Cognitive Behavior Therapy for Insomnia in Those with Depression: A Guide for Clinicians 1st

make a diagnosis. All clients undergo a pre-treatment Hamilton Rating Scale for Depression (Hamilton, 1960) and we use this data to encourage clients to talk about their prominent symptoms. We then ask them to place an X at the place at which best describes their current depression (i.e., today). We provide the same explanation of insomnia and insomnia symptoms, which can include depressed mood, and talk about the point at which we consider an (arbitrary) diagnosis. We ask them to make an X at the spot on the line that characterizes the severity of their insomnia currently. The placement of the X allows us to assess how distressing and/or severe their sleep and mood problems are currently. When someone places the X at the extreme right of the line, this suggests that this is the most severe depression or insomnia imaginable for the client. In cases in which this is highly discrepant from the therapist’s assessment of functioning rating, this provides helpful information for the formulation. For example, a client insomnia rating at the most severe range, when their functioning is assessed to be good and their symptoms are not particularly severe, (e.g., the average sleep efficiency is just below the morbidity cutoff of 79 percent; insomnia is not present every night), may be experiencing considerable anxiety about sleep. The second step is to ask the client to consider where they would like to be at the end of treatment. That is, we ask them to consider their treatment goals with respect to symptom severity. We do this with Figure 9.1b. On this worksheet we ask them to place an X at the place at which they would like to be post-treatment. If the response is at the extreme left pole (see Figure 9.1b) this suggests that the client has some unrealistic expectations for therapy, and serves as good information for the case formulation. We provide an explanation that it is normal and functional to feel sadness occasionally, as well as normal and functional to have occasional sleeplessness, and ask whether absolutely no sad mood and no fluctuations in sleep quality is a realistic goal. We also ask them to consider whether setting a reasonable goal is important, and ask them about what could happen if goals were set too low, too high, or if the plan to pursue the goal wasn’t adequate to meet the goal? Asking such questions sets up the rationale for the goal pursuit focus. Lastly, we ask clients to talk about some of the strategies they 140 Combining Depression and Insomnia Therapies No depression No insomnia Insomnia diagnosis Severe insomnia Depression diagnosis Severe depression X X Figure 9.1a Establishing insomnia and depression as static conditions with a continuum of symptoms

have used to “solve” their depression and sleep problems. This uncovers both strengths (some effective, adaptive strategies that can be incorporated into the treatment plan) as well as unhelpful strategies such as trying to repeatedly think about “why people don’t like me” (i.e., rumination) or “I lay in bed watching TV and wait to fall asleep, and I have a glass of wine before bed” (i.e., sleep effort). Such a discussion about goal pursuit uncovers a plethora of useful information for the case formulation. After agreeing upon realistic treatment goals we provide an introduction to behavioral therapies (including a disclosure about the importance of between-session homework and monitoring) and a basic behavioral conceptualization (i.e., behavior affects and is affected by what we think and how we feel, and changing behavior has a powerful therapeutic effect on sleep, energy, and mood). To demonstrate this principle we begin working on a worksheet completed over several sessions of module 1. We present a divided worksheet (or in our lab we use a white board) with one column labeled ProDepression behaviors and the other column labeled Anti-Depressant Behaviors (Table 9.2). Later, when we discuss avoidance, and introduce the TRAP or TRAC worksheet, clients easily see the connection between Pro-Depression behaviors as avoidance patterns and Anti-Depressant Behaviors as Alternative Coping strategies (see Figure 9.4). We complete a similar sheet for Pro-Fatigue versus Pro-Energy as well as Pro-Sleep versus Pro-Insomnia if these emerge as priorities in this session, but typically we start with the depression worksheet and highlight ones that may also worsen sleep or energy levels. Blank copies of each of these worksheets are provided in the Appendices. Most often, we return to sleep-specific or fatigue-specific areas when they emerge in subsequent sessions. The key, however, is to be responsive and flexible about clients’ needs and priorities. At the end of the module, the worksheets may not be complete, but there are enough entries that clients can begin to see how anti-depressant behaviors, pro-energy, and pro-sleep behaviors have many similarities; thus they can accomplish their goal of feeling better by making relatively few changes. That is, changes in one domain are likely to have a positive impact on the other two. For example, reducing the time spent inactive in a 24 hour period should increase vigor, set the clock, increase Combining Depression and Insomnia Therapies 141 No depression No insomnia Insomnia diagnosis Severe insomnia Depression diagnosis Severe depression X X X X Figure 9.1b Establishing (achievable) treatment goals

a build for deep sleep, and expose the clients to increased opportunities for positive reinforcement. Following the discussion of pro-depression and anti-depressant behaviors, the therapist can introduce the first piece of homework for the client, which is to monitor their activities across the week on The Activity Monitoring form (Figure 9.2). This homework is typically accepted but occasionally, this exercise can be met with resistance. Clients may anticipate shame, e.g., “I would be too embarrassed for you to see how little I do.” This gives an opportunity to the therapist to normalize the presence of avoidance in depression. It also helps the client to see connections between avoidance and feeling poorly, and allows both the therapist and client to devise ways to alter avoidance and obtain a new result. Below is an example of working through this issue. Please note that the client in this chapter is a fictional client named Blake who differs from the CBT-I client Kelly presented in Chapter 10 and throughout the rest of the book. Therapist: It sounds like you are saying that you think you do very little throughout the week is that right? Client: Yes. It’s embarrassing. Therapist: You feel embarrassed? Client: Normal people DO things and its embarrassing that I don’t. Therapist: People with depression are often less active than people without depression precisely because of how poorly they feel, so, in truth, this is not unusual. I find that we can learn quite a lot about patterns by examining what you do throughout the week, and this can really help when we are looking for things that might be helpful to change. Do you suspect that being less active helps the depression or makes it feel worse? Client: I know it makes me feel worse, but I feel too badly to do anything about it. Therapist: I see. So this is a pro-depression behavior that we will probably need to target, but we would need to come up with a pretty powerful strategy to address the fact that you feel unable to increase your activity? Client: Well. . . . yeah. Therapist: OK. If I have a big obstacle to overcome, I find that I need all the information possible in order to come up with a good plan. Does that make sense? Client: Makes sense, yes. Therapist: I find that these monitoring forms uncover the information we need in order to come up with a good plan. Are you willing to do this? Client: OK. 142 Combining Depression and Insomnia Therapies Table 9.2 Anti-depressant behaviors and pro-depression behaviors example Pro-depression behaviors Anti-depressant behaviors Don’t go out Fresh air Hanging out with Joe Hanging out with other friends Drinking Going fishing Thinking about my problems with my Mom Go with friend to a movie Skipping meals or eating chips instead of meals Eat regular meals Staying in my pajamas Shower and get dressed

