RESEARCH ARTICLE

National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans Bradley E. Karlin1,2,3, Mickey Trockel4,5, Adam P. Spira3, C. Barr Taylor4,5 and Rachel Manber4,5 1

Mental Health Services, US Department of Veterans Affairs Central Office, Washington, DC 20420, USA Education Development Center, Inc., New York, NY 10014, USA 3 Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA 4 Department of Psychiatry, Stanford University Medical Center, Palo Alto, CA 94305, USA 5 VISN 21 Mental Illness Research, Education and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA Correspondence to: Dr. B. E. Karlin, PhD, E-mail: [email protected] 2

Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18–64 years) veterans receiving CBT-I nationally in nonsleep specialty settings. Method: Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory—Short Revised. Results: A total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups. Conclusions: Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings. Copyright # 2014 John Wiley & Sons, Ltd.

Objectives:

Key words: cognitive behavioral therapy; insomnia; older adults; geriatrics; veterans; US Department of Veterans Affairs; dissemination; implementation; evidence-based psychotherapy History: Received 5 February 2014; Accepted 23 April 2014; Published online 29 May 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4143

Insomnia (difficulty falling or staying asleep) is a pervasive problem in younger and, often more so, older adults and has been characterized as a major public health problem (Bloom et al., 2009). Epidemiological studies have consistently documented increases in the prevalence of nighttime symptoms of insomnia with increased age (Ohayon, 2002). Among older adults (defined herein as 65 years of age or older), it Copyright # 2014 John Wiley & Sons, Ltd.

is estimated that approximately one-half experience sleep problems (Bloom et al., 2009; Neikrug and Ancoli-Israel, 2010). Untreated insomnia has been associated with significant and extensive personal, health, and societal consequences, including increased risk for disability, hypertension, heart disease, reduced quality of life, and increased health care utilization, with the effects Int J Geriatr Psychiatry 2015; 30: 308–315

Effectiveness of CBT-I with older and younger veterans

of insomnia often greater in older individuals (Schwartz et al., 1999; Katz and McHorney, 2002). In addition, increasing research demonstrates insomnia to be associated with cognitive decline, as well as risk of Alzheimer’s disease, in older adults (Cricco et al., 2001; Elwood et al., 2011; Hahn et al., 2013). Cognitive behavioral therapy (CBT) is a wellestablished treatment for insomnia that has been shown to be efficacious in numerous randomized controlled trials (RCTs) (Morin et al., 1994; Smith et al., 2002; Morin et al., 2009). In light of the strong evidence demonstrating its efficacy, CBT for insomnia (CBT-I) is highly recommended and identified as a first-line treatment in clinical practice guidelines and consensus statements (National Institutes of Health, 2005; Wilson et al., 2010). Moreover, CBT-I has been shown to be as effective as medication in the short term and more effective in the long term (Jacobs et al., 2004). Cognitive behavioral therapy for insomnia has been examined and shown to be efficacious specifically in the context of late-life insomnia (Morin et al., 1999a; Montgomery and Dennis, 2003). A meta-analysis of the efficacy of CBT-I and its core behavioral components for treating insomnia in older adults found moderate mean effects sizes for diary outcomes of latency to sleep onset, time awake after sleep onset, sleep efficiency, and self-rated sleep quality (Irwin et al., 2006). A 2006 report of the American Academy of Sleep Medicine concluded that there is evidence to support the use of CBT-I to treat insomnia in older adults (Morgenthaler et al., 2006). Furthermore, CBT-I is a particularly attractive option with older patients in light of its favorable safety profile relative to hypnotic medications. Unfortunately, the overwhelming majority of older and younger individuals with insomnia remain untreated (Morin et al., 2006b). The undertreatment of insomnia in older adults is compounded by the fact that older individuals substantially underutilize behavioral health services (Karlin et al., 2008; Byers et al., 2012) due to barriers at policy, provider, and patient levels, including the belief that sleep and other psychological and behavioral symptoms are natural by products of aging and limited awareness of and confidence in behavioral interventions with older adults (Alvidrez and Arean, 2002; Karlin and Duffy, 2004; Koenig, 2007). Limited research has examined the effectiveness of CBT-I in routine, nonsleep specialty settings and compared the differential response on insomnia and, particularly, quality of life among older and younger adults. Such information is especially important in light of the fact that insomnia is often highly comorbid Copyright # 2014 John Wiley & Sons, Ltd.

