The Impact of Cognitive-Behavioral Interventions on Sleep Disturbance in Depressed and Anxious Community-dwelling Older Adults: A Systematic Review

Figures & data

Figure 1. PRISMA diagram of the study selection process.

Table 1. Quality ratings from the EPHPP quality assessment tool.

Publication Author (Date)	Selection Bias	Study Design	Confounders	Blinding	Data Collection Methods	Withdrawals & Dropouts	Global Rating
Randomized control trials
Brenes et al. (2012)	Weak	Strong	Strong	Moderate	Strong	Strong	Moderate
Brenes et al. (2016)	Weak	Strong	Weak	Moderate	Strong	Moderate	Weak
Brenes et al. (2020)	Weak	Strong	Strong	Weak	Strong	Moderate	Weak
Bush et al. (2012)	Weak	Strong	Weak	Moderate	Strong	Strong	Weak
Freshour et al. (2016)	Weak	Strong	Strong	Moderate	Strong	Strong	Moderate
Nadorff et al. (2014)	Weak	Strong	Strong	Moderate	Strong	Moderate	Moderate
Sadler et al. (2018)	Moderate	Strong	Strong	Moderate	Strong	Strong	Strong
Stanley et al. (2014)	Weak	Strong	Strong	Moderate	Strong	Strong	Moderate
Stanley et al. (2018)	Weak	Strong	Strong	Moderate	Strong	Moderate	Moderate
Cohort designs
Landreville et al. (2016)	Moderate	Moderate	Strong	Weak	Strong	Strong	Moderate
Lichstein et al. (2013)	Weak	Moderate	Strong	Weak	Strong	Strong	Weak

Table 2. Review studies.