Clients’ may have other negative predictions that can also create resistance. That is, they could resist out of hopelessness, such as, “What’s the point? I already know I need to do something. This won’t help.” The therapist can adopt an open stance to the possibility that monitoring may not be helpful but ask that the client test out this notion. For example, the therapist can say, It is certainly possible that this would not be helpful. But thus far what you have already been doing does not seem to be working. Would you be willing to test out the idea at least for this week? We often find at least one thing, one pattern from activity monitoring that we can use to devise a strategy. So do you see any downside to testing it? Progress is slowed when clients come into sessions having not done their homework. Common reasons have to do with forgetting to do the assignment or forgetting to bring the paperwork in. Some clients may simply state that they became confused and did not know what to write on the form. When assigning homework, it may help to determine ahead of time if there will be any foreseeable barriers to completing the monitoring. There are a variety of ways to troubleshoot monitoring including having the client do the monitoring on the calendar of their smart phone, setting smart phone alarms to serve as reminders to fill out the form, keeping the form in their pocket etc. It can also save valuable session time later to practice with the form in session a few times to make sure that the client is clear how to fill it out. In all sessions, after checking on how the week went (i.e., mood and sleep) the therapist should ask if there were any problems with the homework. Homework must be reinforced every session. Failing to ask about homework sends the message that homework is not important, which in turn will likely lead to less homework getting done. However it is important not to badger clients over missed homework as this can create shame and anticipatory anxiety the next time that the homework is not completed. Beginning with an invitation to learn about struggles the client may have had with the homework ensures a safe environment. Additionally, a functional behavior analysis of homework “stuckness” is incredibly useful. Often, the barrier to homework is a ProDepression behavior that can be or has been listed on the form and the client can be oriented towards troubleshooting by focusing on the Anti-Depressant behaviors that will “unstick” them. The homework from week 1 is the Activity Monitoring Form (see Appendix E for a blank form). If someone has not done any of the form it is important to explore what got in the way. Did they almost do it and got overwhelmed? Did they ever take the form out of their bag throughout the week? Did they complete the form and not bring it? Did they complete it but missed a day or two and perfectionism precluded them from bringing it in? After assessing the nature of the problem, you can complete a form together based on the previous day, so there is something in-session to work with. Whatever is finally produced on the activity monitoring form, the goal of going over the form is to help the client link low mood and low energy with particular activities and improved mood and alertness with other activities. Therapist: You did a great job with this form. I can tell you put a lot of work into it. What did you get out of doing it? Combining Depression and Insomnia Therapies 143

Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6–7 AM in bed in bed in bed in bed in bed in bed in bed awake 85 7–8 AM in bed in bed in bed in bed in bed in bed in bed awake 80 8–9 AM in bed in bed in bed in bed in bed in bed in bed 9–10 AM in bed in bed in bed in bed in bed in bed in bed 10–11 AM in bed awake 80 in bed awake 90 in bed awake 95 in bed awake 55 in bed awake 95 internet 80 in bed awake 90 11–12 AM internet 85 bath 60 Internet 80 shower 30 internet 85 Internet 80 internet 85 12–1 PM internet 85 internet 85 groceries 70 Internet 25 reading 75 back to bed 70 internet 90 1–2 PM internet, read 85 internet 85 breakfast 70 pay bills 55 coffee 65 resting 80 back to bed 95 2–3 PM shower 65 TV 80 TV 85 TV 75 TV 90 TV 85 TV 85 3–4 PM reading 70 internet 80 in bed 80 Internet 80 nap computer 85 shower 70 4–5 PM reading 75 phone (bed) 85 TV 80 Internet 80 lunch 65 shower 65 lunch 60 5–6 PM reading 85 TV 80 Internet 80 lunch 70 reading 75 cook 50 visit mom 45 6–7 PM TV 80 TV 80 TV 80 TV 75 TV 90 dinner 55 visit Mom 50 7–8 PM reading 80 Internet 85 in bed 80 internet 85 nap computer 75 dinner 65 8–9 PM dinner 75 TV 85 in bed 85 Internet 85 dinner 65 computer 80 TV 75 9–10 PM TV 85 TV 85 TV 85 TV 80 TV 85 TV 90 TV 80 10–11 PM in bed Internet 80 in bed 85 internet 85 in bed in bed in bed awake 85 11–12 AM in bed phone (bed) 85 in bed 85 internet 95 in bed in bed in bed 12–1 AM in bed in bed Internet 80 in bed in bed in bed In bed 1–2 AM in bed in bed in bed in bed in bed in bed in bed awake 90 2–3 AM in bed in bed in bed in bed in bed in bed in bed awake 90 3–4 AM in bed in bed in bed in bed in bed in bed in bed 4–5 AM in bed in bed in bed in bed in bed in bed in bed 5–6 AM in bed in bed in bed in bed in bed in bed in bed Rate low mood 0 (absent)–100 (severe) Daily Activity Record BABIT Figure 9.2 Daily Activity Record

Client: I learned I don’t do anything. Therapist: I see a full page here. Can you clarify what you mean by saying that you didn’t do anything? Client: I didn’t do anything productive. I watched TV all day and I can’t believe how much time I spent in bed. I had no idea I stayed in bed so much. It’s depressing. Therapist: I noticed your mood is pretty low when you are lying in bed. Is that what you mean by depressing? Client: Yes. And I also meant that normal people don’t spend that much time in bed. Therapist: I see. So would you say that lying in bed is a pro-depression behavior? Certainly your mood ratings would suggest that you are right about that. Sounds like we might need to target the extra time in bed, given that your mood and energy is lowest when you do that and you see it as a depressing or pro-depression behavior? Client: Yes, but when I’m out of bed, I’m just lying on the couch, so that’s not that much better. Therapist: What do you mean by that? What are your mood ratings when lying on the couch in comparison to lying in bed? Client: They are about the same. But I wouldn’t know what else to do. Therapist: You said earlier that you did absolutely nothing productive but I wonder if that’s true. I see some instances of goal-directed behavior here, do you? Client: Taking a shower? I should have done it every day. Therapist: What do you notice about your mood when you took a shower? Client: It’s one of the highest mood ratings—still low though. Therapist: Yes, but your mood did improve. What was the activity when your mood was highest? Client: When I saw my Mom. Yes, that was nice. It was also a beautiful day so I liked the walk over there. Therapist: So you left the house, went outside, and visited someone, and your mood was the best it was all week? Client: This always works to lift my mood but I don’t always have the energy to do it. Therapist: Well we can talk about ways around this later, but it sounds as though we have found some antidepressant behaviors to add to your list? Client: Yes. In addition to the idea that activation is an antidepressant behavior, the therapist can introduce the idea that activity is a pro-energy and pro-sleep behavior. This is accomplished by helping the client calculate time in bed each day. In Figure 9.2 we see that the client got into bed on Monday at 10 PM and got out of bed at 11 AM on Tuesday morning; thus the time spent in bed was 13 hours (include all time in bed during the day and nap attempts too). This should be done for each day. At this point, the therapist can explain the homeostatic system to the client. A more formal prescription of a sleep or wake schedule can be made in module 2 after collecting sleep diary information, but there is no need to wait a full month before trying to target morning activation. Below is a sample of how this might be achieved: Combining Depression and Insomnia Therapies 145