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with medical and psychiatric problems (Taylor et al., 2007), which, along with older adults in general, are often underrepresented in clinical samples included in RCTs (Bloom et al., 2009). Some early research reported that younger adults with persistent insomnia were more likely to have better treatment response than older adults (Lacks and Powlishta, 1989); other studies have suggested that treatment benefits are comparable (Morin et al., 1999b; Morin et al., 2006a). The limited research on treatment-related improvements in quality of life (Mitchell et al., 2012) is particularly unfortunate given the documented association between insomnia and poor quality of life (Haldemann et al., 1996). To promote the treatment of insomnia among older and younger veterans, the Veterans Health Administration, the health care arm of the US Department of Veterans Affairs (VA), is nationally disseminating and implementing CBT-I throughout the VA health care system as part of a series of evidence-based psychotherapy dissemination and implementation initiatives (Karlin and Cross, 2014). As part of this effort, the Veterans Health Administration has implemented national competency-based staff training programs, including a national training program in CBT-I (Karlin et al., 2013). The goal of the current evaluation is to examine and compare the effectiveness of CBT-I delivered by newly trained therapists in terms of insomnia severity, depression symptom severity, and quality of life among older (>65 years) versus younger (18–64 years) veterans, on the basis of national program evaluation data. In addition to examining the specific effects of CBT-I on insomnia and quality of life, the article examines the relationship between improvement in insomnia and improvement in quality of life. Lastly, we examine the likelihood of older and younger veterans to remain in treatment and the quality and strength of the therapeutic alliance over the course of treatment. Methods Cognitive behavioral therapy for insomnia training program and treatment protocol

Details of the CBT-I protocol with veterans and training program have been reported elsewhere (Manber et al., 2012; Karlin et al., 2013; Trockel et al., 2014). Briefly, the focus of the VA CBT-I training program is to provide competency-based training to mental health clinicians (psychiatrists, psychologists, social workers, nurses, licensed professional mental health counselors, and marriage and family therapists) in Int J Geriatr Psychiatry 2015; 30: 308–315

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the theoretical basis and applied components of CBT-I. Training begins with a 3-day workshop focused on sleep regulation, the theoretical foundations of the etiology and treatment of insomnia, core CBT-I treatment strategies, and treatment considerations in the context of significant comorbidities. After the workshop, training participants participate in 4 months of weekly, 90-min small-group consultation calls with a CBT-I training consultant. To enhance learning, consultants rate the therapists’ competency on specific CBT-I skills based on review of audiotaped sessions and provide corrective feedback. Cognitive behavioral therapy for insomnia treatment protocol

The CBT-I protocol, which is described in detail in a comprehensive therapist manual (Manber et al., in press), consists of six individual sessions. The first session focuses on comprehensive assessment and case conceptualization—which guide selection and sequencing of specific CBT-I treatment components for each individual patient. CBT-I components include sleep restriction therapy, stimulus control, relaxation exercises, and cognitive therapy for nighttime hyperarousal and dysfunctional thoughts about sleep. The final session focuses on maintenance of relevant CBT-I strategies and relapse prevention. Patients

Patients included veterans with insomnia symptoms who were screened by the mental health clinicians who participated in the VA CBT-I training program. These clinicians worked in a variety of mental health and primary care treatment settings in VA medical centers and clinics throughout the nation. Insomnia severity was not used as a specific inclusion or exclusion criterion. Patients were excluded if they had severe daytime sleepiness, bipolar disorder, active substance dependence or abuse within the previous 4 weeks, or current prolonged exposure therapy (Foa, 2011) for posttraumatic stress disorder (Manber et al., 2012). Patients with other mental health and medical comorbidities were not excluded unless they had uncontrolled symptoms that would contraindicate participation in CBT-I, such as patients with severe suicidal ideation or acute paranoid delusions or hallucinations. If patients agreed to receive CBT-I by a clinician in training, they were asked to provide informed consent to be audiotaped for training and program evaluation purposes. Copyright # 2014 John Wiley & Sons, Ltd.

