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Journal of Consulting and Clinical Psychology Copyright 2005 by the American Psychological Association

2005, Vol. 73, No. 6, 1164 –1174 0022-006X/05/$12.00 DOI: 10.1037/0022-006X.73.6.1164

A Placebo-Controlled Test of Cognitive–Behavioral Therapy for Comorbid


Insomnia in Older Adults

Bruce Rybarczyk, Edward Stepanski, and Martita Lopez


Louis Fogg University of Texas at Austin
Rush University Medical Center

Paulette Barry Andrew Davis


Rush University Medical Center University of Chicago
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

The present study tested cognitive– behavioral therapy (CBT) for insomnia in older adults with osteo-
arthritis, coronary artery disease, or pulmonary disease. Ninety-two participants (mean age ⫽ 69 years)
were randomly assigned to classroom CBT or stress management and wellness (SMW) training, which
served as a placebo condition. Compared with SMW, CBT participants had larger improvements on 8 out
of 10 self-report measures of sleep. The type of chronic disease had no impact on these outcomes. The
hypothesis that CBT would improve daytime functioning more than SMW was only supported by a
global rating measure. These results add to findings that challenge the dichotomy between primary and
secondary insomnia and suggest that psychological factors are likely involved in insomnias that are
presumed to be secondary to medical conditions.

Keywords: insomnia, cognitive– behavioral therapy, older adults, chronic disease, stress management

Extensive treatment studies of older adults with primary insom- and that the best approach to the insomnia was to treat the medical
nia have demonstrated the efficacy of behavioral interventions, condition. However, this dichotomy between primary and second-
with outcomes that are comparable with those obtained with ary insomnia fails to take into account the fact that insomnias are
younger adults (Morin, Culbert, & Schwartz, 1994; Murtagh & often triggered by multiple factors, both behavioral and medical. It
Greenwood, 1995). These interventions have included restriction is very difficult to make a reliable diagnostic distinction between
of time spent in bed (Davies, Lacks, Storandt, & Bertelson, 1986), primary and secondary insomnia (American Psychiatric Associa-
stimulus control (Puder, Lacks, Bertelson, & Storandt, 1983), and tion, 1994) because of the problem of identifying specific cause
multicomponent cognitive– behavioral treatments (CBT), which and effect factors (Lichstein, Wilson, & Johnson, 2000; Ohayon,
typically combine sleep restriction, stimulus control, relaxation 1997). In addition, behavioral factors (e.g., variable bed and wake
training, and sleep hygiene (Edinger, Hoelscher, Marsh, Lipper, & times, daytime napping, using the bed for activities other than
Ionescu-Pioggia, 1992; Morin, Colecchi, Stone, Sood, & Brink, sleep) frequently amplify and perpetuate insomnia, irrespective of
1999; Morin, Kowatch, Barry, & Walton, 1993). The multicom- the initial cause. Accordingly, the present study uses the term
ponent CBT studies have yielded effect sizes that are 20% greater comorbid insomnia rather than secondary insomnia because of the
than single component treatments (Morin et al., 1994) and, as a difficulty of making an etiologic determination. Furthermore, our
result, they have become the standard in intervention research for assumption is that the majority of comorbid insomnias, regardless
the past several years. of contributing medical factors, include behavioral and psycholog-
CBT for insomnia was originally developed as a treatment of
ical factors that could respond to CBT.
primary insomnia. Individuals with insomnia comorbid with a
There have been several recent studies of multicomponent CBT
medical condition were considered inappropriate for CBT. The
for secondary or comorbid insomnia. A study with 60 chronic pain
assumption was that such insomnias usually had medical causes
patients determined to have secondary insomnia found that CBT
improved several self-report measures of sleep and an actigraphy
measure of nighttime motor activity (Currie, Wilson, Pontefract, &
Bruce Rybarczyk, Edward Stepanski, Louis Fogg, and Paulette Barry, deLaplante, 2000). These therapeutic gains were essentially main-
Department of Behavioral Sciences, Rush University Medical Center; tained at the 3-month follow-up. A study of CBT with 10 women
Martita Lopez, Department of Psychology, University of Texas at Austin; with nonmetastatic breast cancer, using a multiple baseline design,
Andrew Davis, Department of Medicine, University of Chicago. found self-report and polysomnography improvements in sleep
This research was supported by National Institute on Aging Grant
efficiency and total wake time (Quesnel, Savard, Simard, Ivers, &
AG17491-02 to Bruce Rybarczyk.
Correspondence concerning this article should be addressed to Bruce Morin, 2003). In another CBT study with 44 older adults with
Rybarczyk, Department of Behavioral Sciences, Rush University Medical insomnia secondary to a range of medical or psychiatric illnesses,
Center, 1653 West Congress Parkway, Chicago, IL 60612. E-mail: participants in the treatment group reported significantly greater
brybarcz@rush.edu improvement on wake time during the night, sleep efficiency
1164
CBT FOR COMORBID INSOMNIA IN OLDER ADULTS 1165