Therapist: I wanted to discuss some pro-sleep behaviors. In a week or two we will generate a more full list of pro-sleep versus pro-insomnia behaviors, but for now I would like to focus on one very important pro-sleep behavior. To do that, I need to explain one of our body’s sleep systems called the homeostatic system. This system regulates how much deep sleep we obtain on a given night and it is based on how much time we spent awake and active in a 24 hour period. From the moment we get out of bed, we build up sleepiness and a pressure to sleep. We have to create that pressure or we may have difficulty falling asleep, staying asleep, or our sleep may feel very light. So, suppose there were two people and one went to bed at midnight and got out of bed at 8 AM and the other went to bed at midnight, got out of bed at 10:30 AM and spent 2 hours on the couch in the middle of the day. Who do you think would have a stronger drive for deep sleep; the first or second person? Client: I guess the 8 AM person but I could never be someone that gets out of bed at 8 AM—I’ve never been able to get up early. Therapist: Yes, you are not a morning person. But let me ask the same question but let’s consider someone who is a bit of a night owl, like yourself. So, if there were two owls and one went to bed at 3 AM and got out of bed at 11 AM and the other went to bed at 3 AM, got out of bed at 1 PM and spent 2 hours on the couch in the middle of the day, which one has a stronger drive for deep sleep? Client: Ok, yes, I get it. It’s the person who has been out of bed more. I am noticing I am spending a lot of time on the couch in the middle of the day. Therapist: Yes, I am seeing some time in bed or on the couch napping on Tuesday, Wednesday and Friday. Client: The thing is that I’m tired. Therapist: So the extra time on the couch and in bed each day is because you’re tired right? Client: Exactly. Therapist: What do you think causes the fatigue? Client: I don’t sleep well. Therapist: If we know that the only way to get deep restorative sleep is to be awake and active for a sufficient amount of time each day, could it be that one reason why you are so tired? That is, is it that your sleep is not deep and restorative because you are in bed so much? Client: I’m not sure. Therapist: Would you be willing to test this idea over the next two weeks? Client: I suppose so. Therapist: In addition, you had said you feel bored during the day. What effect do you think boredom has on your energy? Client: Probably not good. Therapist: After spending a few hours on the couch do you feel rejuvenated and full of energy or sluggish? Client: Sluggish and unmotivated. Therapist: Ever heard of the saying an object at rest stays at rest? Client: [Smiles]. 146 Combining Depression and Insomnia Therapies

Therapist: So can we think of a way to test whether decreasing your time in bed and scheduling some specific activities may be pro-sleep and pro-energy behaviors? Client: Looks like I have to get up early . . . Therapist: Given that your body clock is naturally on the late side, I wouldn’t say early, but we probably ought to pick a standard get out of bed time that allows for enough deep sleep drive to build for subsequent nights. This will also allow us to fight some of the sluggishness caused by the lower levels of activity, including nap attempts, in the daytime. Client: As long as I don’t have to get up too early, this sounds like a good idea. Module 2: Sleep Scheduling, Stimulus Control and Modifying Avoidance The details of a SC and SRT session are contained in Chapter 5, so we will not go into much more detail here. Sleep diaries are introduced in Module 1 so SC and SRT can begin in the second module, although elements of these treatments may already be in place in Module 1 depending on what arises. For example, it is common that a standard rise time has already been selected based on environmental constraints (e.g., the rise time on work days) as a way of increasing time out of bed and increasing activities. The agenda for the first CBT-I session is to check-in on mood, suicidal ideation, and sleep, as well as the assigned homework, and to set the agenda to discuss sleep. After presenting psychoeducation about how sleep is regulated and the three main causes of chronic insomnia (e.g., irregular or ill-timed schedule given chronotype, inadequate sleep drive due to decreased activity or increased time resting, and/or arousal problems), we introduce a worksheet that asks the client to look at their sleep diary and check off any pro-insomnia behavior they see (see Table 9.2). In our lab, we present an adapted version of Table 9.3 in which the Pro-Sleep behavior column is blank and the client works on adding behaviors to this column. The completed form seen in Table 9.3 is for the reader only (i.e., as an example of a completed form). The therapist can help uncover any proinsomnia behavior the clients are unable to identify. Once target-worthy behaviors are identified, the client is asked to generate pro-sleep behaviors. This allows the therapist to check in on what the client remembers about pro-sleep drive behaviors discussed previously. It also allows therapists to see the extent of accurate and inaccurate information the client has about sleep. The therapist can use questioning to uncover a more complete list of pro-sleep versus pro-insomnia behaviors (see Table 9.3). From the Pro-Sleep list, clients can refine pro-sleep goals using the Goal Tracking homework form (Figure 9.3), which in most cases will include: 1) a latest possible rise time, irrespective of how they slept, 2) an earliest bed time, 3) refrain from going to bed until sleepy, 4) get out of bed when unable to sleep and do not return until sleepy, 5) no naps, 6) refrain from wakeful activities in bed, and 7) establish a 1-hour wind-down buffer zone before bed. Please see Chapter 5 for how to show clients how to derive a sleep schedule. In those taking hypnotic medication chronically, they typically add a goal of using only the lowest recommended dose (i.e., a consistent low dose and no addition of other types of sleep aides including alcohol) each night at the same time, or as directed by the physician. Remaining biweekly sessions are most often devoted to checking for adherence and troubleshooting as needed (please see Chapter 7 for more troubleshooting details) as well as possibly teaching clients to assess whether sleep Combining Depression and Insomnia Therapies 147

extension as needed. Extending time in bed prescriptions by 15 minutes per week occurs once clients show signs of sleepiness (e.g., subjective complaint of sleepiness or evidence of sleepiness in the form of mean sleep onset latency less than 10 minutes or sleep efficiency greater than 90 percent). Of course, clients need to be taught some basic calculations from the sleep diary such as sleep efficiency (Computed Total Sleep Time or Time in Bed) and total sleep time (Intended Sleep Period-Total Wake Time); for more see Table 4.1 in Chapter 4). The sleep extension conditions above are meant to be guidelines rather than a rigid set of rules, as the decision should be collaboratively and flexibly reached, and consider the pros and cons of a change in prescription. For example, in a client complaining of sleepiness but without much sleep improvement in the absence of safety concerns, the client may extend sleep to address the sleepiness but may also consider an additional 2 weeks of the schedule to try and address the remaining problem before increasing time-in-bed. 148 Combining Depression and Insomnia Therapies Table 9.3 Completed pro-sleep versus pro-insomnia behaviors Pro-Insomnia Behaviors Pro-Sleep Behaviors Ruminate Out of bed problem-solving and reflection Try to produce sleep Have good sleep habits and then let sleep Go to bed early to catch up on sleep unfold naturally Doze or attempt to nap Go to bed when sleepy Stay in bed while awake Stay active if you find yourself dozing Vary the time you get out of bed by Have a regular rise time daily that does not an hour or more vary more than an hour Try to sleep-in Get out of bed when you cannot sleep and do Drink alcohol not return until sleepy Stay busy, avoid getting into bed until Be in bed for about the same amount of time the morning hours as you are sleeping Take sleep aides including natural Limit alcohol and marijuana, especially in the supplements, over the counter hour or two before bed medications, teas, etc. Healthy nutrition Consume caffeinated food or beverages Regular exercise, although not vigorously Sedentary lifestyle right before bed Withdraw from activities, e.g., working Limit caffeine to a cup or two per day and out, socializing, going outside never after mid-afternoon Cancel obligations because you feel Focus on hydration rather than caffeination tired, e.g., call-in sick after a bad night Protect an hour before bed as a wind-down Read and research about the negative period effects of sleep loss Process problems or concerns earlier in the Worry about sleep evening when at your problem solving best Talk about insomnia Keep physically active and schedule active Obsess about or control sleep breaks (i.e., enjoyable activities) environment, e.g., devices to Keep room safe, unlit, and a comfortable measure sleep, blackout shades, blue temperature—a strong sleep drive will take light filters on device screens, sleep care of the rest in separate room from partner out Understand and accept your body takes care of fear they will wake you, white of sleep and compensating for sleep noise machines, eye masks, ear plugs, deprivation naturally refuse to do childcare out of concern it will disrupt sleep etc.

