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Sleep Initiation and Maintenance Disorders: HELP
Articles by Rachel Manber
Based on 30 articles published since 2009
(Why 30 articles?)
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Between 2009 and 2019, Rachel Manber wrote the following 30 articles about Sleep Initiation and Maintenance Disorders.
 
+ Citations + Abstracts
Pages: 1 · 2
1 Editorial The power of pooled analyses to inform about the effects of CBTI on outcomes beyond sleep. 2019

Manber, Rachel. ·Department of Psychiatry and Behavioral Sciences, Stanford University, USA. ·Sleep Med Rev · Pubmed #30691658.

ABSTRACT: -- No abstract --

2 Editorial A step towards stepped care: delivery of CBT-I with reduced clinician time. 2015

Manber, Rachel / Simpson, Norah S / Bootzin, Richard R. ·Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94301-5597, USA. Electronic address: Rmanber@stanford.edu. · Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94301-5597, USA. · Department of Psychology, University of Arizona, USA. ·Sleep Med Rev · Pubmed #25454675.

ABSTRACT: -- No abstract --

3 Review Cognitive Behavioral Therapy for Insomnia in Depression. 2019

Asarnow, Lauren D / Manber, Rachel. ·Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Room 3342, Stanford, CA 94305, USA. Electronic address: lasarnow@stanford.edu. · Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Room 3337, Stanford, CA 94305, USA. ·Sleep Med Clin · Pubmed #31029185.

ABSTRACT: This article reviews the literature on cognitive-behavioral therapy for insomnia in adults and adolescents with depression. Recent research has expanded on previous research, which established that sleep problems are an important predictor of depression and that sleep problems are associated with more severe depression, more suicidality, and worse outcomes for treatment of depression. The relationship between sleep problems and depression is complex, likely bidirectional, and impactful. To further improve the lives of patients with depression who experience insomnia, it will be important to investigate which patients will do better in a sequential versus concomitant approach.

4 Review Beyond the mean: A systematic review on the correlates of daily intraindividual variability of sleep/wake patterns. 2016

Bei, Bei / Wiley, Joshua F / Trinder, John / Manber, Rachel. ·Monash Institute of Cognitive and Clinical Neurosciences, Monash School of Psychological Sciences, Faculty of Biomedical and Psychological Sciences, Monash University, Australia; Centre for Women's Mental Health, Royal Women's Hospital, Australia. Electronic address: bei.bei@monash.edu. · Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Australia. · Melbourne School of Psychological Sciences, University of Melbourne, Australia. · Stanford University School of Medicine, Department of Psychiatry and Behavioral Science, USA. ·Sleep Med Rev · Pubmed #26588182.

ABSTRACT: Features of an individual's sleep/wake patterns across multiple days are governed by two dimensions, the mean and the intraindividual variability (IIV). The existing literature focuses on the means, while the nature and correlates of sleep/wake IIV are not well understood. A systematic search of records in five major databases from inception to November 2014 identified 53 peer-reviewed empirical publications that examined correlates of sleep/wake IIV in adults. Overall, this literature appeared unsystematic and post hoc, with under-developed theoretical frameworks and inconsistent methodologies. Correlates most consistently associated with greater IIV in one or more aspects of sleep/wake patterns were: younger age, non-White race/ethnicity, living alone, physical health conditions, higher body mass index, weight gain, bipolar and unipolar depression symptomatology, stress, and evening chronotype; symptoms of insomnia and poor sleep were associated with higher sleep/wake IIV, which was reduced following sleep interventions. The effects of experimentally reduced sleep/wake IIV on daytime functioning were inconclusive. In extending current understanding of sleep/wake patterns beyond the mean values, IIV should be incorporated as an additional dimension when sleep is examined across multiple days. Theoretical and methodological shortcomings in the existing literature, and opportunities for future research are discussed.

5 Review Insomnia disorder. 2015

Morin, Charles M / Drake, Christopher L / Harvey, Allison G / Krystal, Andrew D / Manber, Rachel / Riemann, Dieter / Spiegelhalder, Kai. ·Université Laval, École de psychologie, 2325 rue des Bibliothèques, Québec City, Québec G1V 0A6, Canada. · Henry Ford Hospital Sleep Disorders and Research Center, Detroit, Michigan, USA. · Department of Psychology, University of California, Berkeley, Berkeley, California, USA. · Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA. · Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA. · Department of Clinical Psychology and Psychophysiology/Sleep Medicine, Center for Mental Disorders, University of Freiburg Medical Center, Freiburg, Germany. ·Nat Rev Dis Primers · Pubmed #27189779.