percentage, and sleep quality rating when compared with a delayed that would remain after behavioral causes are alleviated, we hy-
treatment control group (Lichstein et al., 2000). These gains were pothesized that COPD patients would obtain the smallest benefit
maintained at the 3-month follow-up. Taken together, these studies from behavioral treatment, followed by CAD and then OA. COPD
suggest that CBT is effective with secondary insomnia. has several potent medical factors that can cause secondary insom-
These findings were supported and extended in two recent CBT nia (i.e., respiratory problems, medication side effects) that are
studies by Rybarczyk and colleagues (Rybarczyk, Lopez, Benson, similar to those found in CAD, but the respiratory problems and
Alsten, & Stepanski, 2002; Rybarczyk, Lopez, Schelble, & Stepan- medication side effects are known to be more severe in nature.
ski, 2005). In the first study, Rybarczyk et al. (2002) randomized COPD was also chosen because it represented an ideal group for
24 older adults who had insomnia that was comorbid with a range testing the hypothesis that sleep can be modified with behavioral
of chronic medical conditions to either classroom CBT or delayed methods even when many fixed medical causes of insomnia are
treatment. Compared with no treatment, CBT led to significantly likely to be present.
greater improvement on several self-report measures of sleep at a A final hypothesis was that sleep improvements would have a
4-month follow-up, including sleep efficiency, time awake after significant impact on the daytime functioning of participants.
sleep onset, and global sleep ratings. The second study by Ryba- Morin (2003) has argued that since insomnia has been associated
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rczyk et al. (2005) presented data on an additional group of 12 with significant morbidity and quality of life effects, effective
participants randomized to CBT home treatment, composed of treatments should not only produce changes in sleep parameters
videos of classroom treatment and phone consultation. This group but also other measures of daytime functioning. As such, we used
had results that were comparable with in-person classroom CBT a range of secondary dependent measures, including mood, fa-
reported in the first study. tigue, concentration, and general quality of life. A pain measure
If the findings demonstrating the efficacy of CBT for comorbid was also included, with OA participants as the principal target, as
insomnia in older adults are further corroborated, it would have higher pain levels have been linked to episodes of insomnia in OA
important treatment implications for a large segment of the older patients (Moldofsky, 1989). Thus far, only three CBT intervention
adult population. Lichstein (2000) has estimated that 70% of the studies have demonstrated such secondary benefits (Morgan,
insomnia found among older adults can be qualified as secondary Dixon, Mathers, Thompson, & Tomeny, 2003; Quesnel et al.,
insomnia. Furthermore, older adults with secondary insomnia are 2003; Rybarczyk et al., 2005).
more likely to have daytime consequences and quality of life
effects from their insomnia compared with older adults with pri- Method
mary insomnia (Katz & McHorney, 1998; Lichstein, Durrence,
Bayen, & Riedel, 2001). Thus, it could be hypothesized that Design
treatment of comorbid insomnia would produce more significant
A block randomization procedure was used to assign participants to the
quality of life benefits.
following two different 8-week classroom treatment programs: CBT or an
The primary goal of the present study was to extend this re-
SMW treatment. Once a group of at least 5 participants completed pre-
search by testing whether CBT would outperform a placebo treat- treatment assessment in a given week, the block of participants who
ment of comorbid insomnia. None of the previous comorbid or completed pretreatment assessment by the end of that week were randomly
secondary insomnia intervention studies have used a placebo con- assigned to one of the two treatment conditions. The treatment condition
trol condition. A placebo treatment group is considered ideal for was assigned using a random order generated at the onset of the study. The
insomnia treatment research to control for inherent demand char- study personnel who were in contact with potential participants for tele-
acteristics and expectancy effects (Stepanski, 2000). For our pla- phone and home polysomnographic screening were not aware of the next
cebo treatment, we used a classroom stress management and treatment condition. Study participants were aware that they would be
wellness (SMW) program developed specifically for older adults assigned to one of two treatments (with the SMW treatment being de-
scribed as a viable treatment not previously tested for insomnia) but did not
with chronic illness (Rybarczyk, DeMarco, DeLaCruz, Lapidos, &
find out which one they were receiving until they attended the first class.
Fortner, 2001). The rationale presented to SMW participants was
All participants completed a 2-week sleep log and other questionnaires
that this program was a potential treatment for insomnia, on the within 4 weeks of the start of treatment and an identical posttreatment
grounds that sleep, stress, and mind– body wellness were interre- assessment within 4 weeks of completion of the treatment. After SMW
lated and reciprocal in their effects. In contrast to some placebo participants completed the treatment, they were offered the opportunity to
control groups, which contain no active treatments, the SMW cross over to CBT treatment if their insomnia still met study criteria. The
group used in the present study has demonstrated self-report cop- study protocol was approved by the Rush University Medical Center
ing and wellness benefits in this population. Thus, SMW was able institutional review board and all participants gave written informed con-
to provide some nonsleep benefits to participants, contributing to sent at the time of enrollment.
high credibility and low attrition. To avoid any confound with the
relaxation training component of CBT, we removed relaxation Participants
training as an active treatment component in the SMW class.
The second goal of the study was to test the differential efficacy Participants were recruited between January 2001 and October 2003
either by flyers placed in medical offices and senior centers or by letters
of CBT for older adults with one of three chronic medical condi-
mailed to lists of individuals identified as having one of the three medical
tions: osteoarthritis (OA), coronary artery disease (CAD), or conditions. These lists were obtained from physician practices or disease-
chronic obstructive pulmonary disease (COPD). All three are related support organizations. Participants were paid up to $200, based on
common age-related diseases and are linked to high rates of how much of the protocol they completed.
insomnia (Foley, Ancoli-Israel, Britz, & Walsh, 2004; Katz & Potential volunteers who contacted the study were initially screened by
McHorney, 1998). Based on the likely medical causes of insomnia telephone. The following inclusion criteria were used at this stage: (a) age
1166 RYBARCZYK ET AL.

55 or older; (b) at least three episodes of insomnia per week for at least 6
months (an episode was defined as taking at least 30 min to fall asleep,
being awake for at least 60 min after falling asleep, or accumulating less
than 6.5 hr of sleep per night); (c) daytime consequences of insomnia, such
as fatigue, irritability, or difficulty concentrating; and (d) self-report of a
physician-verified diagnosis of OA, CAD, or COPD (see specific criteria
below). The following telephone screening exclusion criteria were used: (a)
a history of diagnosed sleep disorders other than insomnia; (b) indications
of sleep apnea or restless legs syndrome, based on standard screening
questions; (c) taking greater than the standard clinical dose of a hypnotic
medication or taking more than one benzodiazepine for sleep medication;
(d) any medical condition, such as liver disease, Parkinson’s disease, or
end-stage renal disease, that is highly likely to cause sleep-disordered
breathing or other sleep disorders; and (e) a self-reported current diagnosis
of major psychopathology, such as major depression, or a history of
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psychiatric hospitalization. Every individual was also given the Geriatric


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Depression Scale (GDS; Brink et al., 1982), using a score of 15 as the