Name: Blake_______ Session Week # 5 G O A L T R A CKING FORM Activity Set GOAL Record of Goal Attempts Frequency Duration M T W R F Sa Su Getting out of bed by 7 AM 7 X N/A Y Y Y Y 10:00 AM 11:30 AM 10:00 AM Showering before noon 7X N/A Y Y Y Y 1:00 PM N N Take daughter to the park 3X 15 min. 15 min. N 25 min. 20 min. 15 min. N N Watch a movie 1X N/A Y N Y N N N N Eat breakfast before 10:30 AM 7X N/A Y Y Y Y Y N N Go for evening walk 3X 5 min. 20 min. N 20 min. 20 min. 20 min. N N Wind-down activities 1 hour before bed 7 X N/A Y Y Y Y Y N Y Call Mom to check-in 1X 10 min. 20 min. N N N N N N In bed only when sleepy but no earlier than12:30 AM 7 X N/A Y Y Y Y Y Y Y No wakeful activities in bed 7 X N/A Y Y Y Y Y N Y Out of bed when unable to sleep 7 X N/A Y Y Y Y N N Y No naps 7 X N/A Y Y Y Y Y Y N Figure 9.3 Sample Goal Tracking Form

150 Combining Depression and Insomnia Therapies The Goal Tracking homework form (for an example see Figure 9.3; for a blank handout, see Appendix F) is an essential part of Module 2 and also the last module because it is used to plan post-therapy goals. The goals are written by the client at the end of each session. After the goals are generated, the therapist queries about whether the goals are realistic, behavioral, and measurable. As with sleep diaries during this module, The Goal Tracking form is assigned as homework each week and reviewed at the start of every session. The first part of the review is to reinforce (i.e., praise) the client for bringing in the form, completing the form, attempting homework, and meeting goals. The second part is to check-in on the experience for the client. In cases in which goals were not met, the client and therapist conduct an analysis of what got in the way, which includes the possibility that the goal was too difficult and needs to be adjusted. In those who exhibit low in self-efficacy, goals can be set too low and although goals are met, the expectations are so low that it does not generate any increased self-efficacy. In those who are perfectionistic, setting anything less than very high goals can be met with resistance. The bulk of Module 2 is spent on teaching clients how to set and meet goals in a way that is realistic, provides positive reinforcement, and improves their mood. The TRAP or TRAC handout (see Figure 9.4 for a completed handout) is likewise an important part of this active treatment module (adapted from Martell et al., 2013). Using the TRAP (Trigger → Response → Avoidance Pattern) component of the worksheet, clients learn about triggers for and the consequences of their avoidance patterns. In the example presented in Figure 9.4, the client is triggered by situations in which he is feeling low energy at work. In response to feeling low energy, he begins ruminating about the symptoms, causes, and consequences, and the result is avoidance in the form of leaving work and canceling other obligations. This is a frequent avoidance pattern in insomnia. When clients feel low energy, it is a frequent trigger for rumination about the daytime symptoms of insomnia (Carney et al., 2010b). The rumination typically fixates on the presumed cause of feeling low, which is most often attributed to poor sleep (Harris, Carney, & Edinger, 2009a). The other consequence of rumina - tion is the avoidance of tasks that could increase self-efficacy and the decrease in activities that could provide a break from fatigue, increase sleep drive, and increase positive reinforcement. After clients learn how to identify TRAPs, they complete the TRAC (Trigger → Response → Alternative Coping) component. The TRAC component encourages clients to identify alternative coping responses to the same triggers to produce a different, more desirable outcome. In the example provided in Figure 9.4, the client identifies fatigue coping strategies as an alternative to leaving the task, and work, altogether. One example of a fatigue coping strategy is taking a break before returning to the task. Related fatigue strategies could include re-hydrating rather than caffeinating, or stretching and focusing the eyes away from the screen for rest rather than staying at the desk and squinting. Alternative coping strategies should be easy to derive because they are essentially also found in Anti-depressant and Pro-Sleep columns of their respective worksheets. It should be particularly noted that there are redundancies built into this treatment to acknowledge that attention and retention of information can be difficult for those with depression. Therefore, when depressed clients are unable to generate alternative coping strategies, or remember critical information about sleep, it is important for the

Combining Depression and Insomnia Therapies 151 therapist to utilize repetition and frequent check-ins about what the client remembers from session to session (e.g., check-ins are done after agenda setting at the start of each session). Module 3: Relapse Prevention and Termination Work By session 12 (for some clients this is a 12 session treatment so it will occur around session 10), clients have had multiple weeks of goal setting practice, appraising strategies to meet goals and readjusting goal setting when needed. They have also had ample practice with the TRAP or TRAC worksheets so that they have been practicing alternative antidepressant, pro-sleep, and pro-energy behaviors in response to triggers that previously triggered avoidance behaviors. Lastly, their sleep should be sufficiently improved and adjustments in time-in-bed are likely no longer necessary. For those who responded early in treatment and these skills are solidified, we may discuss whether the client would like to terminate at this point. If this is desirable for both parties, the therapist and client devise a relapse prevention letter and the client makes a list of posttreatment goals. In short, for some clients this module can be condensed into one session. More often however, clients see the benefit of additional sessions to practice their skills and build self-efficacy. In this case, the client and therapist contract for two more sessions and agree on the content and focus for the remaining sessions. In addition, an important part of this module is termination planning, which requires checking in with the client about how they are feeling about the impending end of therapy. For some, this is seen as a positive time—perhaps it is viewed as an accomplish - ment. For others, there is trepidation about whether they can continue the momentum gained during therapy after sessions stop. No matter how the client is feeling about termination, it is important to take time to check-in and make plans for the remaining sessions as well for post-treatment. TRIGGER RESPONSE AVOIDANCE PATTERN OUTCOME TRIGGER RESPONSE ALTERNATIVE COPING OUTCOME Feeling tired at desk Ruminating about why I feel so tired Leave work Get behind at work— feel anxious Lie around at home feeling tired Cancel other obligations TRAP TRAC Feeling tired at desk Ruminating about why I feel so tired Take a break with another activity Return to activity after break Feel efficacious at work Feel more energetic Figure 9.4 TRAP or TRAC Worksheet

In planning for termination, there needs to be an appraisal of the areas in which the client wants to focus. Some clients may want to tackle a particularly challenging goal left on their list. Some clients want to loosen some of the sleep rules and want guidance on how they can proceed. Some anticipate a change or challenge to their sleep in the future (e.g., a trip to Europe, a new baby, or a change in work schedule) and want to discuss how they will adjust their current routine in the future. For others, the desire may be to continue working on goals to increase their confidence. It is important to navigate this final module collaboratively, but by this stage the client should be capable of assuming more of the leadership role. Conversely, in the first module or two, the process is collaborative, but the therapist takes on a more didactic role to teach skills. By the end, the therapist should mainly observe and fine-tune the plans and homework the clients set. It is imperative that clients have competencies in: 1) calculating their total sleep time, total time in bed and sleep efficiency from sleep diaries, 2) determining a time-in-bed schedule based on their total sleep time, 3) determining whether an increase in time-in-bed is needed (based on sleep efficiency greater than 90 percent, subjective sleepiness, and/or sleep onset latency less than 10 minutes), 4) setting or achieving realistic goals for activities, and 5) successfully completing the TRAP or TRAC worksheet. If clients do not exhibit independence on any of these tasks, there should be a focus on fostering autonomy in the remaining sessions. In other words, it should always be an explicit goal of treatment to eliminate the therapist from the equation. One relapse prevention tool used in depressive relapse prevention (e.g., Bieling & Antony, 2003) is the “letter to self.” When one considers Teasdale’s “mind in place” theory of depression, this is a particularly sensible approach (Teasdale, 1997). The “mind in place” idea is that in depression a different mindset is dominant, one that is pro-depression and largely impenetrable to disconfirming antidepressant ideas and behavioral possibilities. Throughout depression treatment, increasing activation of antidepressant areas through behavioral change leads to a different mindset, or, a different, mind in place. Because relapse may result again in a different, pro-depression mindset, the client writes a letter to the future depressive mind, acknowledging that the way they may be thinking, feeling and acting may more closely resemble themselves at pre-treatment. They write a future relapse-self a letter to remind themselves of all the behavior changes that were helpful in shifting out of this mindset. This is assigned as one of the last pieces of homework. The therapist should ask clients to include what behavioral changes were helpful for sleep and fatigue as well. We invite the client to read the letter at the last session, but we also respect that many clients want this letter to remain private. The writing of the letter is more important than reading it aloud. The client can be reminded to put the letter in a spot that they can easily access it when feeling low or having trouble sleeping. Lastly, because the letter is quite personal and may not have all the behavioral recommendations we would like the client to remember, the therapist can also prepare a letter using a template, and fill-in some more personally relevant material in the letter with the client. The letter contains all of the most common elements of treatment but leaves room to write in some idiosyncratic recommendations. Next to the common therapy elements are boxes that can be checked off if they apply to the client—this is done collaboratively. At the end of the letter, there is a reminder about red flags for a 152 Combining Depression and Insomnia Therapies