ABSTRACT: Insomnia disorder affects a large proportion of the population on a situational, recurrent or chronic basis and is among the most common complaints in medical practice. The disorder is predominantly characterized by dissatisfaction with sleep duration or quality and difficulties initiating or maintaining sleep, along with substantial distress and impairments of daytime functioning. It can present as the chief complaint or, more often, co-occurs with other medical or psychiatric disorders, such as pain and depression. Persistent insomnia has been linked with adverse long-term health outcomes, including diminished quality of life and physical and psychological morbidity. Despite its high prevalence and burden, the aetiology and pathophysiology of insomnia is poorly understood. In the past decade, important changes in classification and diagnostic paradigms have instigated a move from a purely symptom-based conceptualization to the recognition of insomnia as a disorder in its own right. These changes have been paralleled by key advances in therapy, with generic pharmacological and psychological interventions being increasingly replaced by approaches that have sleep-specific and insomnia-specific therapeutic targets. Psychological and pharmacological therapies effectively reduce the time it takes to fall asleep and the time spent awake after sleep onset, and produce a modest increase in total sleep time; these are outcomes that correlate with improvements in daytime functioning. Despite this progress, several challenges remain, including the need to improve our knowledge of the mechanisms that underlie insomnia and to develop more cost-effective, efficient and accessible therapies.

6 Review Treatment of sleep disturbances in posttraumatic stress disorder: a review. 2012

Schoenfeld, Frank B / Deviva, Jason C / Manber, Rachel. ·San Francisco Department of Veterans Affairs (VA) Medical Center, San Francisco, CA 94121, USA. Frank.schoenfeld@va.gov ·J Rehabil Res Dev · Pubmed #23015583.

ABSTRACT: Sleep disturbances are among the most commonly reported posttraumatic stress disorder (PTSD) symptoms. It is essential to conduct a careful assessment of the presenting sleep disturbance to select the optimal available treatment. Cognitive-behavioral therapies (CBTs) are at least as effective as pharmacologic treatment in the short-term and more enduring in their beneficial effects. Cognitive-behavioral treatment for insomnia and imagery rehearsal therapy have been developed to specifically treat insomnia and nightmares and offer promise for more effective relief of these very distressing symptoms. Pharmacotherapy continues to be an important treatment choice for PTSD sleep disturbances as an adjunct to CBT, when CBT is ineffective or not available, or when the patient declines CBT. Great need exists for more investigation into the effectiveness of specific pharmacologic agents for PTSD sleep disturbances and the dissemination of the findings to prescribers. The studies of prazosin and the findings of its effectiveness for PTSD sleep disturbance are examples of studies of pharmacologic agents needed in this area. Despite the progress made in developing more specific treatments for sleep disturbances in PTSD, insomnia and nightmares may not fully resolve.

7 Review Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia. 2012

Ong, Jason C / Ulmer, Christi S / Manber, Rachel. ·Rush University Medical Center, Chicago, IL 60612, USA. Jason_Ong@rush.edu ·Behav Res Ther · Pubmed #22975073.

ABSTRACT: While there is an accumulating evidence to suggest that therapies using mindfulness and acceptance-based approaches have benefits for improving the symptoms of insomnia, it is unclear how these treatments work. The goal of this paper is to present a conceptual framework for the cognitive mechanisms of insomnia based upon mindfulness and acceptance approaches. The existing cognitive and behavioral models of insomnia are first reviewed and a two-level model of cognitive (primary) and metacognitive (secondary) arousal is presented in the context of insomnia. We then focus on the role of metacognition in mindfulness and acceptance-based therapies, followed by a review of these therapies in the treatment of insomnia. A conceptual framework is presented detailing the mechanisms of metacognition in the context of insomnia treatments. This model proposes that increasing awareness of the mental and physical states that are present when experiencing insomnia symptoms and then learning how to shift mental processes can promote an adaptive stance to one's response to these symptoms. These metacognitive processes are characterized by balanced appraisals, cognitive flexibility, equanimity, and commitment to values and are posited to reduce sleep-related arousal, leading to remission from insomnia. We hope that this model will further the understanding and impact of mindfulness and acceptance-based approaches to insomnia.

8 Review Insomnia and its effective non-pharmacologic treatment. 2010

Siebern, Allison T / Manber, Rachel. ·Sleep Medicine Center, Stanford University School of Medicine, 450 Broadway Street, M/C 5704, Redwood City, CA 94063, USA. Asiebern@stanford.edu ·Med Clin North Am · Pubmed #20451034.

ABSTRACT: Emerging data underscores the public health and economic burden of insomnia evidenced by increased health risks; increased health care utilization; and work domain deficits (absenteeism and reduced productivity). Cognitive behavioral therapy for insomnia (CBTi) is a brief and effective non-pharmacologic treatment for insomnia that is grounded in the science of sleep medicine and the science of behavior change and psychological theory, and in direct comparisons with sleep medication in randomized control trials that demonstrate that CBTi has comparable efficacy with more durable long-term maintenance of gains after treatment discontinuation. The high level of empirical support for CBTi has led the National Institutes of Health Consensus and the American Academy of Sleep Medicine Practice Parameters to make the recommendation that CBTi be considered standard treatment. The aim of this report is to increase awareness and understanding of health care providers of this effective treatment option.

