Abstract
Objective Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for
insomnia, but half of the patients do not reach remission. This study aimed to explore
subjective remission by investigating the characteristics of patients who reported
lingering sleep problems after CBT-I.
Methods Secondary analyses of a randomized controlled trial of group CBT-I in 72 primary
care patients with insomnia disorder. Sociodemographic characteristics and outcomes
(insomnia severity, sleep variables, hypnotics use, fatigue, depressive symptoms,
and dysfunctional beliefs/attitudes), including baseline data and symptom change,
were investigated in relation to patients' posttreatment response to the yes-or-no
question “Would you say that you have sleep problems?”
Results A total of 56.9% of patients reported sleep problems after CBT-I. At baseline, they
had worse depressive symptoms (14.9 (SD 7.5) vs. 10.2 (SD 5.9), p = 0.006) and more awakenings (2.6 (SD 1.5) vs. 1.8 (SD 1.3), p = 0.034) than those in subjective remission from sleep problems. Patients in the
non-remission and remission groups showed similar improvements in sleep, fatigue,
and depressive symptoms, but patients in the non-remission group had improved less
in insomnia severity, dysfunctional beliefs/attitudes about sleep, and hypnotic use.
In patients with more pronounced depressive symptoms before CBT-I, change in depressive
symptoms during treatment partially explained subjective remission from sleep problems.
Discussion More severe depressive symptoms prior to CBT-I and less improvements in depressive
symptoms during treatment predicted remaining subjective sleep problems after treatment.
These findings highlight the importance of assessing depressive symptoms in primary
care patients with insomnia, as patients with pronounced depressive symptoms may need
tailored treatment.
Keywords cognitive behavioral therapy - sleep initiation and maintenance disorders - depression
- primary health care - treatment outcome - self-assessment