cutoff. Individuals who scored in the “mild” range of the GDS were
permitted in the study to avoid excluding those with adjustment disorder or
whose elevated scores were due to the effects of chronic illness and/or
insomnia (e.g., increased fatigue and decreased social activity.) Individuals
under treatment for depression were eligible if treatment had commenced
more than 2 months prior to enrollment and they met GDS criteria (5
individuals using prescription antidepressants were enrolled).
After passing the telephone screening, participants were required to
undergo a night of home polysomnographic assessment. A board-certified
sleep specialist reviewed the polysomnographic scoring for indications of
a sleep disorder other than insomnia. The exclusion cutoff was ⬎ 15 for the
apnea– hypopnea index and ⬎ 30 for the periodic leg movement index.
These exclusion thresholds were set so that patients with mild variants of
sleep apnea and periodic limb movement disorder would be included, as
there is an increased prevalence of these findings in older adults (Ancoli-
Israel et al., 1991a, 1991b). The goal was to include as many participants
as possible, but not if sleep apnea or periodic limb movement disorder
could be considered the primary cause of insomnia. During the home visit,
all participants were also administered the Mini-Mental State Examination
(MMSE; Folstein, Folstein, & McHugh, 1975) and Brief Symptom Inven-
tory (BSI; Derogatis & Nelisaratos, 1983). They were required to score at
least a 24 on the MMSE. The BSI was scored and used for exclusion when
individuals exhibited behaviors during the screening period that were
judged to potentially interfere with study participation. Following this
approach, 5 individuals were eliminated on the basis of t scores of 70 or
higher on any subscale other than Anxiety and Somatization, which are
often elevated in individuals with insomnia. The same insomnia criteria
used for telephone screening were also required at the 2-week sleep diary
baseline assessment for inclusion in the study, and 2 participants were
excluded at this point because of insufficient insomnia.
Among the 462 individuals who contacted the study and had the nec-
essary age, medical diagnosis and level of insomnia, 149 were excluded on
the basis of having an apparent noninsomnia sleep disorder, and another
135 were eliminated for having an excluded psychiatric or medical con-
dition. Figure 1 illustrates how this pool of 178 potential participants was
then reduced to the final group of 92 participants who completed the study.
Table 1 presents the demographic and other characteristics of these par- Figure 1. Study flowchart. PSG ⫽ polysomnography; CAD ⫽ coronary
ticipants. No differences were found between groups with regard to age, artery disease; OA ⫽ osteoarthritis; COPD ⫽ chronic obstructive pulmo-
gender, education, race, distribution of the targeted chronic illnesses, nary disease; CBT ⫽ cognitive– behavioral therapy; SMW ⫽ stress man-
number of other chronic illnesses, or sleep medication usage ( ps ⱖ .10). agement and wellness training. aIncludes four intent-to-treat dropouts (2 in
Among the 92 participants randomized in the study, 48 had a verified CBT, 2 in SMW). bNumbers below sum to more than 46 per group because
medical diagnosis on the basis of referral to the study by their physician or of 14 participants having more than one diagnosis.
telephone confirmation by their physician. The latter was done for potential
participants who contacted the study but were uncertain of their medical
diagnosis. The other group of participants self-reported their diagnoses OA in one or more joints (confirmed by an X-ray or MRI), ongoing
during telephone screening and met the required self-report criteria. To treatment from a physician, pain ratings of at least “moderate” on the
meet criteria for OA, an individual needed to report physician-diagnosed Short-Form-36 Health Survey (SF-36; Ware, Kosinski, & Keller, 1994)
CBT FOR COMORBID INSOMNIA IN OLDER ADULTS 1167

Table 1
Demographic and Other Baseline Characteristics by Treatment Group

Characteristics CBT (n ⫽ 46) SMW (n ⫽ 46)

Gender 28 women 34 women


18 men 12 men
Mean age (SD) 70.1 (9.1) 67.7 (7.9)
Mean years of education (SD) 14.8 (4.0) 14.3 (2.4)
Race 65% (30) Caucasian 70% (32) Caucasian
29% (13) African-American 28% (13) African-American
4% (2) Hispanic 2% (1) Hispanic
2% (1) Asian
Chronic illnesses on which groups
were matcheda 23 OA 28 OA
21 CAD 17 CAD
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8 COPD 9 COPD
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Mean number of other chronic


illnesses (SD) .61 (.71) .59 (.72)
Mean prescription medications for
any medical condition (SD) 4.8 (3.2) 5.9 (3.8)
Median years of insomnia duration 3.5 3.0
Over-the-counter or prescription sleep
medications used at least once in a
period of 2 weeks 30% (14) 26% (12)

Note. CBT ⫽ cognitive– behavioral therapy; SMW ⫽ stress management and wellness training; OA ⫽
osteoarthritis; CAD ⫽ coronary artery disease; COPD ⫽ chronic obstructive pulmonary disease.
a
Numbers sum to more than 46 per group due to 14 participants having more than one diagnosis.

Pain subscale or the pain rating item from the Arthritis Impact Measure- the following components on a 5-point Likert scale: (a) severity of sleep
ment Scales-(AIMS2; Meenan, Mason, Anderson, Guccione, & Kazis, onset, sleep maintenance, and early morning awakening problems (3
1992). One exception was made for an OA participant who reported mild items); (b) satisfaction with current sleep pattern; (c) interference with
pain but had the highest possible AIMS2 scores for the number of joints daily functioning (e.g., daytime fatigue, ability to function at work or daily
that are painful and the degree of joint stiffness. To meet criteria for CAD chores, concentration, memory, mood); (d) how noticeable the impairment
or COPD, participants needed to have been diagnosed by a physician, using attributed to a sleep problem is to others; and (e) level of distress caused by
objective diagnostic testing, and be under current treatment for that con- the sleep problem. This scale has good internal validity and appropriate
dition. For the CAD group, 78% of these participants reported that they had test–retest reliability over a 2-week interval. Scores vary between 1 and 5
undergone angioplasty or coronary artery bypass surgery. Fourteen partic- (higher scores equal greater levels of impairment). The interference item
ipants (7 in both CBT and SMW) had more than one of the three medical was also used as a secondary measure because of the fact that it serves as
diagnoses. a global measure of daytime functioning.
Thirty-six of the 44 SMW participants who completed treatment con- Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS). The
tinued to have sleep problems that qualified them for the study and were DBAS (Morin, 1993) is a 30-item scale designed to measure various
offered the opportunity to cross over to CBT treatment after posttreatment beliefs, attitudes, expectations, and attributions about sleep and insom-
assessment. Of these, 26 began CBT treatment and 23 completed the
nia. These cognitions involve five conceptually derived themes: misat-
treatment. The two primary reasons for not crossing over were schedule
tributions or amplification of the consequences of insomnia, diminished
conflicts and not wanting to participate in another class.
perception of control and predictability of sleep, unrealistic sleep ex-
pectations, misconceptions about the causes of insomnia, and faulty
Measures beliefs about sleep promoting practices. Items include a 3-in. (7.62-cm)
visual analog scale, with strongly disagree and strongly agree descrip-
Sleep log. The sleep logs were paper-and-pencil records that were
completed by participants each morning for 2 weeks at pretreatment tors at each end of the scale. The DBAS has demonstrated adequate
(during the month prior to treatment) and posttreatment (during the month reliability and validity (Morin, Stone, Trinkle, Mercer, & Remsberg,
after treatment ended). They were also completed on a weekly basis during 1993).
the CBT class. The logs included sleep latency, awakenings (quantity and The Profile of Mood States (POMS). The POMS (McNair, Lorr, &
duration), time in bed, naps, and any medication used for sleep. Droppleman, 1971) is a 65-item self-report measure of affective states for
Pittsburgh Sleep Quality Index (PSQI). The PSQI (Buysse, Reynolds, the past week. Patients are asked to rate their current mood on a 5-point
Monk, Berman, & Kupfer, 1989) is a self-rated questionnaire that assesses Likert scale ranging from not at all to extremely. The instrument consists
sleep quality during the past month. Nineteen individual items lead to of six subscales for the dimensions of vigor, tension, depression, anger,
seven component scores: subjective sleep quality, sleep latency, sleep fatigue, and confusion. It has good test–retest reliability, predictive con-
duration, habitual sleep efficiency, sleep disturbances, use of sleeping struct, and concurrent validity (McNair et al., 1971). The POMS total mood
medication, and daytime dysfunction (i.e., level of sleepiness and enthu- disturbance score, which does not include the Vigor subscale, can be used
siasm). The sum of scores for these seven subscales yields one global score as an overall indicator of distress.
of overall sleep quality. Geriatric Depression Scale (GDS). The GDS (Brink et al., 1982) was
Sleep Impairment Index (SII). The SII is a 7-item measure (Morin et developed specifically for use with older adults and uses a simple “yes/no”
al., 1999) that yields a global score of sleep impairment. Respondents rate answer format. The scale is composed of 30 items, none of which reflect
1168 RYBARCZYK ET AL.