Publication Author (Date)	Total N	Country	Mean Age (SD)	Sex (% female)	Design	Intervention	Comparison condition	Sleep Quality Measures	Other Measures	Findings
Studies assessing CBT interventions for late-life anxiety
Brenes et al. (2012)	60	USA	68.8 (7.3)	83%	RCT	Telephone CBT, including telephone sessions and a workbook consisting of eight chapters: treatment rationale, relaxation techniques, cognitive therapy, problem-solving, thought stopping, behavioral activation, in-vivo exposure and relapse prevention. Two optional chapters on sleep and pain. Booster sessions 2, 4, 8 and 12 weeks after completion.	Information-only comparison: written information on anxiety disorders and a list of referral options were provided.	ISI (S)	PSWQ STAI-T HAMA ASI BDI SF-36	The CBT-T treatment group had greater reductions in insomnia severity at post-treatment, compared to the information-only control group (between-group E.S. = 0.82, p = .005) but the difference in treatment groups was not maintained at the six-month follow-up (between-group E.S. = 0.42, p = .14). The CBT-T group also had greater improvements in anxiety, worry and anxiety sensitivity post-treatment, compared to the information-only group.
Brenes et al. (2016)	141	USA	66.8 (6.2)	82%	RCT	Telephone CBT, including 11 weekly telephone sessions and workbook addressing: anxiety symptoms, relaxation, cognitive restructuring, coping statements, problem-solving, worry control, behavioral activation, exposure therapy and relapse prevention. Two optional sessions on sleep and pain. Booster sessions 2, 4, 8 and 12 weeks after completion.	Telephone-delivered nondirective supportive therapy (NST) that consisted of 10 weekly sessions of supportive therapy. Booster sessions 2, 4, 8 and 12 weeks after completion.	ISI (P)	SF-36 PCT-D	The CBT-T intervention group experienced significantly greater reductions in insomnia severity than the group receiving NST at the four-month follow-up (between-group F = 10.21; p = .002; E.S. = 0.27), an improvement which was maintained at the 9- and 15-month follow-up. The CBT group also experienced greater improvements in health-related quality of life at the 4-month follow-up, relative to the NST group. There was no between-group differential effect on physical disability symptoms between the CBT and NST groups post-intervention (between-group F = 2.60, p = .109).
Brenes et al. (2020)	500	USA	66.5 (5.2)	87%	RPT	CBT consisted of 10 weekly telephone sessions in conjunction with a standardized workbook that consisted of homework/daily practice. CBT topics covered: relaxation techniques, cognitive restructuring, coping statements, problem solving, worry control, behavioral activation, exposure therapy, sleep, pain and relapse prevention.	Yoga: Consisted of 20 75-minute group classes twice a week using an intervention protocol. Classes included centering and breathing, posture practice, and meditation/relaxation.	ISI (S)	PSWQ-A PROMIS	The CBT intervention group had a greater reduction in insomnia symptoms compared with the yoga intervention group (between-group p < .01). There was also a reduction in worry in both the CBT and yoga arms of the trial, but findings suggest that CBT was not superior to yoga in reducing PSWQ-A scores post-intervention (between-group p = .08).
Bush et al. (2012)	134	USA	66.9 (5.8)	78%	RCT	CBT consisted of 10 weekly sessions focusing on psychoeducation, motivational interviewing, relaxation training, cognitive restructuring, exposure, problem-solving skills, and behavioral sleep management.	Enhanced Usual Care (EUC) consisted of 15-minute biweekly telephone calls that focused on providing support and safety monitoring.	PSQI (P)	PSWQ BAI BDI MSPSS LOT	At post-treatment, the CBT group reported significantly greater reductions in PSQI global scores than the group receiving EUC (between-group F = 6.76, p = .0107). However between-group pre- and post-treatment changes on the PSQI component scores did not reach significance. At follow-up, post-treatment group differences were maintained in global PSQI score, with the CBT intervention group reporting significantly better subjective sleep quality (between-group F = 13.61, p = .0003), shorter sleep latency (between-group F = 4.10, p = .045) and less frequent sleep disturbances (between-group F = 8.47, p = .0043), relative to the EUC group.
Freshour et al. (2016)	112	USA	66.8 (6.4)	54%	RCT	CBT administered by expert providers. Follow-up study to Stanley et al. (2014). See Stanley et al. (2014) for intervention details.	CBT administered by lay providers. Follow-up study to Stanley et al. (2014). See Stanley et al. (2014) for intervention details.	ISI (S)	GADSS STAI-T SIGH-A PHQ-8 SF-12	The CBT intervention outcomes reported in Stanley et al. (2014) were maintained at follow-up. There was no significant main effect of treatment group (expert vs. lay providers; F = 0.02, p = .88) or time (F = 0.54, p = .58) on ISI scores. Furthermore, there was no significant interaction between time and treatment on ISI scores (F = 0.39, p = .68), suggesting that the improvements in sleep disturbance were maintained at follow-up and were equivalent between expert and lay providers.
Landreville et al. (2016)	3	Canada	67.7 (2.1)	66%	SCED	CBT guided self-help consisting of 8 modules delivered over 15 weeks, including: therapy objectives, components of anxiety, relaxation, tolerating uncertainty, pleasant activities scheduling, correcting false beliefs about worry, problem-solving skills, cognitive exposure and relapse prevention.	N/A	ISI (S)	PSWQ-A AOS GAD-7 IUI NPOQ CAQ WWQ GAI GDS SDS	The intervention was found to improve time spent worrying and the psychological processes targeted by treatment. All participants no longer met diagnostic criteria for GAD at post-intervention. At baseline all three participants had sleep disturbance meeting diagnostic criteria for insomnia (ISI < 10), which reduced to non-clinical levels at post-intervention and 6-month follow-up. Reliable change index also suggested statistically significant improvement in sleep for each participant.
