Sleep training for adults prevents

depression, study finds

(CNN)Undergoing cognitive behavioral sleep training, which teaches you how to break
bad habits in order to prepare your mind and body for a good night's sleep, may help
prevent depression in older adults with insomnia, a new clinical trial has found.

"What is exciting about these findings is that they are among the first to demonstrate
that treating insomnia with a behavioral strategy, not a pill, can prevent the development
of depression in older adults," said sleep specialist Wendy Troxel, a senior behavioral
scientist at RAND Corporation, who was not involved in the study
The study's findings are "highly significant" because major depression is very common among
older adults and "is associated with an increased risk of cognitive decline, disability, suicide and
all-cause mortality," Troxel added.
Numerous studies have shown that insomnia is a major risk factor for depression, and "some
30% to 50% of older adults complain of insomnia," said study author Dr. Michael Irwin, a
professor of psychiatry and biobehavioral sciences in the David Geffen School of Medicine at
UCLA.
Adults in the randomized clinical trial who received cognitive behavior therapy for their insomnia
were two times less likely to develop depression, Irwin said, adding that if remission from
insomnia was sustained for three years, "there was an 83% reduction in the likelihood of
developing depression."

"That's why this study is so important," Irwin said. "We have shown that we can actually
target insomnia with cognitive behavior therapy and prevent depression from occurring."

Therapist involvement was key

The study, published Wednesday in the journal JAMA Psychiatry, randomly split adults over
age 60 with insomnia but without depression into two groups. Every week for two months, a
control group received eight weeks of basic sleep education, which taught sleep hygiene,
characteristics of healthy sleep, sleep biology, and how stress can impact sleep. But there
was no one-on-one training, Irwin said: "They had to take that information and figure out
how to use it without our help."
The other group received a form of behavioral sleep training called CBT-1, administered
in person in a group setting by trained therapists for eight weeks.
"The benefit of this treatment approach is that it used the most evidence-based
behavioral treatment for insomnia, CBT-I, which has been proven to be as effective,
longer lasting, and (have) fewer side effects than sleep medications -- which can be
particularly problematic in older adults," Troxel said.
CBT-I has five components: Stimulus control, sleep restriction, sleep hygiene, relaxation
and cognitive behavioral therapy. Sleep hygiene and relaxation involve good sleep
habits -- going to bed and getting up at the same time each day, eliminating blue light
and noise, taking warm baths or doing yoga for relaxation, and keeping the bedroom
cool and free of electronic devices.
Stimulus control involves "getting people to get out of bed when they're not able to
sleep," Irwin said. Most people stay in bed, fretting about not falling asleep, which then
turns the bed into a negative space, he explained. Instead, people are taught to get up
after 10 minutes of tossing and turning, do quiet, non-stimulating activites, and "not to
come back to bed until they are sleepy."
Sleep restriction involves limiting time in bed to only the period a person sleeps, plus 30
minutes. It's another way to get people with insomnia to get up instead of lying in bed
awake.
Cognitive therapy works to disrupt "dysfunctional thoughts and beliefs about sleep," Irwin said,
such as "I can never sleep," or "I might die if I don't sleep tonight." A therapist works with the
person to counter such illogical thinking, easing them back into a more realistic mindset that will
allow them to relax and see the bed as a welcoming place.
"I really think a group setting is also really important," Irwin said, "because hearing other
people's difficulties and how they are solving them can often help inform you about something
that you may be dealing with."

A means to an end
At the end of two months, treatment ended, with no further intervention. However, the study
then followed the 291 people for three years, checking in each month to ask about symptoms of
depression.

The group that received CBT-I training with the help of a sleep coach often kept the
training going in their own lives, Irwin said, with good results: "About a third of the
people were still free of insomnia at the end of the three-year study."
The group which received sleep education did show "modest effects in improving and
treating insomnia but (the improvements) were not durable. They didn't last," Irwin said.
"That's why CBT-I is so effective in person, because the therapist is helping that
individual navigate and negotiate with themselves -- and it can be really hard work,"
Irwin added. "I believe that's also why CBT-I apps or online tools often don't work --
people get frustrated, disappointed or angry at themselves, and they basically stop the
work."
The study's results show "a completely new and innovative way" of tackling the growing
problem of depression, wrote Pim Cuijpers, a professor of Clinical Psychology at the
Vrije Universiteit Amsterdam, and Dr. Charles Reynolds, a professor in geriatric
psychiatry at the University of Pennsylvania Medical Center, in an editorial published
alongside the study.
"The stigma associated with major depression as a mental disorder is one of the main
reasons for not seeking treatment," wrote Cuijpers and Reynolds, who were not
involved in the study.
"This major finding offers exciting new opportunities for the prevention field and opens a
new field of research into indirect preventive interventions for avoiding the stigma of
mental disorders."