the somatic and vegetative aspects of depression, thus reducing possible efficiency. Participants were also instructed to lie awake in bed no longer
confounding of depressive and age-related medical illness symptoms. than 15 min, at which time they were to go to another room, engage in a
The SF-36. The SF-36 (Ware, Kosinski, & Keller, 1994) is a 36-item nonstimulating task in a dimly lit room, and return to the bed only when
scale designed to assess the following eight health concepts: physical they felt sleepy again. No activities were permitted in bed other than sleep
functioning, role limitations due to physical health problems, social func- and sex.
tioning, general mental health, role limitations due to emotional problems, The third component to be introduced was cognitive restructuring, which
general health perceptions, vitality, and bodily pain. The SF-36 has dem- emphasized changing unrealistic beliefs and irrational fears regarding sleep
onstrated adequate reliability and validity. Physical and mental component or loss of sleep. The fourth component was relaxation training, designed to
scores have shown good validity as summary scores (Ware et al., 1994). decrease anxiety and reduce cognitive and physiological arousal at bed-
Sickness Impact Profile (SIP): Somatic Autonomy and Social Behavior time. Each participant was given a relaxation audiotape that included the
subscales. Patients’ ratings of their functional level were assessed using following four commonly used modalities: deep breathing, progressive
the 17-item Somatic Autonomy subscale and the 11-item Social Behavior muscle relaxation, autogenic training, and imagery. A final component of
subscale from the SIP (Bergner, Bobbitt, Carter, & Gilson, 1981). The the intervention was sleep-hygiene education, including the use of in-
Somatic Autonomy subscale measures activities of daily living such as creased daytime bright light exposure to address any circadian causes of
transferring and eating. The Social Behavior subscale assesses daily social insomnia. Topics included increasing natural light exposure, daytime ac-
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activities such as hobbies, social and community activities, and house- tivity and exercise, reducing caffeine and alcohol intake, keeping an
This document is copyrighted by the American Psychological Association or one of its allied publishers.

work. These two subscales were included to assess dimensions of func- appropriate bedroom temperature, reducing ambient noise in the bedroom,
tional status not addressed by the SF-36. using warm baths in the evening, and using appropriate food choices and
Short-Form McGill Pain Questionnaire (SF-MPQ). The SF-MPQ was eating patterns.
designed to be a brief version of the long-form MPQ (Melzack, 1987), SMW treatment. The SMW treatment, adapted from Rybarczyk et al.
which has been widely used in the measurement and study of pain. The (2001), consisted of didactic presentations and corresponding skill training
SF-MPQ has been shown to correlate highly with the standard MPQ and to covered the following six topics: (a) the mind– body relationship, (b)
be sensitive to pain management interventions. For the present study, the modifying self-talk for the reduction of stress and anxiety, (c) effective
total score was used. communication and assertiveness, (d) problem solving and goal setting, (e)
Insomnia Treatment Evaluation Questionnaire (ITEQ). The ITEQ was nutrition, and (f) exercise for individuals with chronic conditions. Topics 1
developed by Mimeault and Morin (1999) for measuring insomnia treat- and 2 (which were covered over four separate class sessions) were pre-
ment plausibility. Using an 85-mm visual analog scale ranging from 0 (not sented by a physician with extensive training and speaking experience
at all) to 85 (very much), participants rated the following about the regarding mind– body health, Topics 3 and 4 by were presented by psy-
treatment: (a) if the rationale made sense, (b) how acceptable the treatment chologists, and Topics 5 and 6 were presented by an expert nutritionist and
was for them, (c) suitability for their sleep problems, and (d) expected exercise physiologist.
effectiveness for their sleep problems. Scores were then converted to a At the beginning of the SMW class, participants were given a presen-
100-point scale for ease of interpretation. Individual item scores as well as tation of a treatment rationale based on the common public perception of
a total score were calculated. This measure was administered at the end of an interrelationship between sleep problems and stress, nutrition, and
the second treatment class. exercise. This model suggested that improvements in daytime coping and
wellness would lead to improvements in sleep. As a substitute for an active
treatment of relaxation training, participants were given brief instruction in
Interventions breath awareness, which is one of several components of a mindfulness
meditation intervention (Kabat-Zinn, Lipworth, Burney, & Sellers, 1987).
Each intervention program consisted of eight weekly 2-hr classes Providing a quasi-relaxation training procedure was deemed essential to
matched in as many characteristics as possible (e.g., location, experience increasing the credibility of this program as a treatment for insomnia.
level and skill of instructors, amount of group discussion and question- Rather than the usual intensive training that typically accompanies mind-
and-answer time, number and quality of handouts, use of computerized fulness meditation interventions, participants were given brief instruction
presentations, refreshments, certificates given out at the end of the pro- on paying attention to their breathing rhythm as a means of detaching from
gram) There were 22 groups, averaging 5 members per group (including the stressful events at hand. This technique was chosen due to the fact that
crossovers). All classes were conducted at an academic medical center in it seems plausible yet had no proven efficacy as a stand-alone relaxation
downtown Chicago, IL. Transportation was paid for by the study to intervention. Apart from the simplistic rationale for the intervention and a
facilitate participation of individuals at all income levels. Participants who quasi-relaxation procedure that was intended to be an inactive treatment,
missed a class were given make-up classes for up to two missed sessions. the remainder of the material presented in SMW treatment was a state-of-
CBT. The intervention protocol closely followed Morin’s (1993) in- the-art and empirically based intervention for improving emotional and
somnia treatment protocol, with the exception of an added relaxation physical well-being (Rybarczyk et al., 2001). The presenters understood
training component. The CBT sessions were led by two clinical psychol- that, apart from the mindfulness training, their intervention was to be the
ogists experienced in CBT treatment of insomnia. Each session included a best possible active treatment for wellness and stress reduction.
didactic presentation, a question-and-answer period, and a review of each
individual’s sleep log and group discussion to solve problems encountered
during implementation of the techniques. Statistical Analyses
The main behavioral components, stimulus control (Bootzin & Nicassio,
1978) and sleep restriction (Spielman, Saskin, & Thorpy, 1987), were The 4 participants (2 each from CBT and SMW) who dropped out of
introduced and emphasized during the first three sessions. A strict schedule treatment after randomization were included in the primary analyses, by
of bedtimes and arising times was prescribed to consolidate sleep and replicating their sleep data from pretreatment measurement to posttreat-
decrease time spent awake during the night. Patients initially reduced their ment. To limit Type I errors, the initial statistical test was a multivariate
time in bed to the amount of time they were actually sleeping according to analysis of covariance (MANCOVA) for the following two factors: treat-
their pretreatment sleep logs, but not less than 4.5 hr. Sleep logs were ment (CBT, SMW) and the repeated factor of time (pretreatment and
completed continuously during treatment and the bedtime was moved posttreatment measurement). To estimate possible effects for the 22 spe-
earlier by a maximum of one half hour each week if there was sufficient cific classes, an initial nested multivariate analysis of variance
improvement in sleep efficiency, usually defined as achieving 85% sleep (MANOVA) was conducted with class nested within treatment group. If
CBT FOR COMORBID INSOMNIA IN OLDER ADULTS 1169

