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
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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-
nia have demonstrated the efficacy of behavioral interventions,
with outcomes that are comparable with those obtained with
younger adults (Morin, Culbert, & Schwartz, 1994; Murtagh &
Greenwood, 1995). These interventions have included restriction
of time spent in bed (Davies, Lacks, Storandt, & Bertelson, 1986),
stimulus control (Puder, Lacks, Bertelson, & Storandt, 1983), and
multicomponent cognitive– behavioral treatments (CBT), which
typically combine sleep restriction, stimulus control, relaxation
training, and sleep hygiene (Edinger, Hoelscher, Marsh, Lipper, &
Ionescu-Pioggia, 1992; Morin, Colecchi, Stone, Sood, & Brink,
1999; Morin, Kowatch, Barry, & Walton, 1993). The multicom-
ponent CBT studies have yielded effect sizes that are 20% greater
than single component treatments (Morin et al., 1994) and, as a
result, they have become the standard in intervention research for
the past several years.
CBT for insomnia was originally developed as a treatment of
primary insomnia. Individuals with insomnia comorbid with a
medical condition were considered inappropriate for CBT. The
assumption was that such insomnias usually had medical causes
Bruce Rybarczyk, Edward Stepanski, Louis Fogg, and Paulette Barry,
Department of Behavioral Sciences, Rush University Medical Center;
Martita Lopez, Department of Psychology, University of Texas at Austin;
Andrew Davis, Department of Medicine, University of Chicago.
This research was supported by National Institute on Aging Grant
AG17491-02 to Bruce Rybarczyk.
Correspondence concerning this article should be addressed to Bruce
Rybarczyk, Department of Behavioral Sciences, Rush University Medical
Center, 1653 West Congress Parkway, Chicago, IL 60612. E-mail:
brybarcz@rush.edu
1164
and that the best approach to the insomnia was to treat the medical
condition. However, this dichotomy between primary and second-
ary insomnia fails to take into account the fact that insomnias are
often triggered by multiple factors, both behavioral and medical. It
is very difficult to make a reliable diagnostic distinction between
primary and secondary insomnia (American Psychiatric Associa-
tion, 1994) because of the problem of identifying specific cause
and effect factors (Lichstein, Wilson, & Johnson, 2000; Ohayon,
1997). In addition, behavioral factors (e.g., variable bed and wake
times, daytime napping, using the bed for activities other than
sleep) frequently amplify and perpetuate insomnia, irrespective of
the initial cause. Accordingly, the present study uses the term
comorbid insomnia rather than secondary insomnia because of the
difficulty of making an etiologic determination. Furthermore, our
assumption is that the majority of comorbid insomnias, regardless
of contributing medical factors, include behavioral and psycholog-
ical factors that could respond to CBT.
There have been several recent studies of multicomponent CBT
for secondary or comorbid insomnia. A study with 60 chronic pain
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, &
deLaplante, 2000). These therapeutic gains were essentially main-
tained at the 3-month follow-up. A study of CBT with 10 women
with nonmetastatic breast cancer, using a multiple baseline design,
found self-report and polysomnography improvements in sleep
efficiency and total wake time (Quesnel, Savard, Simard, Ivers, &
Morin, 2003). In another CBT study with 44 older adults with
insomnia secondary to a range of medical or psychiatric illnesses,
participants in the treatment group reported significantly greater
improvement on wake time during the night, sleep efficiency
 CBT FOR COMORBID INSOMNIA IN OLDER ADULTS
percentage, and sleep quality rating when compared with a delayed
treatment control group (Lichstein et al., 2000). These gains were
maintained at the 3-month follow-up. Taken together, these studies
suggest that CBT is effective with secondary insomnia.
These findings were supported and extended in two recent CBT
studies by Rybarczyk and colleagues (Rybarczyk, Lopez, Benson,
Alsten, & Stepanski, 2002; Rybarczyk, Lopez, Schelble, & Stepan-
ski, 2005). In the first study, Rybarczyk et al. (2002) randomized
24 older adults who had insomnia that was comorbid with a range
of chronic medical conditions to either classroom CBT or delayed
treatment. Compared with no treatment, CBT led to significantly
greater improvement on several self-report measures of sleep at a
4-month follow-up, including sleep efficiency, time awake after
sleep onset, and global sleep ratings. The second study by Ryba-
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rczyk et al. (2005) presented data on an additional group of 12
participants randomized to CBT home treatment, composed of
videos of classroom treatment and phone consultation. This group
had results that were comparable with in-person classroom CBT
reported in the first study.
