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Cognitive Behavioral Treatmentin Clinically Referred ChronicInsomniacs: Group VersusIndividual TreatmentIngrid H. Verbeek , Gerdy M. Konings , Albert P.Aldenkamp , August C. Declerck & Ed C. KlipPublished online: 07 Jun 2010.

To cite this article: Ingrid H. Verbeek , Gerdy M. Konings , Albert P. Aldenkamp ,August C. Declerck & Ed C. Klip (2006) Cognitive Behavioral Treatment in ClinicallyReferred Chronic Insomniacs: Group Versus Individual Treatment, Behavioral SleepMedicine, 4:3, 135-151, DOI: 10.1207/s15402010bsm0403_1

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Cognitive Behavioral Treatment in

Clinically Referred Chronic Insomniacs:

Group Versus Individual Treatment

Ingrid H. Verbeek, Gerdy M. Konings,

Albert P. Aldenkamp, and August C. Declerck

Center for Sleep and Wake Disorders Kempenhaeghe

Heeze, The Netherlands

Ed C. Klip

Department of Medical Psychology

Groningen Academic Hospital

Groningen, The Netherlands

In this study, we compared the effect of group and cognitive behavioral treatment

(CBT) in clinically referred patients with chronic insomnia. The participants were 32

individually treated primary insomniacs and 74 individuals with either primary or

secondary insomnia treated in a group (5–7 patients per group). The primary out-

come measures were subjective sleep, quality of life (QOL), and psychological

well-being. CBT produced significant changes in sleep onset latency, total sleep

time, sleep efficiency, and wake after sleep onset. For total sleep time and sleep effi-

ciency, the improvements were maintained at follow-up as well. In the question-

naires, significant improvements from treatment were seen for the Sickness Impact

Profile, Sleep Evaluation Form, and Dysfunctional Beliefs and Attitudes About

Sleep. All these improvements remained significant at follow-up. We conclude that

CBT for insomnia is effective for both individual and group treatment. Improvements

were seen in subjective sleep parameters, QOL, attitudes about sleep, and sleep eval-

uation in general, both posttreatment and at follow-up.

In the last decade, behavioral treatment strategies have been established as a sub-

stitute or support for pharmacological treatment in insomnia (Chesson et al., 1999;

BEHAVIORAL SLEEP MEDICINE, 4(3), 135–151

Copyright © 2006, Lawrence Erlbaum Associates, Inc.

Correspondence should be addressed to Ingrid H. Verbeek, Center for Sleep and Wake Disorders

Kempenhaeghe, Sterkselseweg 65, 5590 AB, Heeze, The Netherlands. E-mail:

verbeeki@kempenhaeghe.nl

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Edinger & Wohlgemuth, 1999; Espie, 1991; Hauri, 1997; Morin, 1993; Oosterhuis

& Klip, 1993, 1997; Verbeek, Schreuder, & Declerck, 1999). These behavioral

techniques include sleep information, sleep hygiene guidelines, relaxation, stimu-

lus control, sleep restriction, and cognitive techniques. The format of treatment

may vary from individual to group or even self-help treatment. In addition to its

cost effectiveness, group therapy has several advantages. First, it provides the op-

portunity for patients to share a problem with fellow patients. Second, model pa-

tients may be strong allies of the therapist in convincing other patients to comply

with the prescribed regime. It is not always possible or desirable to treat insomnia

patients in a group. Some patients may simply prefer individual treatment, or the

clinician may decide that a patient’s individual psychopathology is severe enough

that it would interfere with the group process. Several studies have been published

on the results of group therapy for insomnia. A meta-analysis of 59 outcome stud-

ies that used a group design showed that nonpharmacological interventions pro-

duce reliable and durable changes in the sleep patterns of patients with chronic in-

somnia (Morin, Culbert, & Schwartz, 1994). Oosterhuis and Klip evaluated the

effect of group therapy on chronic insomniacs in primary care. The therapy was

implemented as a course consisting of eight meetings. A group of 27 people who

followed the course was compared with a wait-list control group of 17 people.

Quality of sleep increased significantly in the experimental group. Espie, Inglis,

Tessier, and Harvey (2001) found that group cognitive behavioral treatment (CBT)

offered by primary care nurses instead of clinical psychologists was found to be an

effective treatment for insomnia. Backhaus, Hohagen, Voderholzer, and Riemann

(2001) showed long-term effectiveness in group CBT of six weekly sessions. After

therapy, patients improved their total sleep time and sleep efficiency and reduced

their sleep latency, depression scores, and negative sleep-related cognitions. Re-

cently, a comparison between individual, group, and telephone consultation

showed that there were no significant differences across these three methods of

treatment implementation (Bastien, Morin, Ouellet, Blais, & Bouchard, 2004).

Unfortunately, there were no quality-of-life (QOL) parameters in these studies.

Assessment of QOL may provide important information regarding the actual se-

verity and functional limitations of insomnia, as well as the value of its treatment.