Nadorff et al. (2014)	134	USA	67.4 (6.2)	78%	RCT	CBT consisted of 10 weekly sessions, including: psychoeducation, anxiety recognition, relaxation training, cognitive therapy, exposure therapy, problem-solving and sleep hygiene. Booster sessions at 4, 7, 10 & 13 months.	Enhanced Usual Care (EUC) that consisted of biweekly phone calls to provide support and ensure participant safety.	PSQI (P)	PSWQ BAI BDI QOLI SF-12	The CBT intervention group had greater reductions in bad dream frequency across the assessment period, relative to the EUC group (between-group b = –.07, p= .04). When baseline bad dream frequency was controlled for, the CBT intervention group had fewer bad dreams at post-treatment than those in the EUC group (between-group t (112) = 2.19, p = .03).
Stanley et al. (2014)	223	USA	66.9 (6.6)	53%	RCT	CBT delivered by expert providers; 10 sessions delivered over 3 months. Core components: education, awareness training, motivational interviewing, deep breathing, coping self-statements. Optional modules: behavioral activation, exposure, sleep management, problem-solving, progressive muscle relaxation, thought stopping, cognitive restructuring.	CBT delivered by lay providers; 10 sessions delivered over 3 months. Core components: education, awareness training, motivational interviewing, deep breathing, coping self-statements. Optional modules: behavioral activation, exposure, sleep management, problem-solving, progressive muscle relaxation, thought stopping, cognitive restructuring. Usual Care.	ISI (S)	GADSS STAI-T SIGH-A PHQ-8 SF-12	There was a significant main effect of the treatment group (lay provider, expert provider or usual care). Both CBT treatment groups were observed to have better outcomes (GAD severity, anxiety, depressive symptoms and mental health quality of life) than the usual care group. The two CBT groups, with lay or expert providers, produced comparable improved outcomes in GAD severity, anxiety, depressive symptoms and mental health quality of life. There was a significant main effect of treatment group on ISI scores (between-group F = 4.92, p = .007). Lay and expert provider treatment groups were equivalent in reduction of insomnia symptoms (between-group t = −.28, p = .781), and both lay (between-group t = −2.56, p = .011) and expert (between-group t = −2.85, p = .005) providers were statistically superior to treatment-as-usual.
Stanley et al. (2018)	148	USA	66.7 (9.4)	82%	RCT	CBT skills training program: “Calmer Life”. Up to 12 sessions over three months completed face to face or by telephone. Consisted of intervention components to address mental health and basic unmet needs such as resource counseling, communication, incorporation of religion/spirituality and flexibility in skill content.	Enhanced Community Care with Resource Counseling (ECC-RC). One 30-minute session followed by biweekly 15-minute sessions. Consisted of resource counseling.	ISI (S)	PSWQ-A GAD-7 GAI-SF PHQ-8 GDS	In intention to treat analyses, there were similar improvements in insomnia symptoms in both treatment conditions, but the between-group (CBT vs. ECC-RC) difference in insomnia symptoms was not significant at either the 6 month follow-up (p = .68) or 9 month follow-up (p = .60). A similar pattern of results was seen in other measures including worry and anxiety. In the treatment group combined analyses, there was a significant reduction in ISI scores from baseline to 6 months (within-participants t =  −4.24, p < .0001), and baseline to 9 months (within-participants t = −4.84, p < .0001).
Studies assessing CBT interventions for late-life depression
Lichstein et al. (2013)	5	USA	65.8 (10.4)	80%	Cohort	Telephone CBT consisting of 10 weekly sessions. Insomnia components: sleep hygiene, sleep compression, stimulus control and passive relaxation. Depression components: cognitive-behavioral mediational model, behavioral activation, identification and disputation of unhelpful thoughts.	N/A	CSD (P) ISI (P)	HRSD WAI-O	The CSD showed a meaningful improvement in all variables between baseline and post-treatment, including: sleep onset latency (within-participant E.S. = −1.10), number of awakenings (within-participant E.S. = −0.94), wake after sleep onset (within-participant E.S. = −2.03), and sleep quality rating (within-participant E.S. = +0.63). There was a reduction in the ISI (within-participant E.S. = −1.64), which reduced from clinical levels at baseline, to non-clinical levels at post-treatment and follow-up.
Sadler et al. (2018)	72	Australia	75.0 (7.0)	55%	RCT	Group CBT-I or CBT-I+ (advanced). Consisted of 8 weekly sessions. CBT-I components: stimulus control, sleep restriction, sleep hygiene, relaxation, cognitive restructuring and relapse prevention. CBT-I+ components: components from CBT-I plus behavioral activation, cognitive reframing and positive affirmations.	Psychoeducation control group. Consisted of 8 weekly group sessions. Included psychoeducation about sleep, insomnia and depression.	ISI (P) CSD (S)	GDS DBAS-10 SLEEP-50 GAI-SF BHS EQ-5D-3L	There was a significant main effect of treatment condition (CBT-I vs. CBT-I+ vs. control) on insomnia symptoms (between-group F = 4.01, p = .023) but not on depressive symptoms (between-group F = 2.03, p= .139). The was also a significant treatment and time interaction, as the CBT-I and CBT-I+ intervention groups resulted in significantly greater reductions in insomnia severity (F = 12.24, p < .001) and depressive symptoms (F = 13.66, p < .001) from pre- to post-intervention, relative to the psychoeducation control. Both CBT-I treatment conditions resulted in significant reductions in insomnia severity at post-treatment and follow up – CBT-I (within-participants E.S. = 2.57, 2.82, respectively); CBT-I+ (within-participants E.S. = 2.75, 2.35, respectively). However, the difference between CBT-I groups was not significant. There were also significant improvements across each of the sleep diary parameters for both CBT-I and CBT-I+ from baseline to post-intervention (within-participant p < .001), although no significant differences were reported between the CBT-I treatment conditions.