the class effects were nonsignificant, they were excluded from subsequent group difference for total score, F(1, 70) ⫽ 3.69, p ⫽ .059, and the
analyses. The three medical diagnosis (OA, CAD, COPD) were dummy- suitability item, F(1, 70) ⫽ 3.99, p ⫽ .05. There were no signif-
coded (0 ⫽ present, 1 ⫽ absent) and entered into the model as separate icant differences for the rationale item, F(1, 70) ⫽ 1.80, p ⫽ .184,
covariates. In this way, it is possible to test and correct for both the simple the acceptability item, F(1, 70) ⫽ 2.08, p ⫽ .154, and the expec-
effects for each of the diagnoses as well as the effects of multiple diag-
tation item, F(1, 70) ⫽ 2.42, p ⫽ .124.
noses. In addition, in a separate analysis the overall number of comorbid
medical diagnoses (including the three target diagnoses and other signifi-
cant chronic diseases, reported in Table 1) was used as a covariate to test Log and Self-Report Sleep Measures
whether the number of medical comorbidities affected response to treat-
ment. If there was no significant Diagnosis ⫻ Time interactions or Medical Table 2 provides a summary of pretreatment and posttreatment
Comorbidity ⫻ Time interactions, then the covariates were removed from means and standard deviations for the self-report sleep measures
subsequent analyses. When there was a significant overall Treatment ⫻ along with F for Treatment ⫻ Time analyses and Cohen’s d effect
Time interaction effect, separate analyses of variance (ANOVAs) were sizes (indicating the effect of CBT relative to SMW). There were
conducted for each variable. no significant differences between the two treatment groups on any
The analyses described above were applied to both the sleep measures baseline measure ( ps ⱖ .10), and there were no significant differ-
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and the secondary measures. The secondary measures were reduced to


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ences between the three chronic disease groups for sleep efficiency
eight measures by using the POMS and SF-36 summary scores. Analyses
at baseline ( p ⬎ .10).
for the SMW to CBT crossovers used a repeated measures MANOVA
followed by a paired sample t test on individual sleep measures and the The two-factor (Treatment ⫻ Time) MANCOVAs revealed no
eight secondary measures. Finally, ANOVAs were conducted for the total significant effects for any of the three medical diagnoses or the
of the ITEQ as well as the individual items, comparing treatment plausi- number of medical comorbidities, so both types of covariates were
bility for the two groups. dropped from later analyses. In addition, there were no class
The clinical significance of the treatment outcomes was also calculated effects found for the nested MANOVA, resulting in the class
and compared across groups. The most commonly used and recommended variable being excluded from subsequent analyses. The subsequent
measure of clinical significance in randomized trials of insomnia treatment repeated measures MANOVA indicated a significant Treatment ⫻
is a normative comparison method (Morin, 2003). We used Lichstein et Time interaction across the 10 sleep measures in Table 2, F(10,
al.’s (2000) method of comparing the data with established norms for
72) ⫽ 4.13, p ⬍ .001. Individual repeated measures ANOVAs
self-reported sleep efficiency (i.e., M ⫽ 86.1, SD ⫽ 9.7; Lichstein, 1997).
indicated differential improvement in the CBT group relative to
With this method, there are three different categories of clinically signif-
icant change. For all three categories sleep efficiency must improve by at the SMW group at posttreatment for the following sleep variables:
least 0.5 SD of the norm (i.e., 4.85%). If that criterion is met and the sleep efficiency, F(1, 90) ⫽ 12.33, p ⬍ .001, sleep latency, F(1,
individual’s posttreatment sleep efficiency is equal to or greater than the 90) ⫽ 8.89, p ⬍ .01, time awake after sleep onset, F(1, 90) ⫽ 7.16,
mean of the normative group then there is clinically significant improve- p ⬍ .01, time in bed, F(1, 90) ⫽ 15.77, p ⬍ .001, number of naps,
ment. If the posttreatment sleep efficiency does not reach the mean but is F(1, 90) ⫽ 4.54, p ⬍ .05, PSQI global sleep score, F(1, 85) ⫽
within 1 SD of the mean of the normative group, it is classified as 12.66, p ⬍ .001, SII total score, F(1, 86) ⫽ 22.64, p ⬍ .001, and
moderately clinically significant improvement. Finally, to recognize indi- DBAS total score, F(1, 85) ⫽ 23.26, p ⬍ .001. Figure 2 illustrates
viduals who make very large gains in sleep efficiency but were very low at the changes in sleep efficiency of the three different chronic
pretreatment, there is a third category of substantial improvement. This is
disease CBT groups and the SMW group with all chronic diseases
achieved when an individual’s sleep efficiency improves by at least two
groups combined. Although there was no significant interaction for
SDs of the norm (i.e., 19.4%).
total sleep time, there was a significant effect for time across both
groups, F(1, 90) ⫽ 20.18, p ⬍ .001.
Results
Treatment Plausibility Clinical Significance of Sleep Changes at Posttreatment
The ITEQ (Mimeault & Morin, 1999), administered to partici- The clinical significance outcomes were as follows: the CBT
pants after the second class, was used to assess treatment plausi- group had 10 no improvements, 23 clinically significant improve-
bility ratings for the two treatment groups. Twenty participants had ments, 11 moderately clinically significant improvements, and 2
missing ITEQ data. Reasons for missing data included the follow- substantial improvements; and the SMW group had 35 no im-
ing: the questionnaire inadvertently not being administered to the provements, 7 clinically significant improvements, and 4 moder-
participant’s class (n ⫽ 8), not being present at the second class ately clinically significant improvements. When combining the
when the questionnaire was administered (n ⫽ 6), withdrawing three clinical improvement categories together, CBT had an over-
from the study prior to the second class (n ⫽ 3), and the ques- all rate of 78% clinically significant change compared with 24%
tionnaire not being completed properly (n ⫽ 3). for SMW. The two treatment groups were significantly different
Both treatment groups had mean scores which indicated a high from each other in the overall rate of significant change, ␹2 (1, N ⫽
level of agreement (maximum rating of agreement ⫽ 100) for the 92) ⫽ 27.7, p ⬍ .001.
total score (CBT ⫽ 79, SMW ⫽ 71) and the following four
individual ITEQ items: how much sense the treatment rationale Secondary Measures
made (CBT ⫽ 81, SMW ⫽ 75), the acceptability of the treatment
(CBT ⫽ 81, SMW ⫽ 74), the suitability of the treatment for their In addition to the four individuals who dropped out of the study,
sleep problem (CBT ⫽ 75, SMW ⫽ 63), and expectation for how there were 4 participants who failed to complete either the pre-
effective the treatment was going to be for their sleep problem treatment or posttreatment GDS or SIP as well as 5 participants
(CBT ⫽ 80, SMW ⫽ 72). The ANOVA indicated a treatment who failed to complete either the pretreatment or posttreatment
1170 RYBARCZYK ET AL.