One generally accepted definition of QOL is “the functional impact of an illness

and its consequent therapy upon the patient, as perceived by the patient” (Schipper,

Clinch, & Powell, 1990). Idzikowski (1996) reported the following domains:

physical (ability to conduct activities of daily living), psychological (emotional

problems), and social (interactions with family, friends, and community). Insom-

nia affects all three of these domains. In spite of several attempts to develop a con-

dition-specific QOL measure for insomnia, none has been well validated and

widely used. The coexistence of insomnia with mood disorders and numerous

other health and environmental conditions adds to the challenge of developing a

QOL measure for insomnia (Reimer & Flemons, 2003). A study by Zammit,

136 VERBEEK ET AL.

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Weiner, Damato, Sillup, and McMillan (1999) showed that significant QOL im-

pairments are associated with insomnia. Individuals were recruited through media

advertisements, and data were obtained from individuals with insomnia and from

individuals without sleep complaints (controls). The insomnia group reported

greater impairments on specific QOL domains of the Short-Form Health Survey

(SF–36; Ware & Sherbourne, 1992). No differences were found between partici-

pants receiving pharmacological treatment for insomnia and those who were un-

treated. The influence of CBT on QOL and psychological well-being in connec-

tion with insomnia has not been carefully investigated, and previous articles often

lacked follow-up data. Verbeek, Sweere, and Klip (2005) found improvements in

QOL in individually treated patients (fewer problems with work, improved alert-

ness, more social interactions, and more recreational activities). The improve-

ments were maintained at 6- and 12-month follow-ups. Few data are currently

available about the effect of group treatment on QOL.

The vast majority of insomnia studies has been carried out on participants re-

cruited through media ads. To date, only a few clinical studies have been performed

onpatients seeking treatment inclinical settings.This is important becauseevidence

based on psychometric measures and daytime alertness shows that recruited partici-

pants may not be representative of insomniacs seeking medical attention. Physi-

cian-referred participants with chronic insomnia had higher scores in the pathologi-

cal range on psychometric measures than self-referred participants (Stepanski,

Koshorek, Zorick, Glinn, Roehrs, & Roth, 1989). In his review of the efficacy of

nonpharmacological treatment of chronic insomnia, Morin (Morin, Hauri, et al.,

1999)described that additionaloutcomeresearch isneeded toexamine theeffective-

ness of treatment when it is implemented in clinical settings. Martin and Ancoli-Is-

rael (2002) found significant differences between clinic-based and research-based

studies in the screening assessments, exclusion criteria, and participant drop-out

rate. This heterogeneity in assessment and diagnosis makes cross-study participant

comparisons challenging. They advised replicating in clinical practice the interven-

tions that were carried out in research settings. The value of our study lies in the fact

that it concerns clinically referred patients, and we included QOL parameters.

Theaim of this studywas toevaluate the short- and long-term effectsof groupand

individual CBT in clinically referred patients with chronic insomnia. The primary

outcome measures were subjective sleep, QOL, and psychological well-being.

METHOD

Participants

The participants for individual treatment were 32 chronic primary insomniacs (20

females, 12 males). These participants participated in a study in 1999 that analyzed

CHRONIC INSOMNIACS 137

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the effects of short-term CBT on subjective sleep and QOL in primary insomniacs

without regular use of hypnotics. From 2000, we switched to group therapy; from

that time on, individual treatment was offered only according to the following ex-

clusion criteria. We did not use these individually treated patients in the analyses.

Group treatment included both primary and secondary insomniacs. The partici-

pants for group treatment were 74 chronic insomnia patients (45 females, 29

males) divided over 12 groups (5–7 participants per group). Analyses were made

only for patients who had usable sleep log and questionnaire data at all four mea-

surement times: (a) baseline, (b) postwait-list, (c) after therapy, and (d) 9 months

after therapy. For group treatment and for individual treatment, 40 patients and 18

patients, respectively, had usable data for sleep logs and questionnaires according

to these criteria. All patients were referred to a specialized sleep center by their

general practitioner or specialist and had a primary complaint of insomnia. They

all received a sleep questionnaire that included medical history and a sleep log for

a 2-week period. All patients were screened by a physician for medical history and

sleep history. As needed, polysomnography according to the international criteria

(American Sleep Disorders Association, 1997, 1995) was performed. We only in-

cluded insomniacs without organic sleep disorders. Inclusion criteria were (a) pri-

mary symptom of insomnia defined as having, on at least 4 nights per week, symp-

toms of a sleep onset latency and/or wake after sleep onset of at least 30 min and a

sleep efficiency of no more than 85%; (b) negative effect during waking hours

(e.g., fatigue, impaired functioning, mood disturbances) attributed to insomnia; (c)

insomnia duration of at least 0.5 years; and (d) indication for CBT (bad sleep hy-

giene and/or dysfunctional sleep habits and/or dysfunctional thoughts about

sleep). Exclusion criteria (a) present psychopathology as determined by the psy-

chological interview with a potentially interfering effect on group therapy (e.g., se-

vere depression or burn-out; n = 66). For individual treatment, exclusion was based

on the Symptom Check List (SCL–90) scores of anxiety (score above 22 for men,

above 27 for women) and depression (above 34 for men, above 42 for women; n =

73); (b) patients who refused group therapy (only for group therapy; n = 8); (c) reg-

ular use of hypnotics (greater than or equal to 3 nights a week) and the use of anti-

depressants or over-the-counter medication (only for individual therapy; n = 39).

All patients participated voluntarily in the study, and none were paid or had to pay

for their participation.