9 Review Insomnia and depression: a multifaceted interplay. 2009

Manber, Rachel / Chambers, Andrea S. ·Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA 94305, USA. rmanber@stanford.edu ·Curr Psychiatry Rep · Pubmed #19909664.

ABSTRACT: Historically, insomnia has been viewed as a symptom of depressive illness that is expected to resolve with adequate treatment of the depressive disorder. This article reviews the evidence that increasingly challenges this simplistic view and summarizes research demonstrating the multifaceted interplay between insomnia and depression. It discusses the prevalence, clinical significance, and time course of insomnia, distinguishing between poor sleep and an insomnia disorder. The article also discusses abnormalities in sleep architecture in major depressive disorder and theories about the pathways connecting sleep and depression. It concludes with a discussion of issues related to treatment, including the effects of antidepressants on sleep and new evidence of the utility of adding an insomnia-specific therapy for improved management of depressed patients with comorbid insomnia.

10 Article Treating insomnia in depression: Insomnia related factors predict long-term depression trajectories. 2018

Bei, Bei / Asarnow, Lauren D / Krystal, Andrew / Edinger, Jack D / Buysse, Daniel J / Manber, Rachel. ·Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University. · Department of Psychiatry and Behavioral Sciences, Stanford University. · School of Medicine, University of California, San Francisco. · Department of Medicine, National Jewish Health. · Department of Psychiatry, University of Pittsburgh. ·J Consult Clin Psychol · Pubmed #29504795.

ABSTRACT: OBJECTIVE: Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has been associated with poorer outcomes for both conditions. However, individual differences in depressive symptom trajectories during and after treatment are poorly understood in comorbid insomnia and depression. This study explored the heterogeneity in long-term depression change trajectories, and examined their correlates, particularly insomnia-related characteristics. METHOD: Participants were 148 adults (age M ± SD = 46.6 ± 12.6, 73.0% female) with insomnia and MDD who received antidepressant pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs about sleep were also assessed. RESULTS: Growth mixture modeling revealed three trajectories: (a) Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value < .001) and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom reduction during treatment (p values < .001) and low depression severity at posttreatment, but increased severity over follow-up (p value < .001). (c) Optimal-Responders (13.5%) achieved most gains during early treatment (p value < .001), continued to improve (p value < .01) and maintained minimal depression during follow-ups. The classes did not differ significantly on baseline measures or treatment received, but differed on insomnia-related measures after treatment began (p values < .05): Optimal-Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about sleep. CONCLUSIONS: Three depression symptom trajectories were observed among patients with comorbid insomnia and MDD. These trajectories were associated with insomnia-related constructs after commencing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes. (PsycINFO Database Record

11 Article Characterization of Patients Who Present With Insomnia: Is There Room for a Symptom Cluster-Based Approach? 2017

Crawford, Megan R / Chirinos, Diana A / Iurcotta, Toni / Edinger, Jack D / Wyatt, James K / Manber, Rachel / Ong, Jason C. ·Department of Psychology, Swansea University, Swansea, United Kingdom. · Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois. · Department of Psychology, Rice University, Houston, Texas. · Hofstra Northwell School of Medicine, Hempstead, New York. · Department of Medicine, National Jewish Health, Denver, Colorado. · Department of Psychiatry, Stanford University Medical Center, Palo Alto, California. · Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois. ·J Clin Sleep Med · Pubmed #28633722.

ABSTRACT: STUDY OBJECTIVES: This study examined empirically derived symptom cluster profiles among patients who present with insomnia using clinical data and polysomnography. METHODS: Latent profile analysis was used to identify symptom cluster profiles of 175 individuals (63% female) with insomnia disorder based on total scores on validated self-report instruments of daytime and nighttime symptoms (Insomnia Severity Index, Glasgow Sleep Effort Scale, Fatigue Severity Scale, Beliefs and Attitudes about Sleep, Epworth Sleepiness Scale, Pre-Sleep Arousal Scale), mean values from a 7-day sleep diary (sleep onset latency, wake after sleep onset, and sleep efficiency), and total sleep time derived from an in-laboratory PSG. RESULTS: The best-fitting model had three symptom cluster profiles: "High Subjective Wakefulness" (HSW), "Mild Insomnia" (MI) and "Insomnia-Related Distress" (IRD). The HSW symptom cluster profile (26.3% of the sample) reported high wake after sleep onset, high sleep onset latency, and low sleep efficiency. Despite relatively comparable PSG-derived total sleep time, they reported greater levels of daytime sleepiness. The MI symptom cluster profile (45.1%) reported the least disturbance in the sleep diary and questionnaires and had the highest sleep efficiency. The IRD symptom cluster profile (28.6%) reported the highest mean scores on the insomnia-related distress measures (eg, sleep effort and arousal) and waking correlates (fatigue). Covariates associated with symptom cluster membership were older age for the HSW profile, greater obstructive sleep apnea severity for the MI profile, and, when adjusting for obstructive sleep apnea severity, being overweight/obese for the IRD profile. CONCLUSIONS: The heterogeneous nature of insomnia disorder is captured by this data-driven approach to identify symptom cluster profiles. The adaptation of a symptom cluster-based approach could guide tailored patient-centered management of patients presenting with insomnia, and enhance patient care.