If the findings demonstrating the efficacy of CBT for comorbid
insomnia in older adults are further corroborated, it would have
important treatment implications for a large segment of the older
adult population. Lichstein (2000) has estimated that 70% of the
insomnia found among older adults can be qualified as secondary
insomnia. Furthermore, older adults with secondary insomnia are
more likely to have daytime consequences and quality of life
effects from their insomnia compared with older adults with pri-
mary insomnia (Katz & McHorney, 1998; Lichstein, Durrence,
Bayen, & Riedel, 2001). Thus, it could be hypothesized that
treatment of comorbid insomnia would produce more significant
quality of life benefits.
The primary goal of the present study was to extend this re-
search by testing whether CBT would outperform a placebo treat-
ment of comorbid insomnia. None of the previous comorbid or
secondary insomnia intervention studies have used a placebo con-
trol condition. A placebo treatment group is considered ideal for
insomnia treatment research to control for inherent demand char-
acteristics and expectancy effects (Stepanski, 2000). For our pla-
cebo treatment, we used a classroom stress management and
wellness (SMW) program developed specifically for older adults
with chronic illness (Rybarczyk, DeMarco, DeLaCruz, Lapidos, &
Fortner, 2001). The rationale presented to SMW participants was
that this program was a potential treatment for insomnia, on the
grounds that sleep, stress, and mind– body wellness were interre-
lated and reciprocal in their effects. In contrast to some placebo
control groups, which contain no active treatments, the SMW
group used in the present study has demonstrated self-report cop-
ing and wellness benefits in this population. Thus, SMW was able
to provide some nonsleep benefits to participants, contributing to
high credibility and low attrition. To avoid any confound with the
relaxation training component of CBT, we removed relaxation
training as an active treatment component in the SMW class.
The second goal of the study was to test the differential efficacy
of CBT for older adults with one of three chronic medical condi-
tions: osteoarthritis (OA), coronary artery disease (CAD), or
chronic obstructive pulmonary disease (COPD). All three are
common age-related diseases and are linked to high rates of
insomnia (Foley, Ancoli-Israel, Britz, & Walsh, 2004; Katz &
McHorney, 1998). Based on the likely medical causes of insomnia
1165
that would remain after behavioral causes are alleviated, we hy-
pothesized that COPD patients would obtain the smallest benefit
from behavioral treatment, followed by CAD and then OA. COPD
has several potent medical factors that can cause secondary insom-
nia (i.e., respiratory problems, medication side effects) that are
similar to those found in CAD, but the respiratory problems and
medication side effects are known to be more severe in nature.
COPD was also chosen because it represented an ideal group for
testing the hypothesis that sleep can be modified with behavioral
methods even when many fixed medical causes of insomnia are
likely to be present.
A final hypothesis was that sleep improvements would have a
significant impact on the daytime functioning of participants.
Morin (2003) has argued that since insomnia has been associated
with significant morbidity and quality of life effects, effective
treatments should not only produce changes in sleep parameters
but also other measures of daytime functioning. As such, we used
a range of secondary dependent measures, including mood, fa-
tigue, concentration, and general quality of life. A pain measure
was also included, with OA participants as the principal target, as
higher pain levels have been linked to episodes of insomnia in OA
patients (Moldofsky, 1989). Thus far, only three CBT intervention
studies have demonstrated such secondary benefits (Morgan,
Dixon, Mathers, Thompson, & Tomeny, 2003; Quesnel et al.,
2003; Rybarczyk et al., 2005).
Method
Design
A block randomization procedure was used to assign participants to the
following two different 8-week classroom treatment programs: CBT or an
SMW treatment. Once a group of at least 5 participants completed pre-
treatment assessment in a given week, the block of participants who
completed pretreatment assessment by the end of that week were randomly
assigned to one of the two treatment conditions. The treatment condition
was assigned using a random order generated at the onset of the study. The
study personnel who were in contact with potential participants for tele-
phone and home polysomnographic screening were not aware of the next
treatment condition. Study participants were aware that they would be
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
find out which one they were receiving until they attended the first class.
All participants completed a 2-week sleep log and other questionnaires
within 4 weeks of the start of treatment and an identical posttreatment
assessment within 4 weeks of completion of the treatment. After SMW
participants completed the treatment, they were offered the opportunity to
cross over to CBT treatment if their insomnia still met study criteria. The
study protocol was approved by the Rush University Medical Center
institutional review board and all participants gave written informed con-
sent at the time of enrollment.
Participants
Participants were recruited between January 2001 and October 2003
either by flyers placed in medical offices and senior centers or by letters
mailed to lists of individuals identified as having one of the three medical
conditions. These lists were obtained from physician practices or disease-
related support organizations. Participants were paid up to $200, based on
how much of the protocol they completed.