Treatment

All participants underwent CBT, psychoeducation, sleep hygiene, stimulus control,

sleep restriction, relaxation exercises, and cognitive restructuring. Sleep restriction

is designed to consolidate sleep. The essential features of this intervention are an ini-

tial reduction in time spent in bed, followed by a gradual and slow extension of time

in bed that begins once sleep is consolidated. The instructions for stimulus control

138 VERBEEK ET AL.

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are based on the principle of classical conditioning and are designed to strengthen

the bed as a cue for sleep while weakening it as a cue for activities that are incompati-

ble with sleep (only go to bed when sleepy, use the bed only for sleep, get out of bed

when unable to sleep, wake up at the same time regardless of how much you slept).

Both group and individual treatment contained six consecutive weekly sessions

(each group session lasted 2.5 hr; each individual session lasted 1 hr). The length of

the group sessions was much longer compared with the individual sessions because

for each participant, homework was discussed. Of course, this takes more time in a

group. The content of therapy was the same in both treatments. Follow-up sessions

wereplanned1,3, and6monthsafter thesixth therapysession.Asession-by-session

overview of the treatment protocol is presented in Table 1.

Measures

Sleep logs that were maintained for 1 week (except for 2 at baseline) as well as

questionnaires were examined at four different times: (a) at baseline, (b) just be-

fore the start of treatment after a waiting period (1–3 months), (c) posttreatment,

and (d) follow-up. Patients did not have to fill in questionnaires at baseline if group

therapy began within 1 month after their first clinical interview. The main outcome

measures for the sleep log were sleep onset latency, total sleep time, sleep effi-

ciency, wake after sleep onset, and number of times awake. The data from the sleep

logs consisted of the means of 7 consecutive nights.

An index of QOL was derived from selected items of two validated question-

naires: the Sickness Impact Profile (SIP; Bergner, Bobbitt, Pollard, Martin, &

CHRONIC INSOMNIACS 139

TABLE 1Outline of Insomnia Treatment Protocol

Session Treatment

1 Program overview; acquaintance; general information about insomnia; goal

setting; sleep hygiene

2 Behavioral component (stimulus control and sleep restriction); relaxation

(Jacobson)

3 Behavioral and cognitive components (cognitive restructuring); medication

withdrawal

4 Behavioral and cognitive components; relaxation (Schultz); medication

withdrawal

5 Review of all therapy components; programming generalization of newly learned

skills; thought stopping

6 Evaluation; identification of high-risk situations; review of relapse prevention

strategies; further consolidation of therapeutic gains

Follow up (3x) Consolidation of therapeutic gains; discussing problems. Follow-up 1: 1 month

after sixth session; Follow-up 2: 3 months after Follow-up 1; Follow-up 3: 6

months after Follow-up 2

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Gilson, 1976; Luttik et al., 1987) and the RAND–36 (Brazier et al., 1992; Van der

Zee & Sanderman, 1993). To limit the number of questions, we excluded items

with little relevance for chronic insomnia (e.g., items that dealt with physical limi-

tations like mobility). Because we only used the questionnaires to compare out-

come before and after treatment, we think this choice is justified, although no anal-

yses of internal consistency are done. The SIP has three subscales: social

interactions (range = 0–20), alertness/intellectual functioning (range = 0–10) and

recreation (range = 0–8). The sum score of SIP subscales ranges from 0 to 38; the

lower the score, the better. The RAND–36 is the validated Dutch version of the

MOS SF–36 (Ware & Sherbourne, 1992). With the same rationale as the SIP, we

used only four subscales of the RAND–36: general health (range = 1–5), problems

at work (range = 5–10), social occupation (range = 1–5) and feeling (range =

9–54). The sum score of the SF–36 subscales ranges from 16 to 74; the higher the

score, the better.

Sleep was subjectively evaluated with a Sleep Evaluation Form (SEF), devel-

oped by our center and based on Morin’s Sleep Impairment Index (Morin, 1993).

The SEF has six items: satisfaction with sleep, coping with bad sleep, concerns

about sleep, tiredness, concentration, and mood. All scores range from 1 to 5. The

sum score of SEF ranges from 6 to 30; the higher the score, the better.

Psychological well-being was evaluated with SCL–90 (Arrindell & Ettema,

1986). From the SCL–90, five subscales were selected: anxiety (10 items, range

= 10–50), depression (16 items, range = 16–80), somatization (12 items, range =

12–60), insufficiency (9 items, range = 9–45), and sensibility (18 items, range =

18–90). The sum score of SCL–90 ranges from 65 to 325; the lower the score,

the better.

Beliefs and attitudes about sleep were assessed with an abbreviated version of

the Dysfunctional Beliefs and Attitudes About Sleep scale (DBAS; Morin, 1993).

Patients complete the DBAS by indicating whether they agree with the statements

in the DBAS that express dysfunctional ideas about sleep. The DBAS has five

subscales: unrealistic expectations about sleep (2 statements), beliefs about con-

trol over sleep (7 statements), beliefs about the consequences of insomnia (6 state-

ments), beliefs about the causes of insomnia (1 statement), and beliefs about

sleep-promoting habits (7 statements). The sum score of DBAS ranges from 23 to

115; the lower the score, the better.

Characteristic coping behavior was assessed with the Utrecht Coping List (UCL;

Schreurs, van de Willige, Tellegen, & Brosschot, 1996). The UCL measures coping

behavior when a person is confronted with problems or events that need adjustment.