12 Article Too Long, Too Short, or Too Variable? Sleep Intraindividual Variability and Its Associations With Perceived Sleep Quality and Mood in Adolescents During Naturalistically Unconstrained Sleep. 2017

Bei, Bei / Manber, Rachel / Allen, Nicholas B / Trinder, John / Wiley, Joshua F. ·Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia. · Centre for Women's Mental Health, Department of Psychiatry, University of Melbourne, Royal Women's Hospital, Parkville, Victoria, Australia. · Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. · Department of Psychology, University of Oregon, Eugene, OR. · Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia. ·Sleep · Pubmed #28364491.

ABSTRACT: Introduction: Research has extensively examined the relationship between adolescents' mental health and average sleep duration/quality. Using rigorous methodology, this study characterized adolescents' objective sleep intraindividual variability (IIV) and examined its role on mood beyond the effects of their respective individual mean (IIM) values. Aims and Methods: One hundred forty-six community-dwelling adolescents (47.3% male) aged 16.2 ± 1.0 (M ± SD) years wore an actigraph that assessed bedtime, risetime, time-in-bed (TIB), and sleep onset latency (SOL) throughout a 15-day vacation with relatively unconstrained sleep opportunity. Self-report sleep quality (SSQ), negative mood (MOOD), and other covariates were assessed using questionnaires. For each sleep variable, individuals' mean values (IIM) and IIV were used to simultaneously predict MOOD with SSQ as a mediator. Models were estimated in a Bayesian IIV framework; both linear and quadratic effects of the IIM and IIV were examined. Results: Longer and more variable TIB, as well as more variable SOL (but not mean SOL), were associated with poorer SSQ (ps < .01), which in turn, was associated with more negative MOOD (ps < .05). The indirect effect of SOL IIV was curvilinear, such that as SOL became more variable, the deteriorating effect of high SOL IIV accelerated. Neither bedtime nor risetime IIV was significantly associated with SSQ or MOOD. Conclusions: During relatively unconstrained sleep opportunity, more variable TIB and SOL were associated with more negative mood, mediated by poorer perceived sleep quality. Significant effects of IIV were over and above that of mean values, suggesting that unique aspects of sleep IIV are relevant to how adolescents perceive sleep quality and their mood.

13 Article Are Patients with Childhood Onset of Insomnia and Depression More Difficult to Treat Than Are Those with Adult Onsets of These Disorders? A Report from the TRIAD Study. 2017

Edinger, Jack D / Manber, Rachel / Buysse, Daniel J / Krystal, Andrew D / Thase, Michael E / Gehrman, Phillip / Fairholme, Christopher P / Luther, James / Wisniewski, Stephen. ·Department of Medicine, National Jewish Health, Denver, CO. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC. · Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA. · Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA. · Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA. · Department of Psychology, University of Idaho, Moscow, ID. · Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA. ·J Clin Sleep Med · Pubmed #27784414.

ABSTRACT: STUDY OBJECTIVES: To determine if patients with childhood onsets (CO) of both major depression and insomnia disorder show blunted depression and insomnia treatment responses to concurrent interventions for both disorders compared to those with adult onsets (AO) of both conditions. METHODS: This study was a secondary analysis of data obtained from a multisite randomized clinical trial designed to test the efficacy of combining a psychological/behavior insomnia therapy with antidepressant medication to enhance depression treatment outcomes in patients with comorbid major depression and insomnia. This study included 27 adults with CO of depression and insomnia and 77 adults with AO of both conditions. They underwent a 16-week treatment including: (1) a standardized two-step pharmacotherapy for depression algorithm, consisting of escitalopram, sertraline, and desvenlafaxine in a prescribed sequence; and (2) either cognitive behavioral insomnia therapy (CBT-I) or a quasi-desensitization control (CTRL) therapy. Main outcome measures were the 17-item Hamilton Rating Scale for Depression (HRSD-17) and the Insomnia Severity Index (ISI) completed pre-treatment and every 2 weeks thereafter. RESULTS: The AO and CO groups did not differ significantly in regard to their pre-treatment HRSD-17 and ISI scores. Mixed model analyses that adjusted for the number of insomnia treatment sessions attended showed that the AO group achieved significantly lower, subclinical scores on the HRSD-17 and ISI than did the CO group by the time of study exit. Moreover, a significant group by treatment arm interaction suggested that HRSD-17 scores at study exit remained significantly higher in the CO group receiving the CTRL therapy than was the case for the participants in the CO group receiving CBT-I. Greater proportions of the AO group achieved a priori criteria for remission of insomnia (49.3% vs. 29.2%, p = 0.04) and depression (45.5% vs. 29.6%, p = 0.07) than did those in the CO group. CONCLUSIONS: Patients with comorbid depression and insomnia who experienced the first onset of both disorders in childhood are less responsive to the treatments offered herein than are those with adult onsets of these comorbid disorders. Further research is needed to identify therapies that enhance the depression and insomnia treatment responses of those with childhood onsets of these two conditions.