N/S = not stated. RCT = randomized control trial. RPT = randomized preference trial. SCED = single case experimental design. E.S. = effect size. Sleep measures: ISI = Insomnia Severity Index. PSQI = Pittsburgh Sleep Quality Index. CSD = Consensus Sleep Diary. P = primary study outcome measure, S = secondary study outcome measure. Quality ratings: W = weak, M = moderate, S = Strong.

Brenes, G. A., Miller, M. E., Williamson, J. D., McCall, W., Knudson, M., & Stanley, M. A. (2012). A randomized controlled trial of telephone-delivered cognitive-behavioral therapy for late-life anxiety disorders*. The American Journal of Geriatric Psychiatry, 20(8), 707–716. https://doi.org/https://doi.org/10.1097/JGP.0b013e31822ccd3e

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Brenes, G. A., Danhauer, S. C., Lyles, M. F., Anderson, A., & Miller, M. E. (2016). The effects of telephone-delivered cognitive-behavioral therapy and nondirective supportive therapy on sleep, health-related quality of life, and disability*. The American Journal of Geriatric Psychiatry, 24(10), 846–854. https://doi.org/https://doi.org/10.1016/j.jagp.2016.04.002

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Brenes, G. A., Divers, J., Miller, M. E., Anderson, A., Hargis, G., & Danhauer, S. C. (2020). Comparison of cognitive-behavioral therapy and yoga for the treatment of late-life worry: A randomized preference trial*. Depression and Anxiety, 37(12), 1194–1207. https://doi.org/https://doi.org/10.1002/da.23107

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Bush, A. L., Armento, M. E., Weiss, B. J., Rhoades, H. M., Novy, D. M., Wilson, N. L., Kunik, M. E., & Stanley, M. A. (2012). The Pittsburgh sleep quality index in older primary care patients with generalized anxiety disorder: Psychometrics and outcomes following cognitive behavioral therapy*. Psychiatry Research, 199(1), 24–30. https://doi.org/https://doi.org/10.1016/j.psychres.2012.03.045

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*Nadorff, M. R., Porter, B., Rhoades, H. M., Greising, A. J., Kunik, M. E., & Stanley, M. A. (2014). Bad dream frequency in older adults with generalized anxiety disorder: Prevalence, correlates, and effect of cognitive behavioral treatment for anxiety. Behavioral Sleep Medicine, 12(1), 28–40. https://doi.org/https://doi.org/10.1080/15402002.2012.755125

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*Sadler, P., McLaren, S., Klein, B., Harvey, J., & Jenkins, M. (2018). Cognitive behavior therapy for older adults with insomnia and depression: A randomized controlled trial in community mental health services. Sleep, 41(8), 1–12. https://doi.org/https://doi.org/10.1093/sleep/zsy104

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*Stanley, M. A., Wilson, N. L., Shrestha, S., Amspoker, A. B., Wagener, P., Bavineau, J., Turner, M., Fletcher, T. L., Freshour, J., Kraus-Schuman, C., & Kunik, M. E. (2018). Community-based outreach and treatment for underserved older adults with clinically significant worry: A randomized controlled trial. The American Journal of Geriatric Psychiatry, 26(11), 1147–1162. https://doi.org/https://doi.org/10.1016/j.jagp.2018.07.011

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Landreville, P., Gosselin, P., Grenier, S., Hudon, C., & Lorrain, D. (2016). Guided self-help for generalized anxiety disorder in older adults*. Aging & Mental Health, 20(10), 1070–1083. https://doi.org/https://doi.org/10.1080/13607863.2015.1060945

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*Lichstein, K. L., Scogin, F., Thomas, S. J., Dinapoli, E. A., Dillon, H. R., & McFadden, A. (2013). Telehealth cognitive behavior therapy for co-occurring insomnia and depression symptoms in older adults. Journal of Clinical Psychology, 69(10), 1056–1065. https://doi.org/https://doi.org/10.1002/jclp.22030

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