Current Psychiatry Reports

, Volume 14, Issue 5, pp 519–528 | Cite as

Cognitive-Behavioral Therapy for the Management of Insomnia Comorbid with Mental Disorders

  • María Montserrat Sánchez-Ortuño
  • Jack D. Edinger
Sleep Disorders (MJ Sateia, Section Editor)


Insomnia is frequently comorbid with psychiatric conditions, mostly depression and anxiety disorders. Because disturbed sleep is a symptom of most major mental disorders, it has been traditionally assumed that effective treatment of the psychiatric condition will resolve the coincident insomnia also. However, insomnia often persists after successful treatment of the comorbid mental disorder, suggesting that insomnia often warrants separate treatment attention. Cognitive-behavioral therapy (CBT) is a well established and efficacious treatment for insomnia. Most evidence supporting the efficacy of CBT comes from studies conducted with patients suffering from primary insomnia, yet over the past 20 years there has been growing support for the use of cognitive-behavioral insomnia intervention for patients with comorbid psychiatric conditions. Overall, promising results have been obtained from these studies, not only with regard to insomnia improvement but also concurrent improvements in comorbid psychiatric conditions. In this article we review recent studies in this area with particular focus on treatment of insomnia in the context of depression, post-traumatic stress disorder, and alcohol dependence.


Sleep disorders Comorbid insomnia Secondary insomnia Insomnia due to a mental disorder Primary insomnia Cognitive-behavioral therapy CBT Mental disorders Depression Anxiety Post-traumatic stress disorder PTSD Alcohol dependence Psychosis 



M.M. Sánchez-Ortuño: none; J.D. Edinger: grant and research support from Philips/Respironics, and royalties from Springer Publishing and Oxford University Press.


Papers of particular interest, published recently, have been highlighted as: Of importance •• Of major importance

