relevance of Sleep and Sleep Disorders in Training and Clinical Practice: A Survey Study from Italy

BACKGROUND/OBJECTIVES

Based on previous data reporting the status of health professionals' training about sleep clinical psychophysiology, insomnia, and its treatment in the US and Canada, this paper aims at providing a snapshot of the Italian situation, considering health professionals qualified to offer cognitive behavioral therapy (CBT). Adding information on different countries is important, as national health systems differ significantly, and distinct evidence-based pathways for change may be proposed.

METHODS

Two hundred and thirteen CBT professionals (180 females; 33 males) answered a 5 min survey about their training and experience in recognizing and treating behavioral sleep disorders in their practice. The questionnaire was diffused through the mailing list of the Italian Behavioral and Cognitive Therapy Society (Società Italiana di Terapia Comportamentale e Cognitiva, SITCC) throughout December 2023 and January 2024.

RESULTS

A total of 213 participants completed the survey. Only a minor proportion of respondents (37.1%) reported having received training for diagnosis and treatment of insomnia or other behavioral sleep disorders. Familiarity with psychological therapeutics for sleep was mainly associated with knowledge of sleep hygiene rules, relaxation, and mindfulness techniques, but not with core CBT strategies for insomnia (i.e., sleep restriction and stimulus control) and sleep regulation. The less familiar therapeutics were those for pediatric insomnia.

CONCLUSIONS

The results of this study highlight scarce knowledge and consideration of sleep problems in CBT practice in Italy. As insomnia is prevalent, an independent mental disorder, and a predictor for mental and somatic comorbid conditions, these findings underscore an urgency to enlarge and strengthen CBT professionals' training on sleep psychophysiology, sleep clinical psychology, insomnia, behavioral sleep problems, and their treatment.

Exploring the associations between data-driven insomnia disorder combined with mild anxiety or/and depressive symptoms and the efficacy of Cognitive-Behavioral Therapy for insomnia

Objectives

The endophenotype of insomnia disorder is complex and the treatment is not targeted. The data-driven typing method might provide some bases for precise treatment. The present study was based on a post hoc analysis, aiming to explore the association between subtypes of insomnia disorder and the efficacy of cognitive-behavioral therapy for insomnia (CBT-I).

Methods

The present study was conducted on data of 118 patients with chronic insomnia disorder combined mild anxiety or/and depressive symptoms, who had completed an 8-week randomized controlled trial of CBT-I vs CBT-I plus (CBT-I combined with modules targeting anxiety and depressive symptoms). The silhouette coefficient determined the optimal number of clusters, and a K-means clustering analysis was performed. T-tests were conducted to assess baseline differences at eight weeks, and the changes in self-reported total sleep time (sTST), Pittsburgh Sleep Quality Index (PSQI), Hamilton Depression Rating Scale (HRSD-17), and Hamilton Anxiety Rating Scale (HAMA) scores in order to explore the impact of subtypes and treatment approaches (CBT-I and CBT-I plus) on insomnia and emotional symptoms.

Results

The analysis revealed no significant demographic differences between the two clusters. Subtype 2 was characterized by significantly poorer baseline sleep quality (PSQI: 16.59 vs 12.74, t = -9.90, p < 0.01), higher depressive (HRSD: 18.47 vs 13.21, t = -8.37, p < 0.01), and anxiety levels (HAMA: 17.47 vs 13.46, t = -6.23, p < 0.01), and shorter sTST (4.67 vs 6.09 h, t = 8.31, p < 0.01) compared to Subtype 1. Post-treatment analyses showed significant improvements in both subtypes, with Subtype 2 experiencing a larger increase in sleep duration (csTST: 0.58 vs 1.77 h, t = -7.18, p < 0.01) and more pronounced improvements in sleep quality (cPSQI: 6.92 vs 8.88, t = -3.57, p < 0.001), depression (cHRSD: 8.07 vs 10.59, t = -2.71, p = 0.008), and anxiety (cHAMA: 9.28 vs 11.22, t = -2.56, p = 0.012). Despite these improvements, Subtype 1 maintained significantly better outcomes in sleep quality (PSQI: 5.81 vs 7.71, p < 0.01), depression (HRSD: 5.14 vs 7.89, p < 0.01), and anxiety (HAMA: 4.18 vs 6.25, p < 0.01) at 8 weeks. No significant differences in baseline characteristics were found between treatment groups within subtypes, indicating homogeneity. Within Cluster 1, CBT-I plus was more effective in reducing depressive symptoms (cHRSD: t = -2.48, p = 0.016), whereas CBT-I was superior in enhancing sTST in Cluster 2 (t = 2.01, p = 0.049), with no significant differences in other measures.