Combining Depression and Insomnia Therapies 153 mood or sleep problem returning, and a reminder to start monitoring activity and sleep to determine if all of the checked recommendations are currently implemented. This orients the client to start implementing the checked-off recommendations that were previously successful in addressing their sleep and mood problem. The pre-treatment and final assessment scores (e.g., BDI-II and ISI) are graphed for clients to see their progress in addressing their complaints. We use this as an opportunity to reflect on their therapy experience. See Figure 10.10 in Chapter 10 for Kelly, the case study in Chapter 10, for graphed ISI scores from CBT-I treatment. Although this client was not treated with BABIT the same graphic depiction is used in both treatments to display treatment progress. Preliminary Evidence for BABIT: An Open Trial Both Behavioral Activation and Behavioral Insomnia Therapy are efficacious treatments so a randomized controlled trial confirming the efficacy is unnecessary. However, establishing that we can achieve large effect sizes (that match the effect size in the literature) across both conditions, without adding substantial length to the treatment, in novice therapists and without high dropout rates, would provide support for the utility of this combined approach. Although data collection is still ongoing for BABIT below we provide some initial data. Participants There were 15 enrolled participants and 13 people completing the study at the time of this writing (enrollment is ongoing). This study is being conducted at Ryerson University’s Sleep and Depression Laboratory. Reasons for dropout included clinical nonresponse (at session 13) and travel (i.e., long commute to treatment sessions). Ages ranged from 18–69 years old (mean age was 48.8 years old). There were more females than males (n = 4), which is typical of MDD trials. Participants were predominantly Caucasian; there was one person who identified as West Asian and one who identified as Aboriginal Canadian. There were 8 participants taking antidepressant medications and 10 reporting taking sleeping medication; none met criteria for hypnotic dependence on the DSISD. Procedures The study enrolled those complaining of both MDD and comorbid insomnia. Participants included both clinic-referred clients and individuals solicited from other ongoing research studies or via media advertisements. Women and men were considered for inclusion if they: (1) were aged 18–74 years old; (2) had an insomnia complaint of at least one month duration that met the Research Diagnostic Criteria (Edinger et al., 2004a) for an Insomnia Disorder; (3) showed a mean sleep efficiency (SE = [Total Sleep Time ÷ Time in Bed]  100 percent) < 85 percent during one screening week of sleep diaries with the Consensus Sleep Diary; and (4) met criteria for a Major Depressive Episode (without psychotic features) as verified by the mood module of the SCID; and (5) evidenced at least moderate depression symptom severity by having a

154 Combining Depression and Insomnia Therapies score of > 15 on the 17-item HAM-D administered at a screening appointment. We selected the HAM-D cut-off because it denotes full depressive symptomatology according to consensus definitions in the field (Frank et al., 1991), approximates the moderate level of depression seen at specialty sleep clinics or primary care settings (Gaynes et al., 2005), and allowed for sufficient severity to detect symptom change. We enrolled only those who were able to understand and complete study procedures, benefit from the treatments offered, undergo study procedures without undue discomfort or safety risks, and had no competing primary sleep, psychiatric, or medical disorders, or ongoing treatments that would limit or confound their treatment responses. Thus, excluded from the trial were those who: (1) need immediate psychiatric (e.g., imminently suicidal clients) or medical care (e.g., clients with acute cardiac symptoms), or with an attempted suicide in the past 6 months; (2) had a sleep-disruptive comorbid medical condition (e.g., moderate to severe rheumatoid arthritis; (3) score < 27 on the Mini-Mental Status Exam (MMSE) (Folstein, Folstein, & McHugh, 1975); (4) met criteria for Bipolar Disorder, Schizophrenia or any other psychotic disorders on the basis of a SCID interview; (5) met criteria for Antisocial Personality Disorder or Borderline Personality Disorder on the basis of a SCID II interview schedule; (6) reported frequent travel across time zones or work rotating or night shifts; (7) met criteria for sleep apnea, restless legs syndrome, or Circadian Rhythm Sleep Disorder on the basis of the Duke Structured Interview of Sleep Disorders; and (8) had a history of alcohol, narcotic, benzodiazepine, or other substance abuse or dependence in the 6 months prior to screening. Participants were permitted to use sleeping medications if they were taking them, as long as they were not hypnotic dependent and as long as they were agreeable to taking the medications noncontingently during the trial. Participants were screened using the MMSE, SCID, and DSISD to rule-out cognitive impairment, to confirm the presence of RDC for an Insomnia disorder (DSISD) and DSM-IV-TR criteria for MDD on the SCID respectively. The SCID was also used to exclude those with suspected Bipolar disorder diagnoses, Psychotic disorders, and substance-related disorders. The DSISD was used to rule-out those with hypersomno - lence, suspected sleep apnea, or circadian rhythm disorders. Upon initial acceptance they monitored their sleep prospectively for one week to determine if they met sleep diary criteria (e.g., mean sleep efficiency less than 85 percent). If participants continued to meet entry criteria, they completed a battery of pre-treatment measures that included the Beck Depression Inventory, Second Edition (BDI-II) (Beck et al., 1996) and the ISI (Morin, 1993). The other measures are not reported here as they will be part of the pub - lished effectiveness paper. After completing the battery of questionnaires, participants monitored their sleep prospectively for two weeks. The same battery and sleep diary monitoring procedures were repeated after the last treatment session and at one month post-treatment. Results Figure 9.5 depicts the mean pre-post changes on the BDI-II and ISI. On t-tests, both sleep and depression significantly decreased from pre-treatment (t(12) = 7.38, p < .001 and t(12) = 4.38, p = .001, respectively). This was true even for the BDI-II with sleep item 16 removed (t(12) = 5.74, p < .001). Using Cohen’s d (Cohen, 1992), the effect