The questionnaire contains seven subscales: active tackling (7 items, range = 7–28),

palliative reaction (8 items, range = 8–32), avoidance (8 items, range = 8–32), seek-

ing social support (6 items, range = 6–24), depressive reaction (7 items, range =

7–28), expression of emotions (3 items, range = 3–12), and reassuring thoughts (5

items, range = 5–20). The sum score of the UCL ranges from 44 to 176.

140 VERBEEK ET AL.

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Patient characteristics like age, gender, level of education (low = primary edu-

cation, middle = secondary education, high = higher education), employment sta-

tus (employed, homemaker, sick, retired), and use of medication were all recorded.

Statistics

Analyses were only made for the subgroup of patients with data on all four measure-

ment times (n = 18 individual treatment, n = 40 group treatment). Chi-square analy-

ses were conducted for categorical variables, and t tests (or analyses of variance

[ANOVAs]) were conducted for continuous variables. Chi-square analysis was per-

formed between both groups for demographic data. The level of significance of all

analyses was set at p ≤ .05. A mixed-model ANOVA with repeated measures was

used to determine variances over time for the whole group, between the two groups

(individual and group therapy), and interaction of group over time. Post-hoc analy-

ses following significant effects was performed with Bonferroni corrections.

RESULTS

Demographic data are given in Table 2. The mean ages were 43.68 years for indi-

vidually treated patients and 45.11 years for patients treated in a group (Table 2).

The percentages of women were 56% (individual) and 60% (group). The mean du-

rations of insomnia were 17.92 years (individual) and 11.96 years (group). The

percentages of highly educated patients were 56% (individual) and 30% (group).

The percentages of patients with a middle level of education were 33% (individ-

ual) and 35% (group). The percentages of patients with a low level of education

were 11% (individual) and 23% (group). The percentages of patients who were

employed were 78% (individual) and 68% (group). No significant differences

were seen between individually treated patients and patients treated in a group for

age, gender, duration of insomnia, education, and employment status. At baseline,

13 (33%) of the patients treated in a group and 6 (33%) individually treated pa-

tients took no medication. Twenty-two (55%) of the patients treated in a group and

9 (50%) individually treated patients took hypnotics. The subgroup of patients

with data on all four measurement times was different only from the larger sample

in the number of patients that took no medication (50% in larger sample, 33% in

subgroup). Tables 3 through 5 show the results from the sleep logs and question-

naires. Analyses were made only for the group of patients with data at all four mea-

surement times. Figure 1 shows total sleep time; Figure 2 shows DBAS over time.

Sleep Logs

As measured by the sleep logs, there was a significant Time effect for sleep on-

set latency, F(3, 57) = 11.88, p = .000; total sleep time, F(3, 56) = 9.87, p = .000;

CHRONIC INSOMNIACS 141

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sleep efficiency, F(3, 56) = 32.74, p = .000; and wake after sleep onset, F(3, 56)

= 9.17, p = .000 (Table 4). Post-hoc analyses (with Bonferroni corrections for

multiple comparisons) for the factor Time showed significant improvements af-

ter therapy compared to postwait-list for sleep onset latency (p = .013), total

sleep time (p = .002), sleep efficiency (p = .000), and wake after sleep onset (p =

.000). For sleep onset latency and sleep efficiency, significant improvements

were also seen from baseline to postwait-list (p = .021 and p = .029, respec-

tively). For total sleep time and sleep efficiency, follow-up data were also signif-

icantly improved compared to postwait-list (p = .003 and p = .000, respectively;

Table 3, Figure 1). There was no significant Group effect (Table 4). Only for

wake after sleep onset, there was a modestly significant Group × Time effect,

F(3, 56) = 2.68, p = .049.

Despite these significant effects in subjective sleep parameters, the percentages

of good sleepers posttreatment (according to the definition of sleep onset latency

142 VERBEEK ET AL.

TABLE 2Demographic Data for Patients With Data on All Four Measurement Times

M ± SD

Demographic Data Groupa Individualb

Age 43.68 ± 10.10 45.11 ± 11.15

Gender 24 female, 16 male 10 female, 8 male

Duration of insomnia (years) 11.96 ± 12.16 17.92 ± 15.38

% n % n

Education

High 30 12 56 10

Middle 35 14 33 6

Low 23 9 11 2

Unknown 13 5 0 0

Employment status

Employed 68 27 78 14

Homemaker 10 4 17 3

On sick leave 18 7 6 1

Student 2 1 0 0

Unknown 2 1 0 0

Medication

None 33 13 33 6

Hypnotics 55 22 50 9

Anxiolytics 3 1 11 2

Antidepressants 8 3 0 0

Over-the-counter 0 0 6 1

Unknown 3 1 0 0

an = 40. bn = 18.

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TAB

LE3

Sle

epLo

gsat

Bas

elin

e(A

),P

ostW

ait-

List

(B),

Pos

ttrea

tmen

t(C

),an

dF

ollo

wU

p(D

)fo

rP

atie

nts

With

Dat

aon

All

Fou

rM

easu

rem

entT

imes

A:

Ba

seli

ne

B:

Po

st

Wa

it-L

ist

C:

Postt

reatm

ent

D:

Foll

ow

Up

Gro

up

Indiv

idual

Gro

up

Indiv

idual

Gro

up

Indiv

idual

Gro

up

Indiv

idual

Sle

ep

Log

Param

ete

rs

MSD

MSD

MSD

MSD

MSD

MSD

MSD

MSD

SO

L(i

nm

inute

s)

68.6

958.0

456.7

748.5

849.5

334.4

244.1

546.7

840.3

131.0

323.9

324.8

042.4

130.3

829.4

426.7

8

TS

T(i

nm

inute

s)

324.3

160.4

4316.7

179.3

4323.6

963.0

3323.0

180.1

2345.0

572.9

0367.3

368.0

8357.1

581.8

1367.0

581.4

0

SE

(%)

62.4

513.4

461.9

914.8

069.1

512.3

265.4

916.7

977.4

713.0

180.2

413.4

374.4

412.0

075.5

816.6

1

WA

SO

(in

min

ute

s)

58.9

545.2

763.5

844.7

148.7

344.6

969.5

656.0

539.1

830.3

332.9

926.0

344.2

336.0

661.3

655.5

7

AW

AK

(no.)