Potential volunteers who contacted the study were initially screened by
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-
ment Scales-(AIMS2; Meenan, Mason, Anderson, Guccione, & Kazis,
1992). One exception was made for an OA participant who reported mild
pain but had the highest possible AIMS2 scores for the number of joints
that are painful and the degree of joint stiffness. To meet criteria for CAD
or COPD, participants needed to have been diagnosed by a physician, using
objective diagnostic testing, and be under current treatment for that con-
dition. For the CAD group, 78% of these participants reported that they had
undergone angioplasty or coronary artery bypass surgery. Fourteen partic-
ipants (7 in both CBT and SMW) had more than one of the three medical
diagnoses.
Thirty-six of the 44 SMW participants who completed treatment con-
tinued to have sleep problems that qualified them for the study and were
offered the opportunity to cross over to CBT treatment after posttreatment
assessment. Of these, 26 began CBT treatment and 23 completed the
treatment. The two primary reasons for not crossing over were schedule
conflicts and not wanting to participate in another class.
Measures
Sleep log. The sleep logs were paper-and-pencil records that were
completed by participants each morning for 2 weeks at pretreatment
(during the month prior to treatment) and posttreatment (during the month
after treatment ended). They were also completed on a weekly basis during
the CBT class. The logs included sleep latency, awakenings (quantity and
duration), time in bed, naps, and any medication used for sleep.
Pittsburgh Sleep Quality Index (PSQI). The PSQI (Buysse, Reynolds,
Monk, Berman, & Kupfer, 1989) is a self-rated questionnaire that assesses
sleep quality during the past month. Nineteen individual items lead to
seven component scores: subjective sleep quality, sleep latency, sleep
duration, habitual sleep efficiency, sleep disturbances, use of sleeping
medication, and daytime dysfunction (i.e., level of sleepiness and enthu-
siasm). The sum of scores for these seven subscales yields one global score
of overall sleep quality.
Sleep Impairment Index (SII). The SII is a 7-item measure (Morin et
al., 1999) that yields a global score of sleep impairment. Respondents rate
the following components on a 5-point Likert scale: (a) severity of sleep
onset, sleep maintenance, and early morning awakening problems (3
items); (b) satisfaction with current sleep pattern; (c) interference with
daily functioning (e.g., daytime fatigue, ability to function at work or daily
chores, concentration, memory, mood); (d) how noticeable the impairment
attributed to a sleep problem is to others; and (e) level of distress caused by
the sleep problem. This scale has good internal validity and appropriate
test–retest reliability over a 2-week interval. Scores vary between 1 and 5
(higher scores equal greater levels of impairment). The interference item
was also used as a secondary measure because of the fact that it serves as
a global measure of daytime functioning.
Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS). The
DBAS (Morin, 1993) is a 30-item scale designed to measure various
beliefs, attitudes, expectations, and attributions about sleep and insom-
nia. These cognitions involve five conceptually derived themes: misat-
tributions or amplification of the consequences of insomnia, diminished
perception of control and predictability of sleep, unrealistic sleep ex-
pectations, misconceptions about the causes of insomnia, and faulty
beliefs about sleep promoting practices. Items include a 3-in. (7.62-cm)
visual analog scale, with strongly disagree and strongly agree descrip-
tors at each end of the scale. The DBAS has demonstrated adequate
reliability and validity (Morin, Stone, Trinkle, Mercer, & Remsberg,
1993).
The Profile of Mood States (POMS). The POMS (McNair, Lorr, &
Droppleman, 1971) is a 65-item self-report measure of affective states for
the past week. Patients are asked to rate their current mood on a 5-point
Likert scale ranging from not at all to extremely. The instrument consists
of six subscales for the dimensions of vigor, tension, depression, anger,
fatigue, and confusion. It has good test–retest reliability, predictive con-
struct, and concurrent validity (McNair et al., 1971). The POMS total mood
disturbance score, which does not include the Vigor subscale, can be used
as an overall indicator of distress.
Geriatric Depression Scale (GDS). The GDS (Brink et al., 1982) was
developed specifically for use with older adults and uses a simple “yes/no”
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
confounding of depressive and age-related medical illness symptoms.
The SF-36. The SF-36 (Ware, Kosinski, & Keller, 1994) is a 36-item
scale designed to assess the following eight health concepts: physical
functioning, role limitations due to physical health problems, social func-
tioning, general mental health, role limitations due to emotional problems,
general health perceptions, vitality, and bodily pain. The SF-36 has dem-
onstrated adequate reliability and validity. Physical and mental component
scores have shown good validity as summary scores (Ware et al., 1994).
