Predictors of treatment attendance and adherence to treatment recommendations among individuals receiving Cognitive Behavioral Therapy for Insomnia

Insomnia is very common, affecting up to 37% of adults, and is linked to a host of mental and physical health problems. Cognitive Behavioral Therapy for Insomnia (CBT-I) is recommended as the first line treatment for insomnia by the National Institutes of Health, the American Academy of Sleep Medicine, and the American College of Physicians. 

CBT-I targets underlying behaviors theorized to perpetuate insomnia. The treatment typically consists of stimulus control, sleep restriction, and sleep hygiene. Stimulus control involves helping patients to strengthen the association between the bed or bedroom and sleeping, such as by advising them to refrain from playing on the phone while in bed and to use the bed only for sleeping. Sleep restriction consists of advising patients to limit the amount of time they allow themselves to be in bed, which tends to make the person sleepier in the short term but leads to sleep that is more continuous in the long term. Sleep hygiene instructions consist of common tips such as setting a consistent bed and wake time, cutting out caffeine products late in the day, etc. CBT-I has been shown to be effective at improving the time it takes to fall asleep, improving the patient’s ability to stay asleep, and reducing incidences of waking up earlier than desired. 

Unfortunately the treatment is both lengthy (e.g., usually taking 6 sessions over a 6 to 8 week period) and challenging (e.g., many patients find sleep restriction to be difficult). Not surprisingly, poor attendance and adherence to treatment recommendations are common and have been associated with worse CBT-I outcomes. 

In the present study, we aimed to find clues as to why so many patients either drop out of CBT-I or fail to follow treatment recommendations.  We looked for predictors of treatment attendance, defined as showing up for at least three sessions, and treatment adherence, defined as following the treatment recommendation to keep a consistent bed and wake time.  Participants in the study were community dwelling adults who came to an outpatient clinic for CBT-I. Factors we tested as possible predictors included age, gender, ethnicity, education level, employment status, marital status, number of co-occurring physical health problems, anxiety symptoms, depression symptoms, and severity of insomnia symptoms. Only age and mental health predicted treatment attendance and adherence. Older individuals attended more sessions and deviated less from a consistent bed and wake time. Individuals with higher anxiety and depression symptoms attended fewer sessions. Those with more depression also struggled more with adhering to a consistent wake time. 

It may be possible to improve insomnia treatment utilization for people who also suffer from depression or anxiety symptoms by detecting and treating these symptoms either before or concurrent with CBT-I. Our study also suggests that it is important to consider age when delivering CBT-I.  As younger individuals tend to struggle more with both treatment attendance and adherence, it may be helpful to tailor CBT-I for younger adults.  One possibility might be to incorporate the use of technology, such as phone, email or text reminders, to encourage patients to attend and adhere to treatment.

Insomnia is a common disorder that negatively impacts health and overall quality of life. Although CBT-I is a very effective treatment for insomnia, it is a challenging treatment, which many individuals struggle to follow. Our study identified several characteristics of the types of people who are likely to struggle with CBT-I. Now the challenge is to find ways to tailor treatments toward the needs of these individuals so that they will continue to show up to treatment and follow treatment recommendations. 

Read the full paper: Cui, R. & Fiske, A. (in press). Predictors of treatment attendance and adherence to treatment recommendations among individuals receiving Cognitive Behavioral Therapy for Insomnia. Cognitive Behaviour Therapy.

Photo by: bark

Pictured: Ruifeng Cui


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