Table 2
Pre- and Posttreatment Self-Report Sleep Measures for CBT (n ⫽ 46) and SMW (n ⫽ 46) Groups

Pretreatment Posttreatment

Measure Group M SD M SD Fa Cohen’s d

Sleep efficiency CBT 72.1 (12.7) 85.2 (7.8) 12.3** .77


SMW 71.7 (13.4) 76.0 (13.0)
Sleep latency (min) CBT 46.2 (50.1) 21.8 (20.3) 8.9** .64
SMW 35.9 (26.2) 33.1 (27.3)
WASO (min) CBT 49.8 (38.6) 22.0 (17.8) 7.2** .58
SMW 57.6 (40.8) 48.5 (38.7)
Total sleep time (min) CBT 339.4 (67.8) 371.7 (59.7) 0.2 .08
SMW 345.3 (76.1) 371.2 (66.5)
Total time in bed (min) CBT 470.9 (66.7) 438.3 (57.2) 15.8** .85
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SMW 482.3 (68.9) 492.0 (60.0)


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Number of naps per week CBT 0.6 (0.6) 0.3 (0.5) 4.5* .48
SMW 0.6 (0.6) 0.6 (0.6)
Nap minutes per day CBT 15.7 (23.2) 7.8 (21.7) 2.6 .35
SMW 19.7 (27.0) 18.4 (27.4)
PSQI global scoreb CBT (n ⫽ 45)d 10.8 (3.6) 6.8 (3.9) 12.7** .81
SMW (n ⫽ 42) 10.8 (3.4) 9.5 (3.5)
SIIc CBT (n ⫽ 44)d 21.7 (5.0) 14.9 (5.2) 22.6** 1.02
SMW (n ⫽ 44) 21.3 (5.2) 19.9 (5.5)
DBAS CBT (n ⫽ 43)d 29.5 (10.3) 20.4 (10.8) 23.3** 1.07
SMW (n ⫽ 44) 26.1 (10.7) 27.0 (8.0)

Note. CBT ⫽ cognitive– behavioral therapy; SMW ⫽ stress management and wellness training; WASO ⫽ time awake after sleep onset; PSQI ⫽
Pittsburgh Sleep Quality Index; SII ⫽ Sleep Impairment Index; DBAS ⫽ Dysfunctional Beliefs and Attitudes about Sleep.
a
F test for repeated measures ANOVA Treatment ⫻ Time factor. bLower ratings indicate better sleep. c Lower ratings indicate less sleep impairment.
d
Smaller ns due to missing data for study completers.
* p ⬍ .05. **p ⬍ .01.

POMS or SF-36 measures. The two-factor (Treatment ⫻ Time) Follow-up ANOVAs for individual variables indicated only a
MANCOVAs revealed no significant effects for any of the three significant Time ⫻ Treatment interaction for the SII interference
medical diagnoses or the number of medical comorbidities, so both item, F(1, 86) ⫽ 8.20, p ⬍ .01. One additional subanalysis ad-
types of covariates were dropped from subsequent analyses. The dressed the hypothesis that treating OA participants’ insomnia
MANOVA for the eight secondary measure variables, using the would reduce their pain. A repeated measures ANOVA found no
POMS and SF-36 summary scores, yielded a significant Treat- Time ⫻ Treatment effect for the MPQ measure. Table 3 presents
ment ⫻ Time interaction effect, F(8, 71) ⫽ 2.08, p ⬍ .05. the findings for the eight secondary variables for all participants.

Sleep and Secondary Measures for SMW Participants


Crossing Over to CBT
The sleep measures of the 26 participants who crossed over
from the SMW group showed an overall difference between pre-
treatment and posttreatment scores with a repeated measures
MANOVA, F(10, 16) ⫽ 4.43, p ⬍ .001 (see Table 4). The same
overall difference was found for the secondary measures
MANOVA, F(8, 14) ⫽ 5.1, p ⬍ .01. T tests indicated a significant
difference at posttreatment for the following sleep variables: sleep
efficiency, t(25) ⫽ 5.49, p ⬍ .001, sleep latency, t(25) ⫽ 3.08, p ⬍
.01, wake time after sleep onset, t(25) ⫽ 4.19, p ⬍ .001, SII total
score, t(25) ⫽ 5.73, p ⬍ .001, PSQI global score, t(25) ⫽ 5.94,
p ⬍ .001, SII interference, t(25) ⫽ 6.26, p ⬍ .001, and DBAS total
score, t(25) ⫽ 5.55, p ⬍ .001. For the secondary measures, t tests
indicated a significant difference for SII interference item, t(25) ⫽
6.26, p ⬍ .001, and the SIP Social Behavior subscale, t(25) ⫽ 2.58,
p ⬍ .05.
Figure 2. Sleep efficiency (mean and standard error) at pretreatment and
posttreatment for the three diagnostic groups treated with cognitive– Discussion
behavioral therapy (CBT) compared with all stress management and well-
ness training (SMW) participants. COPD ⫽ chronic obstructive pulmonary The findings from the present study indicate that a standard
disease; OA ⫽ osteoarthritis; CAD ⫽ coronary artery disease. CBT intervention led to significantly greater improvement in sleep
CBT FOR COMORBID INSOMNIA IN OLDER ADULTS 1171