14 Article Efficacy of Cognitive-Behavioral Therapy for Insomnia Combined With Antidepressant Pharmacotherapy in Patients With Comorbid Depression and Insomnia: A Randomized Controlled Trial. 2016

Manber, Rachel / Buysse, Daniel J / Edinger, Jack / Krystal, Andrew / Luther, James F / Wisniewski, Stephen R / Trockel, Mickey / Kraemer, Helena C / Thase, Michael E. ·Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Stanford, CA 94305. rmanber@stanford.edu. · Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California, USA. · Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. · Department of Medicine, National Jewish Health, Denver, Colorado, USA. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA. · Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. · Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and the Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA. ·J Clin Psychiatry · Pubmed #27788313.

ABSTRACT: OBJECTIVES: The Treatment of Insomnia and Depression (TRIAD) study evaluated the efficacy of combining depression pharmacotherapy (using MED, an ecologically valid and generalizable antidepressant medication algorithm) with cognitive-behavioral therapy for insomnia (CBT-I) among individuals with comorbid insomnia and major depressive disorder (MDD) to determine if change in insomnia severity mediates antidepressant outcome. METHODS: This 16-week, 3-site, randomized controlled trial (RCT) randomly assigned 150 participants (recruited between March 2009 and August 2013), who met DSM-IV-TR criteria for insomnia and MDD and were not receiving treatment for either, to receive depression pharmacotherapy plus 7 sessions of either CBT-I or a credible control therapy for insomnia (CTRL). Depression pharmacotherapy followed a standardized 2-step algorithm, which included escitalopram, sertraline, and desvenlafaxine in a prescribed sequence. Primary measures were the Hamilton Depression Rating Scale and the depression module of the Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Nonpatient Edition, administered by raters masked to treatment assignment, and the self-administered Insomnia Severity Index (ISI). RESULTS: CBT-I was superior to CTRL in reducing insomnia severity (P = .028). The overall difference in depression remission between the treatments was not statistically significant (44% in CBT-I and 36% in CTRL; number needed to treat = 15). However, planned secondary analysis revealed that improvements in insomnia at week 6 mediated eventual remission from depression, with early change in ISI predicting depression remission in the CBT-I (P = .0002) but not in the CTRL arm (P = .26). CONCLUSIONS: CBT-I is an efficacious treatment for insomnia comorbid with MDD among patients treated with antidepressant medications. Improvement in insomnia may be related to the change in depression. Future studies should identify which patients are most likely to benefit from the addition of an insomnia-focused therapy to standard antidepressant treatments. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00767624.

15 Article Examining the Variability of Sleep Patterns during Treatment for Chronic Insomnia: Application of a Location-Scale Mixed Model. 2016

Ong, Jason C / Hedeker, Donald / Wyatt, James K / Manber, Rachel. ·Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL. · Department of Public Health Sciences, University of Chicago, Chicago, IL. · Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Palo Alto, CA. ·J Clin Sleep Med · Pubmed #26951414.

ABSTRACT: STUDY OBJECTIVES: The purpose of this study was to introduce a novel statistical technique called the location-scale mixed model that can be used to analyze the mean level and intra-individual variability (IIV) using longitudinal sleep data. METHODS: We applied the location-scale mixed model to examine changes from baseline in sleep efficiency on data collected from 54 participants with chronic insomnia who were randomized to an 8-week Mindfulness-Based Stress Reduction (MBSR; n = 19), an 8-week Mindfulness-Based Therapy for Insomnia (MBTI; n = 19), or an 8-week self-monitoring control (SM; n = 16). Sleep efficiency was derived from daily sleep diaries collected at baseline (days 1-7), early treatment (days 8-21), late treatment (days 22-63), and post week (days 64-70). The behavioral components (sleep restriction, stimulus control) were delivered during late treatment in MBTI. RESULTS: For MBSR and MBTI, the pre-to-post change in mean levels of sleep efficiency were significantly larger than the change in mean levels for the SM control, but the change in IIV was not significantly different. During early and late treatment, MBSR showed a larger increase in mean levels of sleep efficiency and a larger decrease in IIV relative to the SM control. At late treatment, MBTI had a larger increase in the mean level of sleep efficiency compared to SM, but the IIV was not significantly different. CONCLUSIONS: The location-scale mixed model provides a two-dimensional analysis on the mean and IIV using longitudinal sleep diary data with the potential to reveal insights into treatment mechanisms and outcomes.

