We tested whether augmenting conventional depression treatment in youth by treating sleep issues with cognitive behavioral therapy for insomnia (CBT-I) improved depression outcomes. We randomized youth 12-20 years of age to 10 weekly sessions of a sleep hygiene control condition (SH) combined with CBT for depression (CBT-D) (n=19), or an experimental condition consisting of CBT-I combined with CBT-D (n=22).
We assessed outcomes through 26 weeks of follow-up and found medium-large effects favoring the experimental CBT-I arm on some sleep outcomes (actigraphy total sleep time and Insomnia Severity Index “caseness”) and depression outcomes (higher percentage recovered, faster time to recovery), but little effect on other measures. Total sleep time improved by 99 minutes from baseline to week 12 in the CBT-I arm, but not in the SH arm. In addition, our pilot yielded important products to facilitate future studies: the youth-adapted CBT-I program; the study protocol; estimates of recruitment, retention, and attrition; and performance and parameters of candidate outcome measures.
Unipolar depression is a common clinical disorder in adolescence and is marked by frequent recurrence and considerable impairment (Zalsman, Brent, & Weersing, 2006). Early-onset depression is a potent predictor of lifelong recurrent depression (Carballo et al., 2011), suggesting that aggressive treatment of youth-onset depression might ameliorate future risk. Unfortunately, conventional treatments (e.g., antidepressants, cognitive behavioral therapy [CBT], combination treatment) have produced outcomes that are modest at best (March et al., 2004; Weersing & Brent, 2006; Weisz, McCarty, & Valeri, 2006).
We sought to augment depression-focused treatment with an additional intervention to address an associated but distinct condition—insomnia—that interferes with depression recovery, and/or contributes to residual problems. Specifically, we focused on improving sleep in youth depression using cognitive behavioral treatment for insomnia (CBT-I).
There is good rationale for addressing insomnia to improve depression outcomes. First, there is high comorbidity between youth depression and insomnia (Liu et al., 2007; Wolfson & Carskadon, 1998). Second, longitudinal studies indicate that teen insomnia typically precedes depression and predicts its onset (Johnson, Breslau, Roehrs, & Roth, 1999; Johnson, Roth, & Breslau, 2006; Roberts, Roberts, & Chen, 2002) suggesting that insomnia may contribute to depression onset. Third, concurrent insomnia is associated with poorer response to treatment for depression in adults (Emslie et al., 2001; Thase, Simons, & Reynolds, III, 1996). Moreover, residual insomnia is a major component of incompletely remitted depression in both youth and adults (Kennard et al., 2006; Becker, 2006; Smith, Huang, & Manber, 2005) and increases risk of depression recurrence in adults (Dombrovski et al., 2008). Finally, there are now several trials demonstrating that psychological and pharmacological treatments for insomnia markedly improve depression in adults beyond the effects of traditional depression treatments (Fava et al., 2006; Krystal et al., 2007; Manber et al., 2008; Watanabe et al., 2011).
However, the lack of a well-tested insomnia treatment for youth has stymied research in this area. While results from several positive trials of insomnia treatments in depressed adults are encouraging, developmental differences between youth and adult insomnia argue for youth-specific treatments (Clarke & Harvey, 2012). Previous pilots of youth CBT-I, though promising, have lacked a randomized control condition (Bootzin & Stevens, 2005; Schlarb, Liddle, & Hautzinger, 2011). Therefore, we conducted a pilot randomized trial among adolescents with insomnia and unipolar depression. Youth were randomized to either a sleep hygiene control condition (SH) combined with CBT for depression (CBT-D), or an experimental condition consisting of CBT-I combined with CBT-D. This feasibility pilot was not powered for formal hypothesis testing. Nonetheless, we predicted that that youth randomized to CBT-I would have better sleep and depression outcomes than those in the SH control arm. Other important products of this pilot were estimates of recruitment, retention, and intervention and study protocols.