Sickness Impact Profile (SIP): Somatic Autonomy and Social Behavior
subscales. Patients’ ratings of their functional level were assessed using
the 17-item Somatic Autonomy subscale and the 11-item Social Behavior
subscale from the SIP (Bergner, Bobbitt, Carter, & Gilson, 1981). The
Somatic Autonomy subscale measures activities of daily living such as
transferring and eating. The Social Behavior subscale assesses daily social
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activities such as hobbies, social and community activities, and house-
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work. These two subscales were included to assess dimensions of func-
tional status not addressed by the SF-36.
Short-Form McGill Pain Questionnaire (SF-MPQ). The SF-MPQ was
designed to be a brief version of the long-form MPQ (Melzack, 1987),
which has been widely used in the measurement and study of pain. The
SF-MPQ has been shown to correlate highly with the standard MPQ and to
be sensitive to pain management interventions. For the present study, the
total score was used.
Insomnia Treatment Evaluation Questionnaire (ITEQ). The ITEQ was
developed by Mimeault and Morin (1999) for measuring insomnia treat-
ment plausibility. Using an 85-mm visual analog scale ranging from 0 (not
at all) to 85 (very much), participants rated the following about the
treatment: (a) if the rationale made sense, (b) how acceptable the treatment
was for them, (c) suitability for their sleep problems, and (d) expected
effectiveness for their sleep problems. Scores were then converted to a
100-point scale for ease of interpretation. Individual item scores as well as
a total score were calculated. This measure was administered at the end of
the second treatment class.
Interventions
Each intervention program consisted of eight weekly 2-hr classes
matched in as many characteristics as possible (e.g., location, experience
level and skill of instructors, amount of group discussion and question-
and-answer time, number and quality of handouts, use of computerized
presentations, refreshments, certificates given out at the end of the pro-
gram) There were 22 groups, averaging 5 members per group (including
crossovers). All classes were conducted at an academic medical center in
downtown Chicago, IL. Transportation was paid for by the study to
facilitate participation of individuals at all income levels. Participants who
missed a class were given make-up classes for up to two missed sessions.
CBT. The intervention protocol closely followed Morin’s (1993) in-
somnia treatment protocol, with the exception of an added relaxation
training component. The CBT sessions were led by two clinical psychol-
ogists experienced in CBT treatment of insomnia. Each session included a
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.
The main behavioral components, stimulus control (Bootzin & Nicassio,
1978) and sleep restriction (Spielman, Saskin, & Thorpy, 1987), were
introduced and emphasized during the first three sessions. A strict schedule
of bedtimes and arising times was prescribed to consolidate sleep and
decrease time spent awake during the night. Patients initially reduced their
time in bed to the amount of time they were actually sleeping according to
their pretreatment sleep logs, but not less than 4.5 hr. Sleep logs were
completed continuously during treatment and the bedtime was moved
earlier by a maximum of one half hour each week if there was sufficient
improvement in sleep efficiency, usually defined as achieving 85% sleep
efficiency. Participants were also instructed to lie awake in bed no longer
than 15 min, at which time they were to go to another room, engage in a
nonstimulating task in a dimly lit room, and return to the bed only when
they felt sleepy again. No activities were permitted in bed other than sleep
and sex.
The third component to be introduced was cognitive restructuring, which
emphasized changing unrealistic beliefs and irrational fears regarding sleep
or loss of sleep. The fourth component was relaxation training, designed to
decrease anxiety and reduce cognitive and physiological arousal at bed-
time. Each participant was given a relaxation audiotape that included the
following four commonly used modalities: deep breathing, progressive
muscle relaxation, autogenic training, and imagery. A final component of
the intervention was sleep-hygiene education, including the use of in-
creased daytime bright light exposure to address any circadian causes of
insomnia. Topics included increasing natural light exposure, daytime ac-
tivity and exercise, reducing caffeine and alcohol intake, keeping an
appropriate bedroom temperature, reducing ambient noise in the bedroom,
using warm baths in the evening, and using appropriate food choices and
eating patterns.
SMW treatment. The SMW treatment, adapted from Rybarczyk et al.
(2001), consisted of didactic presentations and corresponding skill training
covered the following six topics: (a) the mind– body relationship, (b)
modifying self-talk for the reduction of stress and anxiety, (c) effective
communication and assertiveness, (d) problem solving and goal setting, (e)
nutrition, and (f) exercise for individuals with chronic conditions. Topics 1
and 2 (which were covered over four separate class sessions) were pre-
sented by a physician with extensive training and speaking experience
regarding mind– body health, Topics 3 and 4 by were presented by psy-
chologists, and Topics 5 and 6 were presented by an expert nutritionist and
exercise physiologist.
