Insomnia Treatment May Prevent Depression in Older Adults

Michael Irwin, MD

Findings from a recent study suggest treatment for insomnia in community-dwelling older adults may prevent the occurrence of depression. Patients underwent either 2 months of cognitive behavioral therapy for insomnia (CBT-I) or sleep education therapy (SET) to determine whether CBT-I had the potential to prevent major depressive disorder.

The randomized clinical trial enrolled 291 adults over the age of 60 years (mean age, 70.1 years [standard deviation, 6.7]) diagnosed with insomnia disorder without major depression or health events in the previous year. Patients were randomized to the CBT-I group (n = 156) or the SET group (n = 135) to undergo 2 months of treatment, with 140 participants (89.7%) in the CBT-I group and 130 participants (96.3%) in the SET group completing 2 months of treatment. 

In the CBT-I group, incident or recurrent major depression occurred in 19 participants (12.2%), compared 35 participants (25.9%) in the SET group, demonstrating an overall benefit across subgroups (HR, 0.51 [95% CI, 0.29-0.88]; P = .02). Investigators also concluded that CBT-I participants were more likely to have remission of insomnia disorder sustained before depression event or during follow-up, when compared with SET participants, with sustained remission observed in 41 participants (26.3%) and 26 participants (19.3%) in each respective group (P = .03). When compared with those in the SET group without sustained remission of insomnia disorder, participants who underwent CBT-I with sustained remission of insomnia disorder had an 82.6% decreased likelihood of depression (HR, 0.17 [95% CI, 0.04-0.73]; P = .02). 

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“This selective prevention trial is one of the largest, with the longest follow-up, to answer an important clinical question of high relevance to geriatric psychiatry and older adults at risk for incident and recurrent depression,” lead investigator Michael Irwin, MD, Norman Cousins Professor of Psychiatry and Biobehavioral Science, University of California–Los Angeles (UCLA) Geffen School of Medicine; professor of psychology, UCLA College of Letters and Sciences; director, Cousins Center for Psychoneuroimmunology, UCLA Semel Institute for Neurosciences; and director, Mindful Awareness Research Center, UCLA Semel Institute, et al wrote. 

“Internal validity was established for CBT-I vs SET with similar treatment expectancy, acceptability, and adherence; monthly monitoring; retention; and assessor blinding of diagnostic outcomes. External validity was maximized by long-term follow-up, with the annual incidence of depression in SET vs CBT-I, similar to population estimates for those with and without insomnia, respectively. Dissemination potential was optimized by cost-effective delivery of CBT-I in group format; telemedicine clinician delivery of CBT-I is noninferior to in-person CBT-I, which would expand dissemination to remote communities,” Irwin et al added. 

Patients were recruited between July 1, 2021, and April 30, 2015, with the follow-up period extended from 24 months to 36 months. Follow-up completion was conducted in July 2018, and analyses were performed from March 1, 2019, through March 30, 2020. A total of 114 patients (73.1%) completed 24 months of follow-up in the CBT-I group, while 117 (86.7%) completed the same in the SET group. After 92 participants (59.0%) in the CBT-I group and 86 participants (63.7%) in the SET group agreed to the additional extension, 81 participants (51.9%) and 77 participants (57.0%) in each group completed the 36-month follow-up period, respectively. 

Included patients were assessed for sleep disturbance, with a required Pittsburgh Sleep Quality Index score greater than 5 points, as well as depression, with a required 10-item Center for Epidemiologic Studies-Depression score of greater than 4 points. CBT-I interventions were conducted by a trained psychologist, while SET interventions were conducted by a trained public health education, both in 120-minute group sessions.

During treatment, no serious adverse events were observed. No serious events were attributed to the trial; however, there were 4 illnesses and 1 death in the CBT-I group and 1 death in the SET group during follow-up. Additional research is required for women and patients of different races who may also have a psychiatric or medical comorbidity, as there is a disproportionate burden of risk of insomnia and depression in these subgroups. 

REFERENCE

Irwin MR, Carrillo C, Sadeghi N, Bjurstrom MF, Breen EC, Olmstead R. Prevention of incident and recurrent major depression in older adults with insomnia. JAMA Psychiat. Published online November 4, 2021. doi:10.1001/jamapsychiatry.2021.3422