16 Article CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia. 2016

Kuhn, Eric / Weiss, Brandon J / Taylor, Katherine L / Hoffman, Julia E / Ramsey, Kelly M / Manber, Rachel / Gehrman, Philip / Crowley, Jill J / Ruzek, Josef I / Trockel, Mickey. ·VA Palo Alto Health Care System, Palo Alto, CA. · Stanford University, Stanford, CA. · Philadelphia VA Medical Center, Philadelphia, PA. · University of Pennsylvania, Philadelphia, PA. ·J Clin Sleep Med · Pubmed #26888586.

ABSTRACT: STUDY OBJECTIVES: This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176). METHODS: VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released. RESULTS: Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes. CONCLUSIONS: Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.

17 Article Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. 2015

Trockel, Mickey / Karlin, Bradley E / Taylor, C Barr / Brown, Gregory K / Manber, Rachel. ·Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA. · Stanford University School of Medicine, Palo Alto, CA. · Mental Health Services, U.S. Department of Veterans Affairs Central Office, Washington, DC. · Education Development Center, Inc., New York, NY. · Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. · Mental Illness Research, Education, and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA. · Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA. ·Sleep · Pubmed #25515115.

ABSTRACT: OBJECTIVE: To examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on suicidal ideation among Veterans with insomnia. DESIGN: Longitudinal data collected in the course of an uncontrolled evaluation of a large-scale CBT-I training program. SETTING: Outpatient and residential treatment facilities. PARTICIPANTS: Four hundred five Veterans presenting for treatment of insomnia. INTERVENTIONS: Cognitive behavioral therapy for insomnia (CBT-I). MEASUREMENT AND RESULTS: At baseline, 32% of patients, compared with 21% at final assessment, endorsed some level of suicidal ideation [χ(2)(df = 1) = 125; P < 0.001]. After adjusting for demographic variables and baseline insomnia severity, each 7-point decrease in Insomnia Severity Index (ISI) score achieved during CBT-I treatment was associated with a 65% (OR = 0.35; 95% CI = 0.24 to 0.52) reduction in odds of suicidal ideation. The effect of change in insomnia severity on change in depression severity was also significant. After controlling for change in depression severity and other variables in the model, the effect of change in insomnia severity on change in suicidal ideation remained significant. CONCLUSION: This evaluation of the largest dissemination of CBT-I in the United States found a clinically meaningful reduction in suicidal ideation among Veterans receiving CBT-I. The mechanisms by which effective treatment of insomnia with CBT-I reduces suicide risk are unknown and warrant investigation. The current results may have significant public health implications for preventing suicide among Veterans.

18 Article National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans. 2015

Karlin, Bradley E / Trockel, Mickey / Spira, Adam P / Taylor, C Barr / Manber, Rachel. ·Mental Health Services, US Department of Veterans Affairs Central Office, Washington, DC, 20420, USA; Education Development Center, Inc., New York, NY, 10014, USA; Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA. ·Int J Geriatr Psychiatry · Pubmed #24890708.

ABSTRACT: OBJECTIVES: 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.

19 Article The relationship between beliefs about sleep and adherence to behavioral treatment combined with meditation for insomnia. 2015

Cvengros, Jamie A / Crawford, Megan R / Manber, Rachel / Ong, Jason C. ·a Sleep Disorders Service and Research Center Rush University Medical Center. ·Behav Sleep Med · Pubmed #24354360.

ABSTRACT: This study examined beliefs about sleep, as measured by the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale, as predictors of adherence to 3 specific insomnia treatment recommendations: restriction of time spent in bed, maintenance of a consistent rise time, and completion of daily meditation practice. Higher DBAS scores predicted poorer adherence to restriction of time spent in bed and to maintenance of a prescribed rise time. DBAS scores were not associated with completion of daily meditation. These preliminary findings suggest that pre-treatment beliefs about sleep may impact patient engagement with behavioral recommendations regarding time in bed and consistent rise time during treatment for insomnia.

20 Article A randomized controlled trial of mindfulness meditation for chronic insomnia. 2014

Ong, Jason C / Manber, Rachel / Segal, Zindel / Xia, Yinglin / Shapiro, Shauna / Wyatt, James K. · ·Sleep · Pubmed #25142566.