Combining Depression and Insomnia Therapies 155 sizes for insomnia (d = 2.2) and depression (d = .83) were large. The mean scores at post-treatment for BDI-II and ISI were below the clinical cut-offs for the measure. Conclusions Thus, in this initial open trial of BABIT, BA, and BT for insomnia were feasibly and easily integrated without adding substantively to the length of treatment. This treatment was highly effective, even though the treatment was delivered by novice graduate student therapists. There were both statistically and clinically significant improvements for sleep and depression. Moreover the magnitude of the improvement was large—this mirrors the literature on these therapies when delivered alone. Although in particular settings, particularly sleep settings, CBT-I may be used on its own with positive effects for mood in addition to sleep, CBT-I is not a depression-specific therapy and we have no data to tell us whether the mood improvements are sustained. Thus a combined approach is a reasonable approach to address both sleep and mood, and both CBT-I and BA show long-term benefits (Dobson et al., 2008; Edinger et al., 2001). BABIT is only one possible version of combined therapy and it is unknown as to whether combining the cognitive elements of treatments for depression and insomnia would enhance outcomes. Nonetheless, BABIT is a simple treatment that was easy to train and supervise and thus should be considered at graduate student training clinics where the issue of comorbid insomnia and depression would be highly prevalent. It is perhaps not surprising that combining approaches is so effective. It is, however, exciting that a combined therapy is simple and quick to deliver. This trial originated out of necessity to address the needs of those who were unable or unwilling to take medication, and thus, ineligible for our NIH trial. Reviewers for the NIH trial also asked us to raise the age of entry for the trial out of fear of giving antidepressant medications to those under the age of 21 years. Thus, there are multiple advantages for BABIT. There 31.4 22.6 13.6 10.6 0 5 10 15 20 25 30 35 Beck Depression Inventory II Insomnia Severity Index Pre-treatment Post-treatment d = .83 d = 2.2 Figure 9.5 BABIT Depression and insomnia symptom outcomes N.B. The dashed lines denote the clinical cutoff for each measure.

is no reason to think that CBT approaches for insomnia and depression could not be similarly combined, although CBT approaches tend to be longer in duration than BA and BT for insomnia, so treatment duration may increase. Nonetheless, given the importance of insomnia in depression and the ease at which it can be treated, BABIT holds much promise for access to brief, efficacious, easily disseminated treatment. Summary • Combined evidence-based approaches for depression and insomnia are the best choice for MDD-I clients. • Combining behavioral activation and behavioral insomnia therapy is easily achieved in a brief integrated treatment package delivered by therapy novices—the effect sizes associated with BABIT are large and comparable to those reported with the monotherapies. • BABIT has three modules: 1) an orienting or assessment-focused phase from which a case formulation is formed, 2) an active module that involves: scheduling activities including the sleep schedule using goal tracking forms; using rumination as a cue for activation during the day and stimulus control at night, identifying alternative coping strategies to avoidance patterns, and 3) relapse prevention and termination planning. 156 Combining Depression and Insomnia Therapies

10 Case Study Kelly Throughout the book we have provided sample dialogues between therapist and client based on a fictional client named Kelly. Although fictional, Kelly is an amalgam of numerous examples of cases that are in many respects quite typical of clients with MDDI. In this chapter, we present session by session information about Kelly to provide an example of what the treatment looks like in practice. Assessment Session Kelly is a 60 year old female with current MDD and a presenting complaint of sleep maintenance insomnia and fatigue. She arrived at the clinic early with all of her requested materials including her completed sleep monitoring forms. She is self-referred and lists her reason for coming to the clinic, as “I can’t sleep.” Kelly was interviewed today with a clinical interview and the Duke Structured Interview for Sleep Disorders. Prior to the interview, she completed an Epworth Sleepiness Scale, medical history checklist, Fatigue Severity Scale, Dysfunctional Beliefs and Attitudes about Sleep Scale, the Daytime Insomnia Symptom Response Scale, Beck Depression Inventory, Second Edition, Penn State Worry Questionnaire, State-Trait Anxiety Inventory, and the ISI. Kelly also reports that she is in menopause. She is a full-time school teacher. She is divorced with a 21 year old daughter named Barb. Although she complained of lifelong sleeping difficulties, further query about sleep during childhood revealed that as a child and adolescent she actually slept reasonably well and that the complaint of insomnia appeared to originate in her early twenties, around the time of a major depressive episode and a highly stressful life event. She started medical school in her twenties and then switched programs to attend teachers’ college. She reports three MDD episodes (including this current episode): the first of which was in her twenties when she was struggling to make the decision about whether or not to switch programs. This episode lasted three years and resolved without treatment. The second major depressive episode began coincident with a separation and eventual divorce from her partner at age 42; this episode resolved a year later after several months of taking a prescribed tricyclic antidepressant. However, she appeared to remain somewhat dysthymic post-recovery until her most recent, and ongoing episode, which started 6 years ago (age 54). She takes 20 mg of citalopram each morning and reports she finds it helpful, although she still suffers from pervasive depressed mood, fatigue, insomnia, self-critical thoughts, increased appetite, concentration problems, and anxiety. She reports having had suicidal

ideation in the past but denies any current ideation, and denies any past or current intent or plan for self-harm. She was prescribed trazodone for sleep (50 mg at bedtime) but because she does not like the way she feels the next day, she takes it intermittently. She acknowledges a tendency towards all or none, perfectionistic thinking and engages in harsh self-talk when she views herself as “screwing up.” She reports a problem with rumination, although she views rumination as problem-solving, i.e., it gives her a chance to figure things out. Kelly reports having sleep onset problems, although her main complaint was that she cannot stay asleep throughout the night, and the sleep produced is experienced as “light.” She has occasional hot flashes (about three to six times per month). She is currently on hormone replacement therapy which she reports as helpful in decreasing the frequency of hot flashes. When asked what she does during hot flashes, she reports fanning herself in bed and drinking water. She reports that it takes “hours” to get back to sleep after a hot flash. She attempts to nap at her desk at work or on the couch on weekends but is unable to fall asleep. However, she reports that she occasionally dozes unintentionally while watching television in the evening. Despite feeling very tired in the evening when she goes to bed, she feels instantaneously alert and has difficulty falling asleep. If she is unable to fall asleep within an hour she takes a trazodone. She stated that one of her goals is getting off the trazodone because it makes her groggy the next day. She uses blackout shades and a white noise machine to control the light and noise in her bedroom. She describes her time awake in the beginning of the night as unbearable and says that she cannot “shut off” her brain. Her score on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS16 = 5.1) suggests a high degree of unhelpful beliefs about sleep. Kelly’s Epworth Sleepiness Scale score was a 3 which is not suggestive of clinically relevant daytime sleepiness. During the Duke Structured Interview for Sleep Disorders she met criteria for an Insomnia Disorder. Despite the reported dozing in the evening particularly in front of the television, she did not meet criteria for hypersomnolence. She denied any symptoms suggestive of circadian rhythm disorders, restless leg syndrome, periodic limb movement disorder, sleep disordered breathing or narcolepsy; she denied any unusual behaviors during sleep (e.g., parasomnias). Her medical forms indicate a history of gall bladder problems starting in her 40s and low back pain (two herniated disks) for the past 12 years for which she takes non-steroidal antiinflammatory medication (NSAIDs). Her Fatigue Severity Scale score was clinically elevated (FSS = 5) and suggested a high degree of fatigue symptoms severity. Her score on the Daytime Insomnia Symptom Response Scale (DISRS = 59) is suggestive of a pervasive tendency to respond to feeling tired with repetitive, ruminative thought about her symptoms. Her score on the Penn State Worry Questionnaire was below the clinical cutoff for the measure, as was her trait score on the State-Trait Anxiety Inventory. Her responses on the ISI were suggestive of severe insomnia symptoms (ISI = 28). Kelly was mailed the core version of the Sleep Diary; an expanded one is typically preferred in complicated cases, especially for cases in which it is important to track medication, alcohol and/or caffeine use (see Figures 10.4, 10.6, and 10.8 for an expanded sleep diary). For sleep diary summaries, we used the most recent week for ease of presentation, it is advisable to enter the two weeks and use the mean of both weeks during the assessment session (see Figures 10.5, 10.7, and 10.9 for examples of calculated 158 Case Study

