- Subjects 60 years and older with clinically diagnosed insomnia were recruited for a recent study.
- Researchers investigated the difference between cognitive behavioral therapy for insomnia (CBT-I) and sleep education therapy (SET).
- CBT-I was significantly better at preventing depressive episodes, as well as treating insomnia.
- The benefits of CBT-I improved over time, a notable advantage compared to sedative hypnotics for insomnia.
Let’s face it. We need to think outside the box when it comes to managing increasing rates of depression. The current approach relies on the timely identification of symptoms, followed by a willingness to seek treatment, two barriers many cannot cross.
However, if they are able to overcome the confines of limited psychoeducation and the continued stigma regarding mental health issues, they are faced with an understaffed field with too few psychiatrists, expensive out-of-pocket costs, and potential side effects of recommended medications.
Are we truly committed to preventative health?
From a population health perspective, much is recommended regarding prevention strategies, but the application of our country’s health care dollars doesn’t always reflect a commitment to preventative health. Certainly, we recognize the potential benefits of lowering rates of obesity and tobacco use to lessen disease burden, including diabetes, heart disease, and many cancers, and we are now familiar with these public health campaigns. Preventative mental health, however, has not always been granted the air time or funding it warrants.
Therefore, I am heartened by evidence of well-designed, thoughtful research in preventative strategies for mental illness, including depression, anxiety, and insomnia. A recent trial by Michael Irwin, M.D., and colleagues at UCLA (my residency alma mater) provides a unique example of this kind of investigation.
How did the researchers approach this question?
This study, a 36-month, parallel-group, randomized clinical trial, recruited adults 60 years or older with diagnosed clinical insomnia and without major depression or major health events in the prior year, though many had previous depressive episodes. These subjects were then randomly assigned to 8 weeks of either cognitive behavioral therapy for insomnia (CBT-I) or sleep education therapy (SET), both provided in 120-minute group sessions.
Let’s compare CBT-I and SET.
CBT-I, currently recommended in several major guidelines as the first-line treatment for insomnia, involves five components which are described briefly here: cognitive therapy (targeting anxious thoughts around sleep), stimulus control (bedroom is associated with high-quality sleep), sleep restriction (improving quality of sleep by limiting hours in bed), sleep hygiene (quiet, cool room, avoiding alcohol, caffeine in the evening, etc.), and relaxation training.
SET also involves sleep hygiene, as well as education about the biology of sleep, what characterizes healthy sleep, and how stress may contribute to sleep problems, but does not utilize cognitive techniques or additional behavioral interventions like CBT-I does.
The primary outcome of the trial, i.e., their result of most interest, was the development of an incident (first time) or recurrent depressive episode during the 3-year follow-up period. They also looked at improvement in subjects’ insomnia in each group (CBT-I vs. SET).
Why did researchers even ask this question?
Before we discuss the results, let’s talk about why this study is so important. First, as I noted earlier, it investigates a strategy that may prevent depression, an illness with broad and profound morbidity. Second, it looks at particular individuals (people 60 years and older) who have high rates of insomnia (as many as 50 percent in some studies). This group also has considerable rates of depression (10 percent), achieving remission only a third of the time, and that’s when they are actually treated!
Finally, within our aging population, data suggest an increased risk of depression, suicide, and dementia in those with insomnia. Therefore, specifically investigating the benefit of a recommended treatment to improve sleep and possibly lower depression risk has massive public health implications.
Now for the results...
Just two months of treatment with CBT-I significantly decreased the rates of major depressive episodes. In fact, it reduced the likelihood of a depressive episode by an impressive 60 percent and became more effective as time went by. Compare this to medications for sleep, which carry definite side-effect risks in this age group and certainly don’t work for months, even years, after stopping them.
In addition to preventing depression, CBT-I was also significantly better at treating insomnia, with sustained benefit throughout the study. With growing evidence for the myriad consequences of poor sleep on our metabolism, immune system, and cardiovascular system, among others, this improvement in insomnia will enhance overall health for elderly individuals.
Can we use this information to help more people?
Though there is indeed a shortage of CBT-I providers, this study provided effective treatment in a group model, suggesting options for reaching a broader population. Additionally, the pandemic has vastly increased the acceptance and application of telemedicine, which could help reach the underserved in both rural and urban areas. Digital CBT-I models exist and have been shown to be effective as well, though less robustly than working with a therapist directly.
In summary, this study provides a timely addition to our knowledge base about the prevention of depression. In an interesting editorial about this research, Drs. Pim Cuijpers and Charles Reynolds suggest other intriguing applications of an indirect approach to depression prevention, targeting such specific challenges as procrastination in college students, perfectionism in perinatal women, and deficits in social skills among adolescents.
I, for one, am eagerly awaiting the work of my superb psychiatric colleagues currently pursuing research in preventative mental health. Answers couldn’t come soon enough.
Cuijpers P, Reynolds CF. Increasing the Impact of Prevention of Depression—New Opportunities. JAMA Psychiatry. Published online November 24, 2021. doi:10.1001/jamapsychiatry.2021.3153
Irwin MR, Carrillo C, Sadeghi N, Bjurstrom MF, Breen EC, Olmstead R. Prevention of Incident and Recurrent Major Depression in Older Adults With Insomnia: A Randomized Clinical Trial. JAMA Psychiatry. Published online November 24, 2021. doi:10.1001/jamapsychiatry.2021.3422