ABSTRACT: STUDY OBJECTIVES: To evaluate the efficacy of mindfulness meditation for the treatment of chronic insomnia. DESIGN: Three-arm, single-site, randomized controlled trial. SETTING: Academic medical center. PARTICIPANTS: Fifty-four adults with chronic insomnia. INTERVENTIONS: Participants were randomized to either mindfulness-based stress reduction (MBSR), mindfulness-based therapy for insomnia (MBTI), or an eight-week self-monitoring (SM) condition. MEASUREMENTS AND RESULTS: Patient-reported outcome measures were total wake time (TWT) from sleep diaries, the pre-sleep arousal scale (PSAS), measuring a prominent waking correlate of insomnia, and the Insomnia Severity Index (ISI) to determine remission and response as clinical endpoints. Objective sleep measures were derived from laboratory polysomnography and wrist actigraphy. Linear mixed models showed that those receiving a meditation-based intervention (MBSR or MBTI) had significantly greater reductions on TWT minutes (43.75 vs 1.09), PSAS (7.13 vs 0.16), and ISI (4.56 vs 0.06) from baseline-to-post compared to SM. Post hoc analyses revealed that each intervention was superior to SM on each of the patient-reported measures, but no significant differences were found when comparing MBSR to MBTI from baseline-to-post. From baseline to 6-month follow-up, MBTI had greater reductions in ISI scores than MBSR (P < 0.05), with the largest difference occurring at the 3-month follow-up. Remission and response rates in MBTI and MBSR were sustained from post-treatment through follow-up, with MBTI showing the highest rates of treatment remission (50%) and response (78.6%) at the 6-month follow-up. CONCLUSIONS: Mindfulness meditation appears to be a viable treatment option for adults with chronic insomnia and could provide an alternative to traditional treatments for insomnia. TRIAL REGISTRATION: Mindfulness-Based Approaches to Insomnia: clinicaltrials.gov, identifier: NCT00768781.

21 Article Who is at risk for having persistent insomnia symptoms? A longitudinal study in the general population in Korea. 2014

Suh, Sooyeon / Yang, Hae-Chung / Fairholme, Christopher P / Kim, Hyun / Manber, Rachel / Shin, Chol. ·Korea University Ansan Hospital, Institute of Human Genomic Study, Ansan, Republic of Korea; Stanford University, Department of Psychiatry, Palo Alto, CA, United States. · Korea University Ansan Hospital, Institute of Human Genomic Study, Ansan, Republic of Korea; Yongmoon Graduate School of Counseling Psychology, Seoul, Republic of Korea. · Stanford University, Department of Psychiatry, Palo Alto, CA, United States. · Korea University Ansan Hospital, Institute of Human Genomic Study, Ansan, Republic of Korea; Department of Psychology, Boston University, Boston, MA, United States. · Stanford University, Department of Psychiatry, Palo Alto, CA, United States. Electronic address: rmanber@stanford.edu. · Korea University Ansan Hospital, Institute of Human Genomic Study, Ansan, Republic of Korea; Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea. Electronic address: chol-shin@korea.ac.kr. ·Sleep Med · Pubmed #24457162.

ABSTRACT: OBJECTIVES: Our study had three goals: (1) to investigate the longitudinal course of insomnia symptoms over 4 years (3 time points) by analyzing the trajectory of insomnia symptoms for all participants, (2) to compare persistent insomnia symptom to nonpersistent insomnia symptom groups on mental health and quality of life (QoL), and (3) to conduct exploratory analyses on the relative contribution of multiple factors to persistence of insomnia symptoms. METHODS: Our population-based longitudinal study utilized a community-based sample from the Korean Genome and Epidemiology study (KoGES). Participants were 1247 individuals (40.1% men; mean age, 54.3±7.1 years). Insomnia, QoL (measured by 12-item Short-Form health survey [SF-12]), sleep-interfering behaviors, and depression (measured by the Beck Depression Inventory [BDI]) were followed with biennial examinations at 3 data points spaced 2 years apart (baseline, time 1, and time 2). RESULTS: Among individuals experiencing insomnia symptoms at baseline, the most common trajectory was to experience persistent nocturnal insomnia symptoms across all 3 time points. Those with persistent insomnia symptoms had significantly lower physical and mental QoL (measured by SF-12) and higher depression (measured by BDI) at time points compared to those without persistent nocturnal insomnia symptoms. A follow-up exploratory receiver operating characteristic curve (ROC) analysis identified poor sleep quality, frequent sleep-interfering behaviors, and low mental health QoL as the strongest predictors of persistent insomnia symptoms above other well-known risk factors. CONCLUSIONS: In particular, an interaction between poor sleep quality, sleep-interfering behaviors, and mental health QoL appeared to be the strongest risk factor for persistent insomnia symptoms.

22 Article Cognitive Behavioral Therapy for insomnia with Veterans: evaluation of effectiveness and correlates of treatment outcomes. 2014

Trockel, Mickey / Karlin, Bradley E / Taylor, C Barr / Manber, Rachel. ·Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, USA; Stanford University School of Medicine, USA. · Mental Health Services, U.S. Department of Veterans Affairs Central Office, USA; Bloomberg School of Public Health, Johns Hopkins University, USA. Electronic address: Bradley.Karlin2@va.gov. ·Behav Res Ther · Pubmed #24412462.