  1. 1.
    American Sleep Disorders Association. The international classification of sleep disorders, revised: diagnostic and coding manual. Rochester, MN: American Sleep Disorders Association; 1997.Google Scholar
  2. 2.
    American Psychiatry Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed. Washington, DC: American Psychiatric Association; 2000.Google Scholar
  3. 3.
    American Academy of Sleep Medicine. The international classification of sleep disorders: diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.Google Scholar
  4. 4.
    Stepanski EJ, Rybarczyk B. Emerging research on the treatment and etiology of secondary or comorbid insomnia. Sleep Med Rev. 2006;10(1):7–18.PubMedCrossRefGoogle Scholar
  5. 5.
    Buysse DJ, Reynolds CF, Kupfer DJ, Thorpy MJ, Bixler E, Kales A, et al. Effects of diagnosis on treatment recommendations in chronic insomnia–a report from the APA/NIMH DSM-IV field trial. Sleep. 1997;20(7):542–52.PubMedGoogle Scholar
  6. 6.
    Kupfer DJ. Pathophysiology and management of insomnia during depression. Ann Clin Psychiatry. 1999;11(4):267–76.PubMedGoogle Scholar
  7. 7.
    Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA. 1989;262(11):1479–84.PubMedCrossRefGoogle Scholar
  8. 8.
    Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res. 1997;31(3):333–46.PubMedCrossRefGoogle Scholar
  9. 9.
    Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996;39(6):411–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Johnson EO, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. J Psychiatr Res. 2006;40(8):700–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Buysse D, Reynolds C, Kupfer D, et al. Clinical diagnoses in 216 insomnia patients using the International Classification of Sleep Disorders (ICSD), DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV Field Trial. Sleep. 1994;17(7):630–7.PubMedGoogle Scholar
  12. 12.
    Lichstein KL, Wilson NM, Johnson CT. Psychological treatment of secondary insomnia. Psychol Aging. 2000;15(2):232–40.PubMedCrossRefGoogle Scholar
  13. 13.
    McCrae CS, Lichstein KL. Secondary insomnia: diagnostic challenges and intervention opportunities. Sleep Med Rev. 2001;5(1):47–61.PubMedCrossRefGoogle Scholar
  14. 14.
    Lichstein KL. Secondary insomnia: a myth dismissed. Sleep Med Rev. 2006;10(1):3–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Carney CE, Segal ZV, Edinger JD, Krystal AD. A comparison of rates of residual insomnia symptoms following pharmacotherapy or cognitive-behavioral therapy for major depressive disorder. J Clin Psychiatry. 2007;68(2):254–60.PubMedCrossRefGoogle Scholar
  16. 16.
    Nierenberg AA, Keefe BR, Leslie VC, et al. Residual symptoms in depressed patients who respond acutely to fluoxetine. J Clin Psychiatry. 1999;60(4):221–5.PubMedCrossRefGoogle Scholar
  17. 17.
    Belleville G, Cousineau H, Levrier K, et al. The impact of cognitive-behavior therapy for anxiety disorders on concomitant sleep disturbances: a meta-analysis. J Anxiety Disord. 2010;24(4):379–86.PubMedCrossRefGoogle Scholar
  18. 18.
    •• Myers E, Startup H, Freeman D. Cognitive behavioural treatment of insomnia in individuals with persistent persecutory delusions: a pilot trial. J Behav Ther Exp Psychiatry. 2011;42(3):330–6. In this pilot study, a four-session individual CBT for insomnia intervention in individuals with persecutory delusions was associated not only with subjective sleep improvements, but also with reductions in persecutory delusions. PubMedCrossRefGoogle Scholar
  19. 19.
    Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev. 2009;13(3):205–14.PubMedCrossRefGoogle Scholar
  20. 20.
    Chesson AL, Anderson WM, Littner M, et al. Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999;22(8):1128–33.PubMedGoogle Scholar
  21. 21.
    Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American academy of sleep medicine report. Sleep. 2006;29(11):1415–9.PubMedGoogle Scholar
  22. 22.
    Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;29(11):1398–414.PubMedGoogle Scholar
  23. 23.
    Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10(4):541–53.PubMedGoogle Scholar
  24. 24.
    Edinger JD, Means MK. Cognitive-behavioral therapy for primary insomnia. Clin Psychol Rev. 2005;25(5):539–58.PubMedCrossRefGoogle Scholar
  25. 25.
    Edinger JD, Hoelscher TJ, Marsh GR, et al. A cognitive-behavioral therapy for sleep-maintenance insomnia in older adults. Psychol Aging. 1992;7(2):282–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Morin CM, Kowatch RA, Barry T, Walton E. Cognitive-behavior therapy for late-life insomnia. J Consult Clin Psychol. 1993;61(1):137–46.PubMedCrossRefGoogle Scholar