1.2

90.9

41.5

51.1

21.1

40.9

91.4

40.9

01.2

50.8

71.2

91.1

01.2

80.9

81.5

00.9

5

No

te.

Gro

up

treatm

ent(n

=40);

indiv

idualtr

eatm

ent(n

=18).

SO

L=

sle

ep

onsetla

tency;T

ST

=to

talsle

ep

tim

e;S

E=

sle

ep

eff

icie

ncy;W

AS

O=

wake

aft

er

sle

ep

on-

set;

AW

AK

=num

ber

of

aw

akenin

gs.

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≤ 30 min, SE ≥ 85%, and total sleep time ≥ 300 min) are disappointing (34% in-

dividual and 16% group treatment).

Questionnaires

Table 5 and Figure 2 show the sum scores for the various questionnaires. QOL im-

proved significantly for the whole group after therapy. There was a significant Time

effect for both QOL questionnaires: SF–36, F(3, 31) = 10.60, p = .000, and SIP, F(3,

33) = 8.85, p = .000; the SEF, F(3, 333) = 55.00, p = .000; the SCL–90, F(3, 29) =

6.80, p = .000; and the DBAS, F(3, 33) = 41.43, p = .000 (Table 4). Post-hoc analyses

(with Bonferroni corrections for multiple comparisons) for the factor Time showed

significant improvements from baseline to postwait-list for SF–36 and SEF. Signifi-

cant improvements from postwait-list to after therapy and for postwait-list to fol-

low-up were seen for SIP (p = .000 and p = .025, respectively), SEF (p = .000 and p =

.000, respectively), and DBAS (p = .000 and p = .000, respectively; Table 5, Figure

2). Again, there was no significant Group effect. A significant Group × Time effect

was seen for the SEF scores, F(3, 33) = 4.93, p = .003.

DISCUSSION

The findings presented here complement previous studies showing that CBT is an

effective treatment for chronic primary insomnia (Edinger, Wohlgemuth, Radtke,

Marsh, & Quillian, 2001a; Espie, Inglis, Tessier, & Harvey, 2001; Morin,

144 VERBEEK ET AL.

TABLE 4Mixed Model Analysis of Variance Results for Sleep Log and

Questionnaires

Mixed Model Effects

Domain Time Interactiona Group × Timea Groupb

Sleep onset latency 11.88*** 0.45 1.98

Total sleep time 9.87*** 0.90 0.13

Sleep efficiency 32.74*** 1.10 0.00

Wake after sleep onset 9.17*** 2.68* 0.83

SF–36 10.60*** 1.53 0.44

Sickness Impact Profile 8.85*** 0.08 2.21

Sleep Evaluation Form 55.00*** 4.93** 0.00

SCL–90 6.80*** 0.35 0.21

DBAS 41.43*** 0.99 0.12

Note. n = 40, for group; n = 18, for individual. SF–36 = social functioning; SCL–90 = Symptom

Check List; DBAS = Dysfunctional Beliefs and Attitudes About Sleep.

adf = 3. bdf = 1.

*p < .05. **p < .01. ***p < .001.

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TAB

LE5

Que

stio

nnai

res

atB

asel

ine

(A),

Pos

tWai

t-Li

st(B

),P

osttr

eatm

ent(

C),

and

Fol

low

Up

(D)

for

Pat

ient

sW

ithD

ata

onA

llF

our

Mea

sure

men

tTim

es

A:

Ba

seli

ne

B:

Po

st

Wa

it-L

ist

C:

Postt

reatm

ent

D:

Foll

ow

Up

Gro

up

Indiv

idual

Gro

up

Indiv

idual

Gro

up

Indiv

idual

Gro

up

Indiv

idual

Questi

onnair

es

(Min

–M

ax)

Sum

SD

Sum

SD

Sum

SD

Sum

SD

Sum

SD

Sum

SD

Sum

SD

Sum

SD

SF

–36

(16–74)

44.2

56.6

147.3

47.8

947.2

88.1

251.6

97.7

153.1

59.1

855.7

29.6

253.2

98.0

555.1

49.2

4

SIP

(0–38)

10.6

75.1

28.4

75.4

99.7

05.3

17.8

94.7

46.3

55.0

34.5

94.5

36.3

84.9

64.6

15.5

4

SE

F(6

–30)

13.6

72.0

614.0

33.0

015.2

12.6

714.6

42.7

319.2

82.9

920.8

12.9

320.1

02.6

620.7

54.6

8

SC

L–90

(65–325)

112.4

027.7

2108.3

525.2

8113.2

134.5

298.0

219.0

197.7

827.5

394.1

127.1

897.6

122.5

595.6

126.0

4

DB

AS

(23–115)

67.4

511.4

770.7

113.5

463.5

613.6

465.5

612.0

148.0

510.1

546.3

310.9

946.7

011.8

849.7

815.6

9

CO

PIN

G(4

4–176)

83.2

56.8

492.4

49.5

079.4

38.6

792.5

69.9

981.0

010.1

891.3

111.0

780.5

910.1

991.2

210.0

0

No

te.