Conclusions

The study underscores the heterogeneity within ID subtypes and the differential response of sleep quality and depressive symptoms to CBT-I and CBT-I plus, highlighting the importance of personalized treatment strategies based on insomnia subtypes.

The Effectiveness and Safety Analysis of Duloxetine in Treating Comorbid Depression in Parkinson's Disease: A Retrospective Study

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disorder characterized by both motor and non-motor symptoms, including depression, which significantly impacts the quality of life of affected individuals. This study aims to investigate the real-world effectiveness and safety of duloxetine in treating comorbid depression in patients with Parkinson's disease and to compare its outcomes with traditional treatment approaches.

METHODS

This study included adult patients diagnosed with Parkinson's disease combined with depression from December 2020 to December 2023. Based on the use of duloxetine, the cohort was divided into a traditional treatment group and a duloxetine group (traditional treatment combined with duloxetine). Patients with incomplete medical records, concurrent antidepressant therapy, or major psychiatric or neurological disorders were excluded. Retrospective data, including demographic information, treatment adherence, and various assessment scores, were collected from medical records by trained research staff.

RESULTS

In total, 106 patients were analyzed, with 50 patients receiving traditional treatment and 56 patients receiving duloxetine. The duloxetine group exhibited significantly lower scores than the traditional treatment group in the Unified PD Rating Scale (p = 0.015), Hamilton Depression Rating Scale (p = 0.013), Beck Depression Inventory (p = 0.031), Parkinson's disease Questionnaire-39 (p = 0.006), and Clinical Global Impression-Improvement (p < 0.001) scores. In motor function assessment, the duloxetine group demonstrated improvements in kinetic tremor scores (p = 0.017), gait speed (p < 0.001), Timed Up and Go Test performance (p < 0.001), dyskinesia severity (p = 0.017), and rigidity (p = 0.019) compared to the traditional treatment group. Additionally, the duloxetine group exhibited better cognitive function across various assessments, including the Symbol Digit Modalities Test (p = 0.024), Stroop Color-Word Test (p = 0.048), and Montreal Cognitive Assessment (p = 0.024).

CONCLUSION

Duloxetine is associated with superior efficacy in improving motor and non-motor symptoms, overall clinical status, and cognitive function. These findings support the potential utility of duloxetine as a comprehensive treatment option for comorbid depression in Parkinson's disease.

Treatment of insomnia associated with alcohol and opioid use: a narrative review

Substance use disorders (SUDs) are associated with profound sleep disturbances, including insomnia, sleep fragmentation, and circadian rhythm dysfunction resulting in serious mental and physical consequences. This minireview presents an overview of the neurocircuitry underlying sleep disturbances in SUDs and elaborates on treatment options with emphasis on alcohol use disorder (AUD) and opioid use disorder (OUD). A PubMed, Embase, CINAHL Plus, Cochrane, and Scopus search were conducted using sleep- and AUD/OUD related keywords from January 1st, 2000, to January 31st, 2023, with preferences for recent publications and randomized-controlled trials. A bidirectional relationship exists between insomnia and addiction with the status of each condition impacting the other in dictating clinical outcome. Existing evidence points to a resurgence of insomnia during detoxification, and unless treated satisfactorily, insomnia may lead to relapse. The discussion summarizes the strengths and limitations of cognitive behavioral therapy and pharmacological treatment for insomnia in SUDs covering evidence from both animal and clinical studies. The assumption of reestablishing normal sleep patterns by attaining and maintaining sobriety is misguided. Comorbid insomnia in patients with SUDs should be approached as an independent condition that requires its own treatment. Future clinical trials are needed with the aim of providing a resource for guiding clinical management of the many patients with insomnia and SUD.