  27. 27.
    Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307.PubMedCrossRefGoogle Scholar
  28. 28.
    Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.PubMedCrossRefGoogle Scholar
  29. 29.
    Tan TL, Kales JD, Kales A, et al. Inpatient multidimensional management of treatment-resistant insomnia. Psychosomatics. 1987;28(5):266–72.PubMedCrossRefGoogle Scholar
  30. 30.
    Morin CM, Kowatch RA, O'Shanick G. Sleep restriction for the inpatient treatment of insomnia. Sleep. 1990;13(2):183–6.PubMedGoogle Scholar
  31. 31.
    Greeff AP, Conradie WS. Use of progressive relaxation training for chronic alcoholics with insomnia. Psychol Rep. 1998;82(2):407–12.PubMedCrossRefGoogle Scholar
  32. 32.
    Perlis ML, Sharpe M, Smith MT, et al. Behavioral treatment of insomnia: treatment outcome and the relevance of medical and psychiatric morbidity. J Behav Med. 2001;24(3):281–96.PubMedCrossRefGoogle Scholar
  33. 33.
    Krakow B, Johnston L, Melendrez D, et al. An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. Am J Psychiatry. 2001;158(12):2043–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Morawetz D. Insomnia and depression: which comes first? Sleep Res Online. 2003;5:77–81.Google Scholar
  35. 35.
    Currie SR, Clark S, Hodgins DC, El-Guebaly N. Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics. Addiction. 2004;99(9):1121–32.PubMedCrossRefGoogle Scholar
  36. 36.
    Dopke CA, Lehner RK, Wells AM. Cognitive-behavioral group therapy for insomnia in individuals with serious mental illnesses: a preliminary evaluation. Psychiatr Rehabil J. 2004;27(3):235–42.PubMedCrossRefGoogle Scholar
  37. 37.
    DeViva JC, Zayfert C, Pigeon WR, Mellman TA. Treatment of residual insomnia after CBT for PTSD: case studies. J Trauma Stress. 2005;18(2):155–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Currie SR, Wilson KG, Pontefract AJ, deLaplante L. Cognitive-behavioral treatment of insomnia secondary to chronic pain. J Consult Clin Psychol. 2000;68(3):407–16.PubMedCrossRefGoogle Scholar
  39. 39.
    Rybarczyk B, Lopez M, Benson R, et al. Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychol Aging. 2002;17(2):288–98.PubMedCrossRefGoogle Scholar
  40. 40.
    Krupinski J, Tiller JW. The identification and treatment of depression by general practitioners. Aust N Z J Psychiatry. 2001;35(6):827–32.PubMedCrossRefGoogle Scholar
  41. 41.
    Taylor DJ, Lichstein KL, Weinstock J, et al. A pilot study of cognitive-behavioral therapy of insomnia in people with mild depression. Behav Ther. 2007;38(1):49–57.PubMedCrossRefGoogle Scholar
  42. 42.
    Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck depression inventory - 25 years of evaluation. Clin Psychol Rev. 1988;8(1):77–100.CrossRefGoogle Scholar
  43. 43.
    Manber R, Edinger JD, Gress JL, et al. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008;31(4):489–95.PubMedGoogle Scholar
  44. 44.
    Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62.PubMedCrossRefGoogle Scholar
  45. 45.
    Zayfert C, DeViva JC. Residual insomnia following cognitive behavioral therapy for PTSD. J Trauma Stress. 2004;17(1):69–73.PubMedCrossRefGoogle Scholar
  46. 46.
    • Nappi CM, Drummond SP, Hall JM. Treating nightmares and insomnia in posttraumatic stress disorder: a review of current evidence. Neuropharmacology. 2012;62(2):576–85. This is an updated review about different treatments used to treat the sleep disturbance in patients with PTSD. PubMedCrossRefGoogle Scholar
  47. 47.
    Germain A, Shear MK, Hall M, Buysse DJ. Effects of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study. Behav Res Ther. 2007;45(3):627–32.PubMedCrossRefGoogle Scholar
  48. 48.
    •• Swanson LM, Favorite TK, Horin E, Arnedt JT. A combined group treatment for nightmares and insomnia in combat veterans: a pilot study. J Trauma Stress. 2009;22(6):639–42. This brief report includes CBT for insomnia and imagery rehearsal therapy for nightmares to improve sleep disturbance and PTSD symptoms in a sample of patients with PTSD. PubMedGoogle Scholar
  49. 49.
    Foa E, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of PTSD: the Posttraumatic Diagnostic Scale. Psychol Assess. 1997;9:445–51.CrossRefGoogle Scholar
  50. 50.