Gro

up

treatm

ent:

n=

40;in

div

idualtr

eatm

ent:

n=

18.Q

uali

tyof

life

ism

easure

dby

SF

–36

and

SIP

.Im

pro

vem

enton

SF

–36

and

SE

Fis

show

nby

hig

her

score

s.

Impro

vem

ent

on

SIP

,S

CL

–90,and

DB

AS

isshow

nby

low

er

score

s.S

F–36

=socia

lfu

ncti

onin

g;

SIP

=S

ickness

Impact

Pro

file

;S

EF

=S

leep

Evalu

ati

on

Form

;S

CL

–90

=

Sym

pto

mC

heck

Lis

t;D

BA

S=

Dysfu

ncti

onal

Beli

efs

and

Att

itudes

About

Sle

ep.

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146

FIGURE 1 Mean values for total sleep time, both for individual and group treatment. Stars

indicate time points with significant post-hoc difference (with Bonferroni corrections for multi-

ple comparisons) for the whole group (p < .01). Comparisons are made from postwait-list to af-

ter therapy and follow up. There were no significant group effects.

FIGURE 2 Mean values for Dysfunctional Beliefs and Attitudes About Sleep (DBAS), both

for individual and group treatment. Stars indicate time points with significant post-hoc differ-

ence (with Bonferroni corrections for multiple comparisons) for the whole group (p < .01).

Comparisons are made from postwait-list to after therapy and follow up. There were no

significant group effects.

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Colecchi, et al., 1999). In our analysis, the comparison of postwait-list to after ther-

apy and follow-up is most interesting because these comparisons reflect the

changes that can be attributed to treatment. These comparisons show that CBT

produced significant changes in sleep onset latency, total sleep time, sleep effi-

ciency, and wake after sleep onset. For total sleep time and sleep efficiency, signifi-

cant improvements were seen at follow-up as well. Sleep onset latency and sleep

efficiency already improve during the waiting time. This can be due to the fact that

some patients already received some sleep hygiene advice after the first interview.

Our study did not show different outcomes between individual and group treat-

ment. Bastien et al. (2004) also showed that individual and group treatments are

equallyeffective.Thereareafewadvantagesofgrouptreatment thatarenotshownin

the results, however. First of all, group treatment is cost effective. Although the

group sessions took longer (2.5 hr) compared to individual treatment (1 hr), group

treatment is cost effective by3 participants per group. There is another, perhaps even

more important advantage of group treatment. After the 6-week program, written

evaluations were completed by the patients treated in a group. The most frequent an-

swer to the open question, “What part of the sleep course was most helpful for you?,”

was the behavioral component (sleep restriction and stimulus control). “Cognitive

restructuring” was mentioned second most frequently, and “meeting with other peo-

plewith insomnia”wasmentionedthirdmost frequently(e.g.,moreoften thanrelax-

ationexercises). Ingroup treatment, there is theopportunitytomeetotherchronic in-

somniacs, and it is evident that this is appreciated by the participants.

The different selection criteria between group and individually treated patients

may be a possible explanation for the higher percentage of good sleepers after ther-

apy in individually treated patients compared to patients treated in a group. Only in

the individually treated patients were there exclusion criteria for secondary insom-

nia and the regular use of hypnotics. Another explanation may be that patients for

whom individual treatment was not successful were excluded for follow-up be-

cause of other treatment (e.g., antidepressants). This is confirmed by the finding

that the patients with no data for at least one of the four measurement times (n = 13;

all patients did not have follow-up data) had significantly lower total sleep time

and sleep efficiency at baseline than the group with data at all measurement times

(n = 18). Morin (2003) recently described the need to broaden the scope of out-

come assessment beyond the simple reduction of insomnia symptoms as seen in

the sleep parameters. Effective treatment should also produce clinically meaning-

ful changes in daytime functioning, fatigue, mood, and QOL. The results of our

study show significant improvements in QOL and psychological well-being after

treatment. Again, there was no significant effect between individual and group

treatment. Most of these changes were maintained at follow-up. No significant

changes in coping on the UCL were seen either posttreatment or at follow-up. The

UCL measures characteristic coping behavior when confronted with problems or

events that need adjustment. Specific coping with insomnia is not measured with

CHRONIC INSOMNIACS 147

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this list. This may explain why we did not find any significant improvements in this

list. The changed beliefs and attitudes about sleep as seen in the DBAS make it

likely that CBT leads to a different attitude and experience of sleep. Edinger et al.

(2001b) also found that CBT is effective for reducing dysfunctional beliefs about

sleep. In their study, the improvements were significantly correlated with improve-

ments on both objective and subjective measures of insomnia symptoms.