At the beginning of the SMW class, participants were given a presen-
tation of a treatment rationale based on the common public perception of
an interrelationship between sleep problems and stress, nutrition, and
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
breath awareness, which is one of several components of a mindfulness
meditation intervention (Kabat-Zinn, Lipworth, Burney, & Sellers, 1987).
Providing a quasi-relaxation training procedure was deemed essential to
increasing the credibility of this program as a treatment for insomnia.
Rather than the usual intensive training that typically accompanies mind-
fulness meditation interventions, participants were given brief instruction
on paying attention to their breathing rhythm as a means of detaching from
the stressful events at hand. This technique was chosen due to the fact that
it seems plausible yet had no proven efficacy as a stand-alone relaxation
intervention. Apart from the simplistic rationale for the intervention and a
quasi-relaxation procedure that was intended to be an inactive treatment,
the remainder of the material presented in SMW treatment was a state-of-
the-art and empirically based intervention for improving emotional and
physical well-being (Rybarczyk et al., 2001). The presenters understood
that, apart from the mindfulness training, their intervention was to be the
best possible active treatment for wellness and stress reduction.
Statistical Analyses
The 4 participants (2 each from CBT and SMW) who dropped out of
treatment after randomization were included in the primary analyses, by
replicating their sleep data from pretreatment measurement to posttreat-
ment. To limit Type I errors, the initial statistical test was a multivariate
analysis of covariance (MANCOVA) for the following two factors: treat-
ment (CBT, SMW) and the repeated factor of time (pretreatment and
posttreatment measurement). To estimate possible effects for the 22 spe-
cific classes, an initial nested multivariate analysis of variance
(MANOVA) was conducted with class nested within treatment group. If
 CBT FOR COMORBID INSOMNIA IN OLDER ADULTS
the class effects were nonsignificant, they were excluded from subsequent
analyses. The three medical diagnosis (OA, CAD, COPD) were dummy-
coded (0 ⫽ present, 1 ⫽ absent) and entered into the model as separate
covariates. In this way, it is possible to test and correct for both the simple
effects for each of the diagnoses as well as the effects of multiple diag-
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
whether the number of medical comorbidities affected response to treat-
ment. If there was no significant Diagnosis ⫻ Time interactions or Medical
Comorbidity ⫻ Time interactions, then the covariates were removed from
subsequent analyses. When there was a significant overall Treatment ⫻
Time interaction effect, separate analyses of variance (ANOVAs) were
conducted for each variable.
The analyses described above were applied to both the sleep measures
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and the secondary measures. The secondary measures were reduced to
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eight measures by using the POMS and SF-36 summary scores. Analyses
for the SMW to CBT crossovers used a repeated measures MANOVA
followed by a paired sample t test on individual sleep measures and the
eight secondary measures. Finally, ANOVAs were conducted for the total
of the ITEQ as well as the individual items, comparing treatment plausi-
bility for the two groups.
The clinical significance of the treatment outcomes was also calculated
and compared across groups. The most commonly used and recommended
measure of clinical significance in randomized trials of insomnia treatment
is a normative comparison method (Morin, 2003). We used Lichstein et
al.’s (2000) method of comparing the data with established norms for
self-reported sleep efficiency (i.e., M ⫽ 86.1, SD ⫽ 9.7; Lichstein, 1997).
With this method, there are three different categories of clinically signif-
icant change. For all three categories sleep efficiency must improve by at
least 0.5 SD of the norm (i.e., 4.85%). If that criterion is met and the
individual’s posttreatment sleep efficiency is equal to or greater than the
mean of the normative group then there is clinically significant improve-
ment. If the posttreatment sleep efficiency does not reach the mean but is
within 1 SD of the mean of the normative group, it is classified as
moderately clinically significant improvement. Finally, to recognize indi-
viduals who make very large gains in sleep efficiency but were very low at
pretreatment, there is a third category of substantial improvement. This is
achieved when an individual’s sleep efficiency improves by at least two
SDs of the norm (i.e., 19.4%).
Results
Treatment Plausibility
The ITEQ (Mimeault & Morin, 1999), administered to partici-
pants after the second class, was used to assess treatment plausi-
bility ratings for the two treatment groups. Twenty participants had
missing ITEQ data. Reasons for missing data included the follow-
ing: the questionnaire inadvertently not being administered to the
participant’s class (n ⫽ 8), not being present at the second class
when the questionnaire was administered (n ⫽ 6), withdrawing
from the study prior to the second class (n ⫽ 3), and the ques-
tionnaire not being completed properly (n ⫽ 3).