Is cognitive behavioral therapy for insomnia more cost-effective? New-perspective on economic evaluations: a systematic review and meta-analysis

STUDY OBJECTIVES

To investigate the cost-effectiveness of cognitive behavioral therapy for insomnia (CBTI), with an additional focus on digital CBTI (dCBTI) in adults with insomnia.

METHODS

We searched eight electronic databases for economic evaluations of CBTI: PubMed, Scopus, Web of Science, psycINFO, Cochrane, Library, CINAHL, ProQuest, and National Health Service Economic Evaluation Database. Meta-analyses were performed to investigate the effects and costs between CBTI and control groups (no treatment, other treatments included hygiene education and treatment as usual). Subgroup analyses for dCBTI were conducted.

RESULTS

Twelve randomized controlled trial studies between 2004 and 2023 were included in our systematic review and meta-analyses. The incremental cost-utility ratios and incremental cost-effectiveness ratios showed that the CBTI and dCBTI groups were more cost-effective than controls, from healthcare perspective and societal perspective, respectively. Compared to controls, CBTI demonstrated significantly better efficacy within 12 months. Healthcare costs were significantly higher in the CBTI groups compared to the controls within 6 months but there was no difference at 12 months. Additionally, dCBTI was associated with significantly lower presenteeism costs compared to controls at 6 months.

CONCLUSIONS

Our findings suggest that CBTI is more cost-effective than other treatments or no treatment for adults with insomnia. It may bring more economic benefits in the long term, especially in long-lasting efficacy and cost reduction. In addition, dCBTI is one of the cost-effective options for insomnia.

PROSPERO REGISTRATION NUMBER

CRD42 022 383 440.

URL

www.crd.york.ac.uk/PROSPERO.

NAME FOR PROSPERO REGISTRATION

Cost-effectiveness of cognitive behavioral therapy for insomnia (CBTI): a systematic review with meta-analysis.

Impact of real-world implementation of evidence-based insomnia treatment within a large payor-provider health system: initial provider and patient-level outcomes

Study Objectives

Insomnia has substantial and wide-ranging negative effects on clinical and functional outcomes and on health care expenditures, yet few individuals receive gold-standard insomnia treatment. The current article examines provider and patient outcomes associated with real-world implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I), as part of a pilot initiative designed to establish initial capability for evidence-based insomnia treatment within one of the largest payor-provider systems in the United States.

Methods

Provider training outcomes were assessed using the CBT-I Competency Rating Scale and self-report measures. Patient outcomes were assessed using the Insomnia Severity Index (ISI) and Patient Health Questionnaire-9.

Results

All clinicians (N = 11) achieved competency in CBT-I and reported large increases in knowledge and confidence related to insomnia and insomnia treatment. Clinicians also reported high intention to deliver CBT-I and significant improvements in overall job satisfaction following competency-based CBT-I training. Among all patients who initiated CBT-I (N = 48), mixed effects modeling demonstrated significant reduction in average ISI scores (12.57 to 5.88, SEs = 1.08-1.14). More than two-thirds of patients (68.8%) completed treatment. Among completers of this brief treatment, mean insomnia severity improvement was 71% (Hedges g = 1.56).

Conclusions

Findings provide support for the feasibility and effectiveness of real-world CBT-I implementation, extending past findings to a private, payor-provider context. Patient and provider-level outcomes suggest the significant opportunity private systems may have in increasing the availability of gold-standard treatment for insomnia.