Thus, CBT improves not only sleep, but also general well-being and QOL. This

finding is in contrast with that of Zammit et al. (1999), who found no differences in

QOL between participants who received pharmacological treatment for insomnia

versus those who did not. Both studies are hard to compare because their patients

received pharmacological treatment instead of CBT and were recruited instead of

clinically referred. Stepanski et al. (1989) found that physician-referred partici-

pants had higher scores on the pathological range on all psychometric parameters

than those who were self-referred. It is an interesting finding that, in our clinically

referred patients, improvements were seen in daytime functioning (psychological

well-being, QOL, sleep evaluation in general). This is in contrast with the study by

Means, Lichstein, Epperson, and Johnson (2000), where the effect of progressive

relaxation led to improvements in sleep but not to improvements in daytime func-

tioning. Perhaps the behavioral and cognitive elements of CBT are crucial in ob-

taining these daytime improvements. Recent literature confirms that the critical el-

ements for CBT are reported home use of stimulus control, sleep restriction, and

cognitive restructuring (Harvey, Inglis, & Espie, 2002). Besides differences in

QOL, there are more changes between recruited and clinically referred patients.

The recruited patients from the studies of Morin, Colecchi, et al. (1999) and

Edinger et al. (2001a) reflect an older patient population. The mean ages of our pa-

tients were 45.1 years (individual treatment) and 43.7 years (group treatment)

compared to 64.4 years (Morin, Colecchi, et al., 1999) and 55.3 years (Edinger et

al., 2001a). The mean ages of onset of sleep complaints in our population ranged

from 27.2 to 31.7 years, compared to 42 to 48 years in the recruited participant

studies mentioned before. It is well known that sleep deteriorates with age. Even

without the correction for age, our patients experienced subjectively worse sleep

than the recruited patients from the literature studies mentioned previously. When

looking at the demographic data, no significant differences were seen in age, gen-

der, education, or duration of insomnia between individually treated patients and

patients treated in a group. The percentage of patients with a high level of educa-

tion was much higher in individual therapy (46.9% compared to 27.0% in group

therapy). This was not significant, however. Compared to individual treatment,

significantly more patients in group treatment took hypnotics at baseline. In the

subgroup of patients for which the analyses were made, however, no significant

difference was seen between hypnotic usage and no usage at baseline. Espie,

Inglis, and Harvey (2001) already found that patients using hypnotics respond

equally well to CBT.

148 VERBEEK ET AL.

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The limitations of our study lie in the fact that there was no randomization for

individual or group treatment and that the criteria for allocation to group or indi-

vidual treatment were different. The individually treated patients in this analysis

were primary insomniacs and no regular users of hypnotics. The fact that there

were no significant changes between group and individual treatment, even though

the selection criteria were different, supports the finding that both treatment mo-

dalities have comparable effects. Bastien et al. (2004) also found no difference be-

tween group and individual treatment. Another limitation of our study lies in the

fact that there was no control group. Although we had a waiting-list control, there

were already some significant improvements from baseline to postwait-list (sleep

onset latency, sleep efficiency, SF–36, and SIP). These improvements may be ex-

plained from the sleep hygiene advice patients already received after the first inter-

view. Short-term CBT, however, adds more significant improvements in subjective

sleep, QOL, and psychological well-being.

We conclude that CBT for insomnia is equally effective for both individual and

group treatment. Improvements was seen in subjective sleep parameters, QOL, at-

titudes about sleep, and sleep evaluation in general, both posttreatment and at fol-

low-up. Group CBT has two extra advantages: It allows participants to meet fellow

patients, and it is cost effective.

REFERENCES

American Sleep Disorders Association. (1997). ICSD—International classification of sleep disorders,

revised: Diagnostic and coding manual. Rochester, MN: Author.

American Sleep Disorders Association Report. (1995). Practice parameters for the use of

polysomnography in the evaluation of insomnia. Sleep, 18, 55–57.

Arrindell, W. A., & Ettema, J. M. H., SCL–90. (1986). Handleiding bij een multidimensionele

psychologie indicator [Manual for multidimensional psychology indicator]. Lisse, The Netherlands:

Swets and Zeitlinger.

Backhaus, J., Hohagen, F., Voderholzer, U., & Riemann D. (2001). Long-term effectiveness of a

short-term cognitive-behavioral group treatment for primary insomnia. European Archives of Psy-

chiatry and Clinical Neuroscience, 25, 35–41.

Bastien, C. H., Morin, C. M., Ouellet, M., Blais, F. C., & Bouchard, S. (2004). Cognitive-behavioral

therapy for insomnia: Comparison of individual therapy, group therapy, and telephone consultations.

Journal of Consulting and Clinical Psychology, 72, 653–659.

Bergner, M., Bobbitt, R. A., Pollard, W. E., Martin, D. P., & Gilson, B. S. (1976). The Sickness Impact

Profile: Validation of a health status measure. Medical Care, 14, 57–67.

Brazier, J. E., Harper, R., Jones, N. M. B., Cathain, A., Thomas, K. J., Usherwood, T., et al. (1992). Vali-

dating the SF-36 health survey questionnaire: Outcome measure for primary care. British Medical

Journal, 305, 160–164.

Chesson, A. L., Anderson, W. M., Littner, M., Davila, D., Hartse, K., Johnson, K., et al. (1999). Practice

parameters for the nonpharmacological treatment of chronic insomnia. Sleep, 22, 1128–1133.

Edinger, J. D., & Wohlgemuth, W. K. (1999). The significance and management of persistent primary

insomnia: The past, present and future of behavioral insomnia therapies. Sleep Medicine Reviews, 3,

101–118.