Both treatment groups had mean scores which indicated a high
level of agreement (maximum rating of agreement ⫽ 100) for the
total score (CBT ⫽ 79, SMW ⫽ 71) and the following four
individual ITEQ items: how much sense the treatment rationale
made (CBT ⫽ 81, SMW ⫽ 75), the acceptability of the treatment
(CBT ⫽ 81, SMW ⫽ 74), the suitability of the treatment for their
sleep problem (CBT ⫽ 75, SMW ⫽ 63), and expectation for how
effective the treatment was going to be for their sleep problem
(CBT ⫽ 80, SMW ⫽ 72). The ANOVA indicated a treatment
1169
group difference for total score, F(1, 70) ⫽ 3.69, p ⫽ .059, and the
suitability item, F(1, 70) ⫽ 3.99, p ⫽ .05. There were no signif-
icant differences for the rationale item, F(1, 70) ⫽ 1.80, p ⫽ .184,
the acceptability item, F(1, 70) ⫽ 2.08, p ⫽ .154, and the expec-
tation item, F(1, 70) ⫽ 2.42, p ⫽ .124.
Log and Self-Report Sleep Measures
Table 2 provides a summary of pretreatment and posttreatment
means and standard deviations for the self-report sleep measures
along with F for Treatment ⫻ Time analyses and Cohen’s d effect
sizes (indicating the effect of CBT relative to SMW). There were
no significant differences between the two treatment groups on any
baseline measure ( ps ⱖ .10), and there were no significant differ-
ences between the three chronic disease groups for sleep efficiency
at baseline ( p ⬎ .10).
The two-factor (Treatment ⫻ Time) MANCOVAs revealed no
significant effects for any of the three medical diagnoses or the
number of medical comorbidities, so both types of covariates were
dropped from later analyses. In addition, there were no class
effects found for the nested MANOVA, resulting in the class
variable being excluded from subsequent analyses. The subsequent
repeated measures MANOVA indicated a significant Treatment ⫻
Time interaction across the 10 sleep measures in Table 2, F(10,
72) ⫽ 4.13, p ⬍ .001. Individual repeated measures ANOVAs
indicated differential improvement in the CBT group relative to
the SMW group at posttreatment for the following sleep variables:
sleep efficiency, F(1, 90) ⫽ 12.33, p ⬍ .001, sleep latency, F(1,
90) ⫽ 8.89, p ⬍ .01, time awake after sleep onset, F(1, 90) ⫽ 7.16,
p ⬍ .01, time in bed, F(1, 90) ⫽ 15.77, p ⬍ .001, number of naps,
F(1, 90) ⫽ 4.54, p ⬍ .05, PSQI global sleep score, F(1, 85) ⫽
12.66, p ⬍ .001, SII total score, F(1, 86) ⫽ 22.64, p ⬍ .001, and
DBAS total score, F(1, 85) ⫽ 23.26, p ⬍ .001. Figure 2 illustrates
the changes in sleep efficiency of the three different chronic
disease CBT groups and the SMW group with all chronic diseases
groups combined. Although there was no significant interaction for
total sleep time, there was a significant effect for time across both
groups, F(1, 90) ⫽ 20.18, p ⬍ .001.
Clinical Significance of Sleep Changes at Posttreatment
The clinical significance outcomes were as follows: the CBT
group had 10 no improvements, 23 clinically significant improve-
ments, 11 moderately clinically significant improvements, and 2
substantial improvements; and the SMW group had 35 no im-
provements, 7 clinically significant improvements, and 4 moder-
ately clinically significant improvements. When combining the
three clinical improvement categories together, CBT had an over-
all rate of 78% clinically significant change compared with 24%
for SMW. The two treatment groups were significantly different
from each other in the overall rate of significant change, ␹2 (1, N ⫽
92) ⫽ 27.7, p ⬍ .001.
Secondary Measures
In addition to the four individuals who dropped out of the study,
there were 4 participants who failed to complete either the pre-
treatment or posttreatment GDS or SIP as well as 5 participants
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)
MANCOVAs revealed no significant effects for any of the three
medical diagnoses or the number of medical comorbidities, so both
types of covariates were dropped from subsequent analyses. The
MANOVA for the eight secondary measure variables, using the
POMS and SF-36 summary scores, yielded a significant Treat-
ment ⫻ Time interaction effect, F(8, 71) ⫽ 2.08, p ⬍ .05.