Case Study 159 diaries). Kelly attempted to monitor her sleep on the sleep diary, but she reported some difficulty in completing all of the entries and returned diaries with missing data (see Figure 10.1). She expressed concern about whether she was estimating correctly. Followup inquiry revealed some degree of perfectionism in approaching the task, she was however fairly easily redirected to providing a “guesstimate” and she reported that she did not anticipate a problem completing diaries in the future. The partially completed diaries provided some corroboration of her sleep onset and maintenance difficulties. The diaries suggested that she lingers in bed in the morning after the final awakening and there was some (e.g., over 2 hours) variability in her rise time. She took trazodone on two nights and Advil PM on one night as sleep aides during the monitored week. She reported that she took them because she “couldn’t take another night without sleep.” When queried about whether she did not sleep on the previous nights, she acknow - ledged that she slept, albeit poorly. There was no evidence of Sleep State Misperception. Kelly reports that she feels wide awake and then frustrated when getting into bed. She also reports worrying and occasionally experiencing hot flashes in bed. During interview, there were instances suggestive of sleep effort-related beliefs. She stated that she tries to get “every scrap of sleep” possible, thus lingering in the morning and attempting to nap. She acknowledged that because she feels so tired during the day, she has decreased her activities. Specifically, she no longer works out, she only occasionally socializes or engages in leisure activities. She currently has two cups of coffee (one in the morning and one after lunch) and will drink an energy drink or two in the afternoon if she is very tired. She denied use of any energy drinks during the last week. Formulation or Proposed Treatment Plan: Four biweekly sessions focused on the following: 1. Light, fragmented sleep is likely due to diffused sleep drive. The inadequate sleep drive may be due to dozing, delaying build-up of sleep drive by lingering in the morning, nap attempts, and decreased activity. Although occasional low back pain and NSAIDs may contribute, the LBP is episodic (and not currently active) so this is not a major factor at this time. Plan: Sleep restriction and scheduling activities. It is also possible that the antidepressant medication may be fragmenting sleep— plan: proceed with CBT-I first and assess response. 2. Conditioned arousal due to staying in bed while awake, frustrated, worrying, ruminating, and in the midst of a hot flash. Plan: Stimulus Control during wakefulness. 3. Daytime fatigue may be due to irregular circadian input and excessive resting. There was over 2 hours of variability between the earliest and latest rise time on the sleep diary which may be producing jetlag symptoms. Plan: Psychoeducation about jetlag and the circadian system, and Stimulus Control (i.e., set standard rise time 7 days per week). Encourage client to increase activities. A scheduled evening activity may also help with the current problem of evening dozing. 4. Eliminate contingent use of trazodone or other aides such as Advil PM. 5. Belief that one cannot cope with sleep loss: challenge via behavioral experiments and eliminate sleep effort behaviors (e.g., contingent use of caffeine and sleep medications).

Consensus Sleep Diary-Core (Please Complete Upon Awakening) NAME: Kelly Sample Today’s Date 4/5/08 1/8/14 1/9/14 1/10/14 1/11/14 1/12/14 1/13/14 1/14/14 1. What time did you get into bed? 10:15 PM 11:15 PM 10:45 PM 10:45 PM 11 PM 11 PM 10:45 PM 11 PM 2. What time did you try to go to sleep? 11:30 PM 11:15 PM 10:45 PM 10:45 PM 11 PM 11 PM 10:45 PM 11 PM 3. How long did it take you to fall asleep? 55 min. 30–45 min. ?. ? 45–60 min. ? ? ? 4. How many times did you wake up, not counting your final awakening? 6 times 3 2 2–3 1 3 2 1 5. In total, how long did these awakenings last? 2 hours 5 min. 80 min. 15 min. ? 30 min. 90 min. 45 min. ? 6. What time was your final awakening? 6:35 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 8:10 AM 7:45 AM 7. What time did you get out of bed for the day? 7:20 AM 7:10 AM ? 7:10 AM 7:15 AM 6:30 AM 8:30 AM 8:45 PM 8. How would you rate the quality of your sleep?  Very poor ✓ Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good ✓ Very good ✓ Very poor  Poor  Fair  Good  Very good 9. Comments (if applicable) I have a cold trazodone 50mg Advil PM trazodone 50mg Figure 10.1

6. Rumination: Challenge belief that it is advantageous or productive with behavioral experiment. Use counter arousal strategies to manage rumination. Consider mindfulness as a strategy for repetitive thought. 7. Perfectionistic beliefs: Challenge via Socratic questioning and thought records. Assessment Session Homework: Continue monitoring with sleep diaries. Return to clinic next week to begin CBT-I. Session 1 Plan • Reinforce sleep diary completion and troubleshoot any issues. • Make calculations of sleep efficiency. • Introduce Stimulus Control, Sleep Restriction, and the Buffer Zone. • Establish non-contingent medication use. Session 1 Notes ISI was completed; score was suggestive of severe insomnia (ISI = 29). Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of moderately severe depression (BDI-II = 26). She correctly and consistently completed the sleep diaries; the following mean sleep indices (see Figure 10.2) are calculated from the sleep diaries: mean sleep onset latency was about 50 minutes, wakefulness after sleep onset (WASO) was an hour and forty minutes, total sleep time was about 5.6 hours and sleep efficiency was 61 percent. There were 3 hours of variability in the earliest and latest rise times during the recording period. She reported that these values were fairly representative of her sleep generally. Based on information during the assessment of dozing in the evening, followed by sleep onset problems when relocating to the bedroom, the therapist used this informa - tion to explain the concept of conditioned arousal and the rationale for Stimulus Control. In delivering this information, the therapist learned the client has concerns that getting out of bed will limit her sleep opportunity. Therapist: I want to make sure I understand. You have concerns that if you get out of bed when you are unable to sleep, you won’t get “enough” sleep? Client: That’s right. If I stay in bed, at least there is a chance that I could sleep. Therapist: I suppose it is possible that you could fall asleep quickly but if your report and the diaries are true, it would appear that once you wake up, it takes you considerable time to fall back to sleep. In other words, when you wake up, you are not ready to return to sleep right away, so it doesn’t seem like this strategy gets you what you want. Client: What’s the alternative? Therapist: You said you were worried that it could take you longer to fall asleep if you got out of bed, let’s say that you are right, what is the advantage of staying up longer with respect to your sleep the next night? Client: It’s hard to think of it like an advantage, but I guess you would build-up more sleep drive? Case Study 161

Consensus Sleep Diary-Core (Please Complete Upon Awakening) NAME: Kelly Sample Today’s Date 4/5/08 1/15/14 1/16/14 1/17/14 1/18/14 1/19/14 1/20/14 1/21/14 1. What time did you get into bed? 10:15 PM 11:15 PM 10:30 PM 9:15 PM 11 PM 11:20 PM 10:45 PM 10:45 PM 2. What time did you try to go to sleep? 11:30 PM 11:15 PM 10:30 PM 9:15 PM 11 PM 11:20 PM 10:45 PM 10:45 PM 3. How long did it take you to fall asleep? 55 min. 40 min. 40 min. 80 min. 40 min. 50 min. 40 min 60 min. 4. How many times did you wake up, not counting your final awakening? 6 times 1 1 2 1 2 3 3 5. In total, how long did these awakenings last? 2 hours 5 min. 80 min. 60 min. 100 min. 90 min. 180 min. 90 min. 120 min. 6. What time was your final awakening? 6:35 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 6:30 AM 8:10 AM 7:55 AM 7. What time did you get out of bed for the day? 7:20 AM 7:10 AM 7:40 AM 7:10 AM 7:30 AM 7:30 AM 9:00 AM 9:45 AM 8. How would you rate the quality of your sleep?  Very poor ✓ Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good 9. Comments (if applicable) I have a cold trazodone 50mg Hot flash trazodone 50mg Figure 10.2

