Disclosures: The study authors and Cuijpers report no relevant financial disclosures. Reynolds reports being coinventor of the Pittsburgh Sleep Quality Index for which he receives royalties.
December 01, 2021
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Cognitive behavioral therapy reduces depression risk in older adults with insomnia

Disclosures: The study authors and Cuijpers report no relevant financial disclosures. Reynolds reports being coinventor of the Pittsburgh Sleep Quality Index for which he receives royalties.
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Cognitive behavioral therapy for insomnia may help prevent major depression among older adults with insomnia disorder, according to results of a randomized clinical trial published in JAMA Psychiatry.

“Prevention of depression represents a paradigm shift in mental health, and effective depression prevention strategies are urgently needed to protect older adults from the risks of depression and to enhance their mental health,” Michael R. Irwin, MD, director of the Cousins Center for Psychoneuroimmunology at the University of California, Los Angeles, told Healio Psychiatry. “Few depression prevention studies have been conducted in older adults, and most trials have targeted those who are already beginning to show signs of depression. This prior research has found that treatments can reduce the severity of depressive symptoms, but not actually prevent an episode depression from occurring.”

infographic with Irwin quote

According to Irwin, past research showed insomnia was a potent risk factor for depression. Cognitive behavioral therapy for insomnia (CBT-I) has proven highly effective in treating insomnia and producing sustained remission, Irwin noted.

In the current study, Irwin and colleagues sought to determine whether treating insomnia disorder with CBT-I vs. sleep education, the active comparator condition, prevented major depressive disorder among older adults. They conducted an assessor-blinded, parallel-group, single-site randomized clinical trial that assessed a community-based sample of 431 individuals, with enrollment of 291 individuals aged 60 years or older with insomnia disorder but with no major depression or major health events in the past year (mean age, 70.1 years; 57.7% women). The researchers randomly assigned 156 participants to CBT-I and 135 participants to sleep education therapy for 2 months. Incident major depressive disorder diagnosed via interview and DSM-5 criteria served as the primary outcome. Sustained remission of insomnia disorder before depression event or duration of follow-up served as the secondary outcome.

Among all participants, 140 completed CBT-I and 130 completed sleep education therapy, with 114 completing 24 months of follow-up among the CBT-I group and 117 among the sleep education therapy group. Following protocol modification, 81 CBT-I participants and 77 sleep education therapy participants completed 36 months of follow-up.

Results showed incident or recurrent major depression among 19 CBT-I participants (12.2%) and 35 sleep education therapy participants (25.9%). The overall benefit (HR = 0.51; 95% CI, 0.29-0.88) appeared consistent across subgroups. CBT-I participants (26.3%) were more likely to have continuously sustained insomnia disorder remission before depression event or during follow-up compared with sleep education therapy participants (19.3%). CBT-I participants with sustained insomnia disorder remission were 82.6% less likely to experience depression (HR = 0.17; 95% CI, 0.04-0.73) compared with sleep education therapy participants without sustained insomnia disorder remission.

“Screening for insomnia with a simple questionnaire, such as the seven-item Insomnia Severity Index, and providing treatment for insomnia with CBT-I effectively prevents depression in older adults,” Irwin said. “Wide dissemination of insomnia screening and treatment has the potential to substantially reduce the incidence of depression.”

In a related editorial, Pim Cuijpers, PhD, of the department of clinical, neuro and developmental psychology at the Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, of the department of psychiatry at the University of Pittsburgh School of Medicine in Pennsylvania, highlighted potential avenues for future research in this area.

“If prevention of major depression can be realized by focusing on insomnia, would it be possible to prevent depressive disorder by focusing on other problems that are associated with depression?” they wrote. “Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents? This approach offers all kinds of new opportunities to develop and test indirect interventions for problems that are less stigmatizing but are significantly associated with the onset of depression.”