Follow-up ANOVAs for individual variables indicated only a
significant Time ⫻ Treatment interaction for the SII interference
item, F(1, 86) ⫽ 8.20, p ⬍ .01. One additional subanalysis ad-
dressed the hypothesis that treating OA participants’ insomnia
would reduce their pain. A repeated measures ANOVA found no
Time ⫻ Treatment effect for the MPQ measure. Table 3 presents
the findings for the eight secondary variables for all participants.

Sleep and Secondary Measures for SMW Participants

Figure 2. Sleep efficiency (mean and standard error) at pretreatment and
posttreatment for the three diagnostic groups treated with cognitive–
behavioral therapy (CBT) compared with all stress management and well-
ness training (SMW) participants. COPD ⫽ chronic obstructive pulmonary
disease; OA ⫽ osteoarthritis; CAD ⫽ coronary artery disease.
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.
Discussion
The findings from the present study indicate that a standard
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
treatment efficacy rate was 78% for CBT compared with only 24%
for SMW. In addition, the greater efficacy of CBT was further
reinforced by the fact that the 26 participants who crossed over to
CBT following SMW treatment significantly improved on 6 out of
10 sleep measures. Also notable were the moderate to large Co-
hen’s d effect sizes (see Table 2), which represent the effects after
controlling for placebo treatment.
These overall findings add to the recently published studies
showing high levels of efficacy for behavioral treatments that
target secondary and comorbid insomnias (Currie et al., 2000;
Lichstein et al., 2000; Quesnel et al., 2003; Rybarczyk et al.,
2002). Furthermore, the results of the present study go beyond the
findings of the previous studies by being the first to use a placebo
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control group that controlled for expectancy and demand effects
that influence self-report in the insomnia population (Stepanski,
2000). The effect sizes found in the present study (see Table 2),
along with those observed in the previous studies, indicate that
efficacy levels are generally on par with those reported in studies
testing CBT with primary insomnia (see meta-analysis by Morin et
al., 1994). Even the lack of a significant difference in increased
total sleep time for the present study (32 min for CBT vs. 26 min
for SMW) should be viewed in light of the significant time effect
for both groups and the fact that sleep gains rarely exceed 30 – 45
min in either behavioral or drug therapy studies for primary
insomnia (Morin, 2003). Overall, these recent treatment studies of
secondary and comorbid insomnia pose a significant challenge to
the conventional view that these insomnias are either inappropriate
or less appropriate for behavioral treatment (Mendelson & Jain,
1995; National Institutes of Health, 1991).
The unexpected finding of the study was that, contrary to
hypothesis, the type of chronic disease condition did not have an
impact treatment response, indicating that all three conditions
responded uniformly well to CBT treatment. It was hypothesized
that the COPD group would benefit least from treatment because
of the large portion of insomnia in this population that was likely
to be predetermined by medical factors (e.g., arousals and in-
creased wakefulness related to hypercapnia and steroid or bron-
chodilator medication side effects). As can be seen in Figure 2, the
rate of change in sleep efficiency was not different across the OA,
CAD, and COPD groups. This unexpected finding has significant
implications for insomnia treatment and diagnosis. It appears to be
a significant disservice to patients with chronic illness to continue
to assume that behavioral treatments would be ineffective because
of the presence of medical conditions and their sequelae. In addi-
tion, from both a theoretical and diagnostic system perspective, the
dichotomy between primary and secondary insomnia needs to be
reconsidered.
Although not entirely equal to the active treatment, the SMW
program had high levels of credibility and appears to have been an
effective placebo control condition. SMW had mean treatment
plausibility ratings of 71 out of a possible 100 after the second
class, and ratings that were not significantly different than CBT for
three of four individual items of the ITEQ. In addition, attrition
rates were very low and identical for both treatment conditions
(i.e., n ⫽ 2), suggesting that participants were highly satisfied with
the quality of both treatment programs.
Two inferences can be made from overall sleep efficiency
improvement of 4.3% in the SMW group compared with 13.1% in
the CBT group. First, it can be inferred from these data that the
maximum amount of self-reported sleep change that can be attrib-
uted to expectancy effects, demand characteristics, and generic
social support (i.e., placebo effects) is approximately one third of
that obtained by the actual active treatment elements of CBT. A
number of insomnia treatment studies have used a placebo control
(see Stepanski, 2000, for review), such as quasi-desensitization,
but none have used a stress management and wellness program for
this purpose. Because the SMW is an untested treatment, it is
possible that some improvement in stress levels and wellness also
led to indirect effects on sleep. As such, a second inference from
this study is that an intervention that improves daytime coping and
wellness is, at best, also about one third as effective as CBT for
treating insomnia in this population.
