title: Cognitive Behavioral Therapy for insomnia with Veterans: evaluation of effectiveness and correlates of treatment outcomes.
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.
authors.affiliation: Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, USA; Stanford University School of Medicine, USA.
authors.forename: Mickey
authors.initials: M
authors.lastname: Trockel
authors.affiliation: 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.
authors.forename: Bradley E
authors.initials: BE
authors.lastname: Karlin
authors.affiliation: Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, USA; Stanford University School of Medicine, USA.
authors.forename: C Barr
authors.initials: CB
authors.lastname: Taylor
authors.affiliation: Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, USA; Stanford University School of Medicine, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Manber
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D017060:Patient Satisfaction; D007319:Sleep Initiation and Maintenance Disorders / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology*; D055815:Young Adult
keywords: Adherence; Alliance; Cognitive Behavioral Therapy; Dissemination; Insomnia; Veterans