“What is exciting about these findings is that they are among the first to demonstrate that treating insomnia with a behavioral strategy, not a pill, can prevent the development of depression in older adults,” said sleep specialist Wendy Troxel, a senior behavioral scientist at RAND Corporation, who was not involved in the study.
The study’s findings are “highly significant” because major depression is very common among older adults and “is associated with an increased risk of cognitive decline, disability, suicide and all-cause mortality,” Troxel added.
Adults in the randomized clinical trial who received cognitive behavior therapy for their insomnia were two times less likely to develop depression, Irwin said, adding that if remission from insomnia was sustained for three years, “there was an 83% reduction in the likelihood of developing depression.”
“That’s why this study is so important,” Irwin said. “We have shown that we can actually target insomnia with cognitive behavior therapy and prevent depression from occurring.”
Therapist involvement was key
The study, published Wednesday in the journal JAMA Psychiatry, randomly split adults over age 60 with insomnia but without depression into two groups. Every week for two months, a control group received eight weeks of basic sleep education, which taught sleep hygiene, characteristics of healthy sleep, sleep biology, and how stress can impact sleep. But there was no one-on-one training, Irwin said: “They had to take that information and figure out how to use it without our help.”
The other group received a form of behavioral sleep training called CBT-1, administered in person in a group setting by trained therapists for eight weeks.
“The benefit of this treatment approach is that it used the most evidence-based behavioral treatment for insomnia, CBT-I, which has been proven to be as effective, longer lasting, and (have) fewer side effects than sleep medications — which can be particularly problematic in older adults,” Troxel said.
CBT-I has five components: Stimulus control, sleep restriction, sleep hygiene, relaxation and cognitive behavioral therapy. Sleep hygiene and relaxation involve good sleep habits — going to bed and getting up at the same time each day, eliminating blue light and noise, taking warm baths or doing yoga for relaxation, and keeping the bedroom cool and free of electronic devices.
Stimulus control involves “getting people to get out of bed when they’re not able to sleep,” Irwin said. Most people stay in bed, fretting about not falling asleep, which then turns the bed into a negative space, he explained. Instead, people are taught to get up after 10 minutes of tossing and turning, do quiet, non-stimulating activites, and “not to come back to bed until they are sleepy.”
Sleep restriction involves limiting time in bed to only the period a person sleeps, plus 30 minutes. It’s another way to get people with insomnia to get up instead of lying in bed awake.
Cognitive therapy works to disrupt “dysfunctional thoughts and beliefs about sleep,” Irwin said, such as “I can never sleep,” or “I might die if I don’t sleep tonight.” A therapist works with the person to counter such illogical thinking, easing them back into a more realistic mindset that will allow them to relax and see the bed as a welcoming place.
“I really think a group setting is also really important,” Irwin said, “because hearing other people’s difficulties and how they are solving them can often help inform you about something that you may be dealing with.”
A means to an end
At the end of two months, treatment ended, with no further intervention. However, the study then followed the 291 people for three years, checking in each month to ask about symptoms of depression.
The group that received CBT-I training with the help of a sleep coach often kept the training going in their own lives, Irwin said, with good results: “About a third of the people were still free of insomnia at the end of the three-year study.”
The group which received sleep education did show “modest effects in improving and treating insomnia but (the improvements) were not durable. They didn’t last,” Irwin said.
“That’s why CBT-I is so effective in person, because the therapist is helping that individual navigate and negotiate with themselves — and it can be really hard work,” Irwin added. “I believe that’s also why CBT-I apps or online tools often don’t work — people get frustrated, disappointed or angry at themselves, and they basically stop the work.”
The study’s results show “a completely new and innovative way” of tackling the growing problem of depression, wrote Pim Cuijpers, a professor of Clinical Psychology at the Vrije Universiteit Amsterdam, and Dr. Charles Reynolds, a professor in geriatric psychiatry at the University of Pennsylvania Medical Center, in an editorial published alongside the study.
“The stigma associated with major depression as a mental disorder is one of the main reasons for not seeking treatment,” wrote Cuijpers and Reynolds, who were not involved in the study.
“This major finding offers exciting new opportunities for the prevention field and opens a new field of research into indirect preventive interventions for avoiding the stigma of mental disorders.”