CHRONIC INSOMNIACS 149

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

18:

11 1

8 N

ovem

ber

2014

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001a). Cognitive

behavioral therapy for treatment of chronic primary insomnia. A randomized controlled trial. Jour-

nal of the American Medical Association, 285, 1856–1864.

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001b). Does

cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep? Sleep, 24,

591–598.

Espie, C. A. (1991). The psychological treatment of insomnia. Chichester, England: Wiley.

Espie, C. A., Inglis, S. J., & Harvey, L. (2001). Predicting clinically significant response to cognitive

behavior therapy for chronic insomnia in general medical practice: Analyses of outcome data at 12

months posttreatment. Journal of Consulting and Clinical Psychology, 69, 58–66.

Espie, C. A., Inglis, S. J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behav-

iour therapy for chronic insomnia: Implementation and evaluation of a sleep clinic in general medi-

cal practice. Behaviour Research and Therapy, 39, 45–60.

Harvey, L., Inglis, S. J., & Espie, C. A. (2002). Insomniacs’ reported use of CBT components and rela-

tionship to long-term clinical outcome. Behaviour Research and Therapy, 40, 75–83.

Hauri, P. J. (1997). Can we mix behavioral therapy with hypnotics when treating insomnia? Sleep, 20,

1111–1118.

Idzikowski, C. (1996). Impact of insomnia on health-related quality of life. Pharmaco Economics,

10(Suppl. 1), 15–24.

Luttik, A., Jocobs, H. M., & de Witte, L. P. (1987). De Sickness Impact Profile, Nederlandse versie.

Vakgroep Huisartsgeneeskunde [Dutch version. Department of General Practitioner Medicine]. The

Netherlands: Universiteit Utrecht.

Martin, J. L., & Ancoli-Israel, S. (2002). Assessment and diagnosis of insomnia in non-pharmacologi-

cal intervention studies. Sleep Medicine Reviews, 6, 379–406.

Means, M. K., Lichstein, K. L., Epperson, M. T., & Johnson, C. T. (2000). Relaxation therapy for in-

somnia: Nighttime and day time effects. Behaviour Research and Therapy, 38, 665–678.

Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford.

Morin, C. M. (2003). Measuring outcomes in randomized clinical trials of insomnia treatments. Sleep

Medicine Reviews, 7, 263–279.

Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological

therapies for late-life insomnia. A randomized controlled trial. Journal of the American Medical As-

sociation, 281, 991–1056.

Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insom-

nia: A meta-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172–1180.

Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999).

Nonpharmacological treatment of chronic insomnia. An American Academy of Sleep Medicine re-

view. Sleep, 22, 1134–1152.

Oosterhuis, A., & Klip, E. C. (1993). Beter leren slapen; effectiviteit van de gedragstherapeutische

slaapcursus van de Kruisverenigingen [Learn to sleep better; Effectiveness of a behavioral therapeu-

tic sleepcourse of the National Association of Home Care]. Gedragstherapie, 26, 191–202.

Oosterhuis, A., & Klip, E. C. (1997). The treatment of insomnia through mass media, the results of a

televised behavioural training programme. Social Science Medicine, 45, 1223–1229.

Reimer, M. A., & Flemons, W. W. (2003). Quality of life in sleep disorders. Sleep Medicine Reviews, 7,

335–349.

Schipper, H., Clinch, J., & Powell, V. (1990). Definitions and conceptual issues. In B. Spilker (Ed.),

Quality of life assessments in clinical trials (pp. 5–24). New York: Raven Press.

Schreurs, P. J. G., van de Willige, G., Tellegen, B., & Brosschot, J. F. (1996). Utrechtse Coping

Lijst [Utrecht Coping List]. In A. V. A. M. Evers, J. C. van Vliet-Mulder, & J. ter Laak (Eds.),

Documentatie van tests en testresearch in Nederland NIP (pp. 52–56). Assen, The

Netherlands: Van Gorcum.

150 VERBEEK ET AL.

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

18:

11 1

8 N

ovem

ber

2014

Stepanski, E., Koshorek, G., Zorick, F., Glinn, M., Roehrs, T., & Roth, T. (1989). Characteristics of in-

dividuals who do or do not seek treatment for chronic insomnia. Psychosomatics, 30, 421–427.

Van der Zee, K. I., & Sanderman, R. (1993). Het meten van de algemene gezondheidstoestand met de

RAND-36, een handleiding [Measuring common health with the RAND-36]. The Netherlands: Uni-

versity of Groningen, Nordic Center for Health Questions.

Verbeek, I., Schreuder, K. E., & Declerck, A. C. (1999). Evaluation of short-term non-pharmacological

treatment of insomnia in a clinical setting. Journal of Psychosomatic Research, 47, 369–383.

Verbeek, I., Sweere, Y., & Klip, E. C. (2005). Effect of behavioral treatment on objective and subjective

sleep and quality of life in patients with chronic primary insomnia. Manuscript submitted for publi-

cation.

Ware, J. E., & Sherbourne, C. D. (1992).The RAND-36 Short-form Health Status Survey: I. Conceptual

framework and item selection. Medical Care, 30, 473–481.

Zammit, G. K., Weiner, J., Damato, N., Sillup, G. P., & McMillan, C. A. (1999). Quality of life in peo-

ple with insomnia. Sleep, 22(Suppl. 2), S379–385.

CHRONIC INSOMNIACS 151

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

18:

11 1

8 N

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