Who benefits from indirect prevention and treatment of depression using an online intervention for insomnia? Results from an individual-participant data meta-analysis

BACKGROUND

Major depressive disorder (MDD) is highly prevalent and burdensome for individuals and society. While there are psychological interventions able to prevent and treat MDD, uptake remains low. To overcome structural and attitudinal barriers, an indirect approach of using online insomnia interventions seems promising because insomnia is less stigmatized, predicts MDD onset, is often comorbid and can outlast MDD treatment. This individual-participant-data meta-analysis evaluated the potential of the online insomnia intervention GET.ON Recovery as an indirect treatment to reduce depressive symptom severity (DSS) and potential MDD onset across a range of participant characteristics.

METHODS

Efficacy on depressive symptom outcomes was evaluated using multilevel regression models controlling for baseline severity. To identify potential effect moderators, clinical, sociodemographic, and work-related variables were investigated using univariable moderation and random-forest methodology before developing a multivariable decision tree.

RESULTS

IPD were obtained from four of seven eligible studies (N = 561); concentrating on workers with high work-stress. DSS was significantly lower in the intervention group both at post-assessment (d = -0.71 [95% CI-0.92 to -0.51]) and at follow-up (d = -0.84 [95% CI -1.11 to -0.57]). In the subsample (n = 121) without potential MDD at baseline, there were no significant group differences in onset of potential MDD. Moderation analyses revealed that effects on DSS differed significantly across baseline severity groups with effect sizes between d = -0.48 and -0.87 (post) and d = - 0.66 to -0.99 (follow-up), while no other sociodemographic, clinical, or work-related characteristics were significant moderators.

CONCLUSIONS

An online insomnia intervention is a promising approach to effectively reduce DSS in a preventive and treatment setting.

Temporal pathways between circadian rhythm, depression and anxiety in the transition from adolescence to early adulthood

BACKGROUND

Sleep and circadian rhythm problems intertwine with affective disorders. Adolescents are particularly vulnerable to developing sleep and affective problems. Yet, the temporal pathways between circadian rhythm, depression and anxiety in the transition phase from adolescence to early adulthood are not fully understood.

METHODS

233 adolescents (76 % females) participated at two time points (T1 and T2) at an interval of 19-months (aged 16.8 and 18.4 years). We used The Beck Depression Inventory-II, Generalized Anxiety Disorder Assessment, GENEActiv actigraphy across 8 days (delayed sleep phase (DSP), sleep duration, midpoint, and regularity), and iButton 1922L thermologgers across 3 days (intrinsic circadian period length, amplitude, and mesor).

RESULTS

A shorter sleep duration at T1 associated with an increase in affective problems at T2, and affective problems at T1 associated with an increase in sleep irregularity at T2. A longer circadian period at T1 associated with an increase in males' affective problems at T2. Moderate to severe depression and anxiety at T1 associated with a 2.69-fold risk (95 % CI 1.38-5.26, p = 0.004) and 2.11-fold risk (95 % CI 1.04-4.25, p = 0.038) of poor sleep quality at T2. Moderate to severe generalized anxiety associated with a 3.17-fold risk (95 % CI 1.35-7.41, p = 0.008) of DSP at T2.

LIMITATIONS

The follow-up period is short.

CONCLUSIONS

The results revealed bidirectional temporal links between sleep and affective problems. Novel observations include a heightened risk of future DSP following a current anxiety disorder and a heightened risk of affective problems following a longer circadian period measured from the 24-hour temperature variation in males.

Insomnia and Death Anxiety: A Theoretical Model with Therapeutic Implications

Insomnia is common, growing in prevalence [...].

[Insomnia in the context of affective disorders]

The article analyzes the current literature on the relationship of insomnia with affective disorders, in particular with depression and anxiety. Research shows that there is a strong multi-channel relationship between insomnia, depression, and anxiety, with insomnia being considered a risk factor for mood disorders more often than vice versa. The so-called insomnia paradox of bipolar disorder is described, the essence of which is that in manic episodes the frequency of insomnia is higher than in depressive episodes. The data of a network meta-analysis, which found an evidence base for the use of a variety of drugs used for the pharmacological treatment of insomnia in adults, are presented. Efficiency and convenience in taking the drug Valocordin-Doxylamine are noted.