Contrary to hypothesis, the analyses comparing CBT with SMW
only found one measure that indicated significant secondary ben-
efits from CBT treatment relative to SMW. The overall analysis
found an interaction effect between groups, and Table 3 shows
several trends with other measures. However, only the interference
item from the SII showed significant differences on follow-up
analyses. The crossover group confirmed the same improvement in
SII interference and also showed an additional benefit for the SIP
Social Behavior subscale. The fact that additional significant in-
teractions were not obtained is likely related to the fact that some
participants in the SMW group had improved sleep and some in
the CBT group did not have improved sleep, thereby narrowing the
differences between groups on the secondary measures. In addi-
tion, the particular area of daytime benefit is likely to vary across
individuals, such that a global measure (i.e., SII interference) that
inquires about a broad array of potential benefits (e.g., daytime
fatigue, ability to function at work or daily chores, concentration,
memory, mood), is likely to be more responsive to group changes.
This partial support for daytime benefits following successful
treatment of insomnia is notable given that a wide range of
non-intervention studies have shown a strong correlation between
insomnia and daytime functioning in adults (Zammit, Weiner,
Damato, Sillup, & McMillan, 1999), older adults (Stein & Barrett-
Connor, 2002), and adults with chronic illness (Katz & McHorney,
2002). However, thus far only three intervention studies have
found secondary benefits in these areas when insomnia was alle-
viated (Morgan et al., 2003; Quesnel et al., 2003; Rybarczyk et al.,
2005). The absence of consistent findings in this area may indicate
that the relationship between insomnia and quality of life is more
complicated than hypothesized or that direct improvements in
quality of life may only occur in certain individuals with specific
types of medical issues. Future research will need to address this
issue with more fine-grained analyses, examining longer-term
outcomes.
There are several limitations to the present study that need to be
considered. First, the aim of the study was to examine the short-
term benefits of CBT compared with a placebo control, with no
comparisons for longer term effects. Studies have consistently
demonstrated that initial CBT treatment effects are durable up to
1-year posttreatment for primary, secondary, and comorbid insom-
nias in older adults (Currie et al., 2000; Lichstein et al., 2000;
Morin et al., 1999; Rybarczyk et al., 2002). As a result, we did not
view follow-up measurement as essential for testing the hypothe-
ses of the present study. Nonetheless, it is conceivable that the
unique characteristics of participants in this study affected the
 CBT FOR COMORBID INSOMNIA IN OLDER ADULTS
durability of the treatment effect. A second arguable weakness of
the study was the lack of equal group sizes across the three
diseases. Although equal group sizes were initially planned for the
study, this plan was modified because of the difficulties in recruit-
ing COPD participants and preliminary analyses showing no trend
toward reduced efficacy of CBT within this group (see Figure 2).
Third, the inclusion of measures of compliance with the various
facets of CBT (see Lichstein et al., 2000) would have helped
determine which components were accepted and practiced by
participants. Similarly, measures of treatment fidelity have been
included in recent CBT insomnia studies (e.g., Lichstein et al.,
2000) and would have added additional rigor to the present study.
Finally, the findings reported would have been further strength-
ened by pre- and posttreatment measurement of objective poly-
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
somnographic data, which has long been considered the gold
standard in hypnotic intervention studies and recently has become
a common feature in controlled clinical trials of behavioral inter-
ventions (Morin, 2003). However, because insomnia is essentially
a subjective experience and objective measures are not required for
diagnosis, treatment success can and should be determined primar-
ily by self-report data. When self-report measures are the only
outcome measure, as in the present study, it is highly desirable to
use polysomnography to screen out other sleep disorders and to
use a placebo control group to control for the expectancy and
demand effects in treatment studies (Stepanski, 2000).
In summary, contrary to conventional thinking, the self-report
data from this study support the recent findings that CBT treatment
for insomnia is effective with older adults, even when comorbid
chronic diseases are present. Furthermore, these benefits exceed
those that are obtained by stress management and wellness train-
ing, suggesting that the effects of CBT go well beyond placebo
effects or those that can be obtained by group support or improving
coping and wellness. Although there was only one measure indi-
cating that CBT led to significant improvements in daytime func-
tioning compared with SMW, it was the only global measure of
daytime benefits from improved sleep. This suggests that such
benefits, if they are present, may vary across individuals. These
limitations notwithstanding, the overall findings have significant
treatment implications for a large segment of older adults with
comorbid insomnia.
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Received October 4, 2004
Revision received March 22, 2005
Accepted March 24, 2005 䡲