Table 3
Pre- and Posttreatment Secondary Measures for CBT and SMW Groups

Pretreatment Posttreatment

Measure Group M SD M SD Fa Cohen’s d

SII interference CBT (n ⫽ 44) 3.0 (1.1) 2.1 (1.0) 8.2** .73
SMW(n ⫽ 44) 3.1 (1.1) 2.8 (1.0)
GDS total CBT (n ⫽ 45) 5.4 (3.8) 4.7 (4.5) 0.1 .15
SMW (n ⫽ 43) 5.5 (4.4) 4.7 (4.4)
POMS Total Distress Scale CBT (n ⫽ 45) 33.7 (22.8) 30.2 (21.1) 2.3 .40
SMW (n ⫽ 42) 33.2 (22.6) 35.7 (20.9)
SF-36 Health Survey
Mental CBT (n ⫽ 43) 53.1 (6.8) 54.6 (9.3) 0.1 .03
SMW (n ⫽ 43) 52.1 (9.7) 53.2 (8.0)
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Physical CBT (n ⫽ 43) 39.0 (10.1) 41.0 (10.5) 0.2 .08


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SMW (n ⫽ 43) 35.5 (12.0) 36.9 (12.1)


SF-MPQ total CBT (n ⫽ 44) 7.7 (8.6) 7.4 (8.5) 0.1 .08
SMW (n ⫽ 43) 10.0 (9.0) 10.2 (9.5)
SIP Somatic Autonomy CBT (n ⫽ 45) 0.3 (0.6) 0.1 (0.4) 2.3 .38
SMW (n ⫽ 43) 0.3 (0.7) 0.5 (1.2)
SIP Social Behavior CBT (n ⫽ 45) 3.6 (3.1) 3.2 (3.3) 0.1 .03
SMW (n ⫽ 43) 3.4 (3.1) 2.8 (2.8)

Note. CBT ⫽ cognitive– behavioral therapy; SMW ⫽ stress management and wellness training; SII ⫽ Sleep Impairment Index; GDS ⫽ Geriatric Depression
Scale; POMS ⫽ Profile of Mood States; SF-36 ⫽ Short-Form-36 Health Survey; SF-MPQ ⫽ Short-Form McGill Pain Questionnaire; SIP ⫽ Sickness Impact Profile.
a
F test for repeated measures ANOVA Treatment ⫻ Time factor.
** p ⬍ .01.

compared with an intervention targeting coping and wellness on 8 sleep functions, including sleep efficiency, sleep latency, time
out of 10 measures of sleep (see Table 2), using intent-to-treat awake after sleep onset, naps per day, daytime impairment caused
analyses. These group differences were across a wide range of by sleep problems, global measures of sleep, and beliefs about

Table 4
CBT Pre- and Posttreatment Measures for Crossover Participants (n ⫽ 26)

Pretreatment (after
SMW class) Posttreatment

Measure M SD M SD ta

Sleep efficiency 73.9 (12.8) 84.2 (7.8) 5.49**


Sleep latency (min) 41.8 (37.8) 25.3 (17.0) 3.08**
WASO (min) 55.5 (39.4) 26.3 (17.1) 4.19**
Total sleep time (min) 362.5 (64.8) 381.9 (61.0) 2.02
Total time in bed (min) 486.0 (66.8) 457.9 (53.8) 2.45
Number of naps per week 0.4 (0.5) 0.3 (0.4) 1.48
Nap minutes per day 9.6 (13.0) 7.0 (13.9) 1.38
PSQI global scoreb 9.8 (3.0) 6.8 (3.0) 5.94**
SIIc 21.1 (4.1) 14.9 (5.0) 5.73**
DBAS 27.2 (8.4) 19.7 (9.5) 5.55**
SII interference 73.9 (12.8) 84.2 (7.8) 6.26**
GDS Total 3.6 (2.5) 3.9 (3.3) 0.77
POMS Total Distress Scale 31.3 (13.9) 25.4 (13.5) 1.88
SF-36 Health Survey
Mental 55.1 (5.6) 56.4 (6.1) 1.28
Physical 39.0 (11.7) 40.5 (10.2) 0.92
SF-MPQ total 9.2 (7.4) 8.6 (6.8) 0.40
SIP Somatic Autonomy 0.6 (2.1) 0.01 (0.2) 1.42
SIP Social Behavior 2.7 (2.7) 1.5 (2.1) 2.58**

Note. CBT ⫽ cognitive– behavioral therapy; SMW ⫽ stress management and wellness training; WASO ⫽ time
awake after sleep onset; PSQI ⫽ Pittsburgh Sleep Quality Index; SII ⫽ Sleep Impairment Index; DBAS ⫽
Dysfunctional Beliefs and Attitudes about Sleep; GDS ⫽ Geriatric Depression Scale; POMS ⫽ Profile of Mood
States; SF-36 ⫽ Short-Form-36 Health Survey; SF-MPQ ⫽ Short-Form McGill Pain Questionnaire; SIP ⫽
Sickness Impact Profile.
a
T score for paired t test. bLower ratings indicate better sleep. cLower ratings indicate sleep impairment.
** p ⬍ .01.
1172 RYBARCZYK ET AL.

sleep. With the clinical significance classifications, the overall the CBT group. First, it can be inferred from these data that the
treatment efficacy rate was 78% for CBT compared with only 24% maximum amount of self-reported sleep change that can be attrib-
for SMW. In addition, the greater efficacy of CBT was further uted to expectancy effects, demand characteristics, and generic
reinforced by the fact that the 26 participants who crossed over to social support (i.e., placebo effects) is approximately one third of
CBT following SMW treatment significantly improved on 6 out of that obtained by the actual active treatment elements of CBT. A
10 sleep measures. Also notable were the moderate to large Co- number of insomnia treatment studies have used a placebo control
hen’s d effect sizes (see Table 2), which represent the effects after (see Stepanski, 2000, for review), such as quasi-desensitization,
controlling for placebo treatment. but none have used a stress management and wellness program for
These overall findings add to the recently published studies this purpose. Because the SMW is an untested treatment, it is
showing high levels of efficacy for behavioral treatments that possible that some improvement in stress levels and wellness also
target secondary and comorbid insomnias (Currie et al., 2000; led to indirect effects on sleep. As such, a second inference from
Lichstein et al., 2000; Quesnel et al., 2003; Rybarczyk et al., this study is that an intervention that improves daytime coping and
2002). Furthermore, the results of the present study go beyond the wellness is, at best, also about one third as effective as CBT for
findings of the previous studies by being the first to use a placebo treating insomnia in this population.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