Measures Demographics. At the first session, patients com-

pleted a form assessing age, gender, education level, race, and ethnicity. Insomnia severity. The Insomnia Severity Index (ISI)

was used to assesses severity of insomnia symptoms at every CBT-I session. The ISI is a validated measure that has demonstrated reliability in assessment of changes in insomnia severity (Morin et al., 2011). Scores range from 0 to 28, with higher scores indicating more severe insomnia. Recommended cutoff scores for the ISI are as follows: 0–7: no significant insomnia, 8–14: mild or subthreshold insomnia, 15–21: moderate clinical insomnia, and 22–28: severe clinical insomnia. The ISI was administered by the clinicians to patients before each CBT-I session, beginning with the assessment session. No specific ISI cutoff score was required for participation in CBT-I. Depression. At the first and last CBT-I sessions, the Beck Depression Inventory-II (BDI-II) was used to assess depression symptom severity. The BDI-II is a 21-item self-report scale with total score ranges from 0 to 63. Use of the BDI-II has been well established with both younger adults and older adults (Beck et al., 1988; Segal et al., 2008). Recommended cutoff scores are the following: 0–13: minimal depression, 14–19: mild depression, 20–28: moderate depression, and 29–63: severe depression. The BDI-II was administered by clinicians before the assessment session and at the beginning of session 6 (or at the last session if a patient improved with fewer sessions). Prior to analysis, the BDI-II item assessing sleep disturbance was omitted. Then, the average item score was multiplied by 21 (the original number of items) to derive a measure of depression symptom severity independent of insomnia, with the original BDI-II scoring range. Quality of life. At the first and last CBT-I sessions,

physical, psychological, social, and environmental quality of life status was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF), an abbreviated 26-item version of the WHOQOL-100. The WHOQOL-BREF has been shown to have good psychometric properties for use with younger and older adults (Skevington et al., 2004; Steinbüchel et al., 2006). The WHOQOL- BREF was administered by clinicians before the assessment session and at the beginning of session 6 (or at the last session if a patient improved with fewer sessions). Int J Geriatr Psychiatry 2015; 30: 308–315

Effectiveness of CBT-I with older and younger veterans

Therapeutic alliance. The Working Alliance Inventory

—Short Revised (WAI-SR), patient report version, (Hatcher and Gillaspy, 2006) was employed to assess quality of the therapeutic alliance. The WAI-SR generates a total score and subscale scores for “goal”, “task”, and “bond” therapeutic alliance domains. The psychometric properties of the WAI-SR have been established (Munder et al., 2010; Perdrix et al., 2010). The WAISR was administered after sessions 1 and 3.

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for demographic variables. This regression analysis of the effects of changes of insomnia severity on change in overall quality of life was limited to patients who completed both the ISI and the WHOQOL-BREF at initial and final assessment. Results Patients

Data analysis

Intention to treat analysis using mixed effects models (Raudenbush and Byrk, 2002) was used to compare the effects of older (≥65 years) versus younger (85 years enrolled in treatment provided by 305 therapists in the CBT-I training program. The demographic characteristics of the overall sample and by age group are presented in Table 1. Among patients who answered specific demographic questions, the older cohort was significantly [χ 2 (1) = 12.8, p < 0.001] more likely to be male (98% vs. 87%) and significantly [χ 2 (1) = 6.89, p = 0.009] less likely to be Hispanic (2.5% vs. 9.8%). Of the 657 patients, 28 were deemed inappropriate for CBT-I early in the evaluation process and 19 began treatment too late in their therapists’ consultation phase of training to complete treatment prior to final assessment. Of the remaining 610, 406 (67%) completed 6 CBT-I sessions (n = 332) or finished early due to symptom relief—on the basis of consensus agreement between the therapist and patient (n = 74). Among patients who finished early due to symptom relief, most (n = 46) completed five CBT-I sessions, 27 completed three or four sessions, and 1 patient with finished after two sessions with a final ISI score of 3. Of the 204 patients who either did not complete treatment or were lost to follow-up, 150 dropped out of CBT-I treatment or could not attend sessions

Table 1 Demographics

Age Gender Male Female Race White/Caucasian African American/Black Other or multiracial Hispanic/Latino ethnicity Not Hispanic/Latino Hispanic/Latino Education High school or less Some college College graduate

Age

National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans.

Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment ...
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