ABSTRACT: This paper examines the effectiveness of Cognitive Behavioral Therapy for insomnia (CBT-I) in Veterans and the effects of two process measures on CBT-I outcomes: 1) therapist ratings of patient adherence and 2) patient ratings of therapeutic alliance. Data are from 316 therapists in the Department of Veterans Affairs CBT-I Training Program and 696 patients receiving CBT-I from therapists undergoing training. Mixed effects model results indicate Insomnia Severity Index scores decreased from 20.7 at baseline to 10.9 (d = 2.3) during a typical course of CBT-I. Patients with highest tercile compared to those with lowest tercile adherence achieved, on average, 4.1 points greater reduction in ISI scores (d = 0.95). The effect of therapeutic alliance on change in insomnia severity was not significant after adjusting for adherence to CBT-I. These results support the effectiveness and feasibility of large-scale training in and implementation of CBT-I and indicate that greater focus on patient adherence may lead to enhanced outcomes. The current findings suggest that CBT-I therapists and training programs place greater emphasis on attending to and increasing patient adherence.

23 Article Factors associated with clinically significant insomnia among pregnant low-income Latinas. 2013

Manber, Rachel / Steidtmann, Dana / Chambers, Andrea S / Ganger, William / Horwitz, Sarah / Connelly, Cynthia D. ·Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA 94301-5597, USA. rmanber@stanford.edu ·J Womens Health (Larchmt) · Pubmed #23863074.

ABSTRACT: BACKGROUND: Poor sleep, common during pregnancy, is associated with negative health risks. The study aimed to identify predictors of clinically significant insomnia among pregnant Latinas. METHODS: A total of 1289 pregnant Latinas recruited from obstetric clinics completed the Insomnia Severity Index (ISI) and questions about demographics and sleep. RESULTS: Clinically significant insomnia (ISI≥10) was present among 17% of participants. Significant correlates of clinically significant insomnia were higher scores on the Edinburgh Postnatal Depression Scale (EPDS) after removing the sleep item (47% of women with EPDS≥9 and 9% with EPDS<9), completing measures in English (rather than Spanish: 26% versus 13%), and income but not pregnancy week, age, highest education level, or marital status. The highest percentage of clinically significant insomnia (59%) was experienced by women with EPDS≥9 who completed measures in English. The lowest percentage of clinically significant insomnia (6.2%) was experienced by women with EPDS<9 who completed measures in Spanish. CONCLUSIONS: In this sample of low-income, mostly Spanish-speaking pregnant Latinas, rates of clinically significant insomnia appear to be higher than rates among nonpregnant Latinas. Rates of clinically significant insomnia are particularly high among Latinas with elevated depressive symptom severity, a known risk for insomnia. Acculturation, as indicated by completing measures in English, may be another risk specific to Latinas, possibly owing to loss of some ethnicity-specific protective factors (e.g., social support, strong family ties, and group identity). It will be important to directly test this explanation in future research.

24 Article National dissemination of cognitive behavioral therapy for insomnia in veterans: therapist- and patient-level outcomes. 2013

Karlin, Bradley E / Trockel, Mickey / Taylor, C Barr / Gimeno, Julia / Manber, Rachel. ·Mental Health Services. · Department of Psychiatry, Stanford University Medical Center. ·J Consult Clin Psychol · Pubmed #23586730.

ABSTRACT: OBJECTIVE: To evaluate the effects of national training in and implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I) in the U.S. Department of Veterans Affairs (VA) health care system on clinicians' competency and patients' insomnia severity, symptoms of depression, and quality of life. METHOD: A prospective cohort of 102 VA clinicians (including mental health staff in various mental health and primary care settings) participated in the VA CBT-I Training Program during 2011 and 2012. Patients included 182 veterans treated by clinicians enrolled in the training. Clinicians were rated on taped therapy sessions, using a standardized competency rating form. Patients' symptoms were assessed using the Insomnia Severity Index (ISI) and standardized measures of depression and quality of life. RESULTS: Of 102 clinicians attending workshop training, 94 (92%) met all training requirements, including minimum competency score criteria. Of 182 patients, 122 (67%) completed treatment. The mixed effects model revealed significant reductions in average patient ISI score (from 19.9 to 10.2, standard error = 3.0). Patients also improved on measures of depression and quality of life. CONCLUSION: National training in and implementation of CBT-I resulted in a significant increase in therapist competency to deliver CBT-I for almost all clinicians and in a large reduction in insomnia severity and improvement in depression and quality of life among veterans. Observed effect sizes are comparable to results of randomized clinical trials. These results suggest CBT-I can be feasibly and effectively disseminated to routine clinical settings, with very favorable patient outcomes.

25 Article Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. 2012

Manber, Rachel / Carney, Colleen / Edinger, Jack / Epstein, Dana / Friedman, Leah / Haynes, Patricia L / Karlin, Bradley E / Pigeon, Wilfred / Siebern, Allison T / Trockel, Mickey. ·Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94301-5597, USA. Rmanber@stanford.edu ·J Clin Sleep Med · Pubmed #22505869.

ABSTRACT: Strong evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI). A significant barrier to wide dissemination of CBTI is the lack of qualified practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and flexibility of the treatment protocol. We developed a case conceptualization-driven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.

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