control group that controlled for expectancy and demand effects Contrary to hypothesis, the analyses comparing CBT with SMW
that influence self-report in the insomnia population (Stepanski, only found one measure that indicated significant secondary ben-
2000). The effect sizes found in the present study (see Table 2), efits from CBT treatment relative to SMW. The overall analysis
along with those observed in the previous studies, indicate that found an interaction effect between groups, and Table 3 shows
efficacy levels are generally on par with those reported in studies several trends with other measures. However, only the interference
testing CBT with primary insomnia (see meta-analysis by Morin et item from the SII showed significant differences on follow-up
al., 1994). Even the lack of a significant difference in increased analyses. The crossover group confirmed the same improvement in
total sleep time for the present study (32 min for CBT vs. 26 min SII interference and also showed an additional benefit for the SIP
for SMW) should be viewed in light of the significant time effect Social Behavior subscale. The fact that additional significant in-
for both groups and the fact that sleep gains rarely exceed 30 – 45 teractions were not obtained is likely related to the fact that some
min in either behavioral or drug therapy studies for primary participants in the SMW group had improved sleep and some in
insomnia (Morin, 2003). Overall, these recent treatment studies of the CBT group did not have improved sleep, thereby narrowing the
secondary and comorbid insomnia pose a significant challenge to differences between groups on the secondary measures. In addi-
the conventional view that these insomnias are either inappropriate tion, the particular area of daytime benefit is likely to vary across
or less appropriate for behavioral treatment (Mendelson & Jain, individuals, such that a global measure (i.e., SII interference) that
1995; National Institutes of Health, 1991). inquires about a broad array of potential benefits (e.g., daytime
The unexpected finding of the study was that, contrary to fatigue, ability to function at work or daily chores, concentration,
hypothesis, the type of chronic disease condition did not have an memory, mood), is likely to be more responsive to group changes.
impact treatment response, indicating that all three conditions This partial support for daytime benefits following successful
responded uniformly well to CBT treatment. It was hypothesized treatment of insomnia is notable given that a wide range of
that the COPD group would benefit least from treatment because non-intervention studies have shown a strong correlation between
of the large portion of insomnia in this population that was likely insomnia and daytime functioning in adults (Zammit, Weiner,
to be predetermined by medical factors (e.g., arousals and in- Damato, Sillup, & McMillan, 1999), older adults (Stein & Barrett-
creased wakefulness related to hypercapnia and steroid or bron- Connor, 2002), and adults with chronic illness (Katz & McHorney,
chodilator medication side effects). As can be seen in Figure 2, the 2002). However, thus far only three intervention studies have
rate of change in sleep efficiency was not different across the OA, found secondary benefits in these areas when insomnia was alle-
CAD, and COPD groups. This unexpected finding has significant viated (Morgan et al., 2003; Quesnel et al., 2003; Rybarczyk et al.,
implications for insomnia treatment and diagnosis. It appears to be 2005). The absence of consistent findings in this area may indicate
a significant disservice to patients with chronic illness to continue that the relationship between insomnia and quality of life is more
to assume that behavioral treatments would be ineffective because complicated than hypothesized or that direct improvements in
of the presence of medical conditions and their sequelae. In addi- quality of life may only occur in certain individuals with specific
tion, from both a theoretical and diagnostic system perspective, the types of medical issues. Future research will need to address this
dichotomy between primary and secondary insomnia needs to be issue with more fine-grained analyses, examining longer-term
reconsidered. outcomes.
Although not entirely equal to the active treatment, the SMW There are several limitations to the present study that need to be
program had high levels of credibility and appears to have been an considered. First, the aim of the study was to examine the short-
effective placebo control condition. SMW had mean treatment term benefits of CBT compared with a placebo control, with no
plausibility ratings of 71 out of a possible 100 after the second comparisons for longer term effects. Studies have consistently
class, and ratings that were not significantly different than CBT for demonstrated that initial CBT treatment effects are durable up to
three of four individual items of the ITEQ. In addition, attrition 1-year posttreatment for primary, secondary, and comorbid insom-
rates were very low and identical for both treatment conditions nias in older adults (Currie et al., 2000; Lichstein et al., 2000;
(i.e., n ⫽ 2), suggesting that participants were highly satisfied with Morin et al., 1999; Rybarczyk et al., 2002). As a result, we did not
the quality of both treatment programs. view follow-up measurement as essential for testing the hypothe-
Two inferences can be made from overall sleep efficiency ses of the present study. Nonetheless, it is conceivable that the
improvement of 4.3% in the SMW group compared with 13.1% in unique characteristics of participants in this study affected the
CBT FOR COMORBID INSOMNIA IN OLDER ADULTS 1173

durability of the treatment effect. A second arguable weakness of Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J.
the study was the lack of equal group sizes across the three (1989). The Pittsburgh Sleep Quality Index: A new instrument for
diseases. Although equal group sizes were initially planned for the psychiatric practice and research. Psychiatry Research, 28, 193–213.
study, this plan was modified because of the difficulties in recruit- Currie, S. R., Wilson, K. G., Pontefract, A. J., & deLaplante, L. (2000).
ing COPD participants and preliminary analyses showing no trend Cognitive– behavioral treatment of insomnia secondary to chronic pain.
toward reduced efficacy of CBT within this group (see Figure 2). Journal of Consulting and Clinical Psychology, 68, 407– 416.
Davies, R., Lacks, P., Storandt, M., & Bertelson, A. D. (1986). Counter-
Third, the inclusion of measures of compliance with the various
control treatment of sleep-maintenance insomnia in relation to age.
facets of CBT (see Lichstein et al., 2000) would have helped
Psychology and Aging, 1, 233–238.
determine which components were accepted and practiced by Derogatis, L. R., & Nelisaratos, N. (1983). The Brief Symptom Inventory:
participants. Similarly, measures of treatment fidelity have been An introductory report. Psychological Medicine, 13, 595– 605.
included in recent CBT insomnia studies (e.g., Lichstein et al., Edinger, J. D., Hoelscher, T. J., Marsh, G. R., Lipper, S., & Ionescu-
2000) and would have added additional rigor to the present study. Pioggia, M. (1992). A cognitive– behavioral therapy for sleep-
Finally, the findings reported would have been further strength- maintenance insomnia in older adults. Psychology and Aging, 7, 282–
ened by pre- and posttreatment measurement of objective poly-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

289.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

somnographic data, which has long been considered the gold Foley, D., Ancoli-Israel, S., Britz, P., & Walsh, J. (2004). Sleep distur-
standard in hypnotic intervention studies and recently has become bances and chronic disease in older adults: Results of the 2003 National
a common feature in controlled clinical trials of behavioral inter- Sleep Foundation Sleep in America Survey. Journal of Psychosomatic
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Kabat-Zinn, J., Lipworth, L., Burney, R., & Sellers, W. (1987). Four-year
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