    •• Ulmer CS, Edinger JD, Calhoun PS. A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study. J Clin Sleep Med. 2011;7(1):57–68. This study includes CBT for insomnia and imagery rehearsal therapy for nightmares to improve sleep disturbance and PTSD symptoms in a sample of patients with PTSD. PubMedGoogle Scholar
  51. 51.
    Weathers F, Huska J, Keane T. The PTSD Checklist Military Version [PCL-M]. Boston, MA: National Center for PTSD; 1991.Google Scholar
  52. 52.
    Drummond SP, Gillin JC, Smith TL, DeModena A. The sleep of abstinent pure primary alcoholic patients: natural course and relationship to relapse. Alcohol Clin Exp Res. 1998;22(8):1796–802.PubMedGoogle Scholar
  53. 53.
    Brower KJ, Aldrich MS, Robinson EA, et al. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry. 2001;158(3):399–404.PubMedCrossRefGoogle Scholar
  54. 54.
    Arnedt JT, Conroy D, Rutt J, et al. An open trial of cognitive-behavioral treatment for insomnia comorbid with alcohol dependence. Sleep Med. 2007;8(2):176–80.PubMedCrossRefGoogle Scholar
  55. 55.
    •• Arnedt JT, Conroy DA, Armitage R, Brower KJ. Cognitive-behavioral therapy for insomnia in alcohol dependent patients: a randomized controlled pilot trial. Behav Res Ther. 2011;49(4):227–33. This study includes CBT for insomnia to improve self-reported sleep and daytime symptoms in a small sample of alcohol-dependent individuals. Furthermore, data about alcohol relapse rates are reported. PubMedCrossRefGoogle Scholar
  56. 56.
    Morin CM, Vallières A, Ivers H. Dysfunctional beliefs and attitudes about sleep [DBAS]: validation of a brief version (DBAS-16). Sleep. 2007;30(11):1547–54.PubMedGoogle Scholar
  57. 57.
    Freeman D, Brugha T, Meltzer H, et al. Persecutory ideation and insomnia: findings from the second British National Survey of Psychiatric Morbidity. J Psychiatr Res. 2010;44(15):1021–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Green CE, Freeman D, Kuipers E, et al. Measuring ideas of persecution and social reference: the Green et al. Paranoid Thought Scales [GPTS]. Psychol Med. 2008;38(1):101–11.PubMedCrossRefGoogle Scholar
  59. 59.
    Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychol Med. 1999;29(4):879–89.PubMedCrossRefGoogle Scholar
  60. 60.
    •• Edinger JD, Olsen MK, Stechuchak KM, et al. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep. 2009;32(4):499–510. This study compares the effects of CBT for insomnia in a sample of primary insomnia sufferers and insomnia sufferers with, primarily, comorbid mental disorders. PubMedGoogle Scholar
  61. 61.
    Edinger JD, Means MK, Carney CE, Manber R. Psychological and behavioral treatments for insomnia II: implementation and specific populations. In: Kryger M, Roth T, Dement W, editors. Principles and practice of sleep medicine. St. Louis, MO: Elsevier; 2011.Google Scholar
  62. 62.
    •• Manber R, Bernert RA, Suh S, et al. CBT for insomnia in patients with high and low depressive symptom severity: adherence and clinical outcomes. J Clin Sleep Med. 2011;7(6):645–52. This study’s results identify aspects of CBT for insomnia that merit attention to improve outcomes among patients with insomnia and elevated depressive symptom severity. PubMedGoogle Scholar
  63. 63.
    • Belleville G, Cousineau H, Levrier K, St-Pierre-Delorme M. Meta-analytic review of the impact of cognitive-behavior therapy for insomnia on concomitant anxiety. Clin Psychol Rev. 2011;31(4):638–52. This meta-analytic includes 72 CBT insomnia trials reporting data on anxiety. The authors conclude that CBT for insomnia has only a moderate impact on anxiety. PubMedCrossRefGoogle Scholar
  64. 64.
    • Sánchez-Ortuño MM, Carney CE, Edinger JD, et al. Moving beyond average values: assessing the night-to-night instability of sleep and arousal in DSM-IV-TR insomnia subtypes. Sleep. 2011;34(4):531–9. This study highlights differences between primary and comorbid insomnia sufferers with respect to self-reported sleep and pre-sleep arousal measures. PubMedGoogle Scholar
  65. 65.
    • Riemann D. Does effective management of sleep disorders reduce depressive symptoms and the risk of depression? Drugs. 2009;69 Suppl 2:43–64. This is a review article discussing whether effective management of sleep disorders could reduce both concurrent depressive symptoms and the risk of developing subsequent depression. PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • María Montserrat Sánchez-Ortuño
    • 1
  • Jack D. Edinger
    • 2
  1. 1.School of NursingUniversity of MurciaMurciaSpain
  2. 2.Department of Medicine, Division of Sleep MedicineNational Jewish HealthDenverUSA

Personalised recommendations