Therapist: And what is the advantage with respect to conditioned arousal? In other words, if you are wide awake when you get into bed and wide awake when you wake up in bed, how would getting out of bed help with getting rid of that association? Client: It’s supposed to get rid of it but this sounds horrible. Therapist: Do you play chess? Client: A little. Therapist: I wonder if giving up a night or two to get rid of the conditioned arousal, especially knowing that you would be rewarded with deeper sleep subsequently is sort of like giving up a pawn to clear the path to take your opponent’s king? Client: I see what you mean. Therapist: Staying in bed won’t win the game because we see that it is associated with insomnia for you. It is kind of difficult to give up “trying” to sleep if you stay in bed. Client: I would be willing to give up my pawn I guess [smiles] but I am a little skeptical. Therapist: Fair enough. Can we re-evaluate whether it was worth it after two weeks? Client: OK. Given the TST of 5.6 hours, the time-in-bed prescription was set at 6 hours. The client selected 6:30 AM as the standard rise time, which means that the bedtime was 12:30 AM. However, the therapist pointed out that there were no times at which the client stayed up until 12:30 AM currently and in fact, the client reported dozing in the evening. The therapist suggested to move the bedtime earlier to 11:30 PM and set the rise time at 5:30 AM, to correspond to the client’s early circadian tendency. The therapist reviewed the rationale and rule of beginning wind-down activities (i.e., the Buffer zone) an hour before the prescribed bedtime. The therapist requested that the client either keep the medication dose and timing every night throughout treatment or discontinue it altogether. The client expressed ambivalence about taking the medication but ultimately decided to keep it steady throughout the treatment and to discuss this plan with her family doctor at her scheduled appointment this week. The therapist provided a summary of treatment recommendations (see Figure 10.3). The therapist discussed the caffeine recommendation and they agreed that the client would limit use to two cups per day (with the last cup around 1 PM). Assigned Homework Session 1 • Complete two weeks of diaries. • Follow the prescription on client summary (schedule is 10:30 PM–5:30 AM) and institute Stimulus Control. • Take trazodone at same time each night. • Limit caffeine to two cups of coffee. • Return to clinic in two weeks. Case Study 163

Session 2 Plan • Review diaries, complement completion and/or troubleshoot incomplete sleep diaries. • Check-in on homework and troubleshoot any adherence issues. • Assess for whether sleep extension is warranted (i.e., check for an elevated sleep efficiency on the sleep diary or ask about subjective sleepiness). • Time permitting, add some activity scheduling to help with fatigue, combat dozing, and challenge the idea that life stops when experiencing fatigue. Session 2 Notes ISI was completed; score was suggestive of moderately severe insomnia (ISI = 21). Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of 164 Case Study My plan for better sleep Over the next two weeks, I will do the following: 1. I will use a standard get-up-out-of-bed time, seven days per week, regardless of the sleep I obtain on any particular night. My latest time out of bed is: 5:30 AM . To accomplish this I will set an alarm for every morning at this time. 2. I will go to bed only when I am sleepy, but never before my earliest possible bedtime. My earliest bedtime is 11:30 PM . 3. I will get up out of bed when I can’t sleep. I will give up the effort to sleep, and go to another room until I feel sleepy enough to fall asleep quickly before returning to bed. 4. If I still cannot fall asleep when I return to bed, repeat step 3. 5. I will avoid doing wakeful things while in bed. In other words, I will use the bed for sleeping only. If sexual activity is not alerting, this can be an exception to the rule. 6. If I find myself worrying, problem-solving, ruminating, planning in bed, or engaging in sleep effort, I will get up and stay out of bed until this thinking dissipates and I feel sleepy enough to return to bed. This includes if I wake up because of a hot flash. 7. I will avoid daytime napping or spending time lying down throughout the day except in the case of safety. 8. I will fill out my sleep diary each morning, preferably within an hour of rising, so that I can track the impact of this plan on my sleep. Other helpful hints: I will limit caffeine to one drink as far away from bedtime as possible, and attempt to refrain from alcohol and smoking, including marijuana. I will ensure my bedroom is quiet, dark, and cool. I will attempt to exercise, although not right before bed. Figure 10.3 Treatment plan summary example: Kelly

Case Study 165 moderate level of depression (BDI-II = 21). She correctly and consistently completed the sleep diaries; the following mean sleep indices are calculated from the sleep diaries: mean sleep onset latency was reduced from session 1 (M = 20 minutes) and within normal limits, WASO was reduced from session 1 (M = 25 minutes) and now within normal limits, total sleep time was about the same 6.2 hours and sleep efficiency was improved from 74 percent to 80 percent. She reported that the diaries were representative of her sleep generally. The session began with a complement about her completion of the diaries, a mood and sleep check and an invitation to talk about her experience in following the new sleep rules. The client reported some difficulty following the recommendation to get out of bed by 5:30 AM. Figure 10.4 depicts a summary of the sleep diary data from the most recent week. Again, we typically use 2 weeks’ worth of data but for ease of presentation, we are using the most recent week. The mean rise time was 6 hours and 57 minutes which is almost an hour and a half later than the prescribed rise time. The average final awakening was over 30 minutes later than the prescribed wake-up time (6:05 AM) and further query with the client confirmed that she stopped setting the alarm clock about 4 days after the previous session. The client cited a few reasons for this difficulty which included not wanting to feel cold when getting out of bed. The client agreed to take the blanket to a transition spot to stay warm and also to keep socks by her bed to put on before getting out of bed. The therapist used an analogy of willingness to sacrifice a pawn and experiencing less time in bed to experience better quality sleep. The client agreed to test it out by setting an alarm every morning. This discussion also uncovered some anxiety about sleep loss. Anxiety about the consequences of sleep loss was cited as a reason for non-adherence to the caffeine recommendations, i.e., evidence of increased use of energy drinks in the late afternoon. Upon further exploration, the client revealed a high degree of anxiety and aversion to the experience of fatigue. The therapist explored whether openness to the experience of fatigue would be a helpful new stance (see Chapter 9 for the exchange). The client acknowledged that contingent caffeine use was an unhelpful avoidance strategy and she agreed to eliminate the energy drinks. The client reported following stimulus control recommendations to get out of bed in the middle of the night, including when the awakening was caused by a hot flash. There was one hot flash in the past week and the client reported that she got out of bed and read until she was sleepy again. Of note is that her WASO improved from almost an hour to within normal limits (WASO M = 25 minutes). The client reported some difficulty following the recommendation to go to bed no earlier than 11:30 PM. The average bedtime was 30 minutes earlier than the prescribed 11:30 PM bedtime (see Figure 10.5). The client also reported some dozing in the evening. To address this issue, the therapist discussed the sleepiness or fatigue distinction and they discussed activities that would decrease the likelihood of dozing in the evening. In a discussion of fatigue, it was revealed that the client felt bored and was somewhat inactive. A life compass exercise revealed that fatigue and insomnia prevented her from living a life consistent with her values. Moreover she often felt isolated because of her lack of activities outside the home. The client agreed to schedule at least 2 activities and to monitor her activity level on a monitoring form.

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 11/22/14 11/23/14 11/24/14 11/25/14 11/26/14 11/27/14 11/28/14 1. What time did you get into bed? 11:30 PM 11:30 PM 10:45 PM 11:20 PM 10:30 PM 11 PM 11:10 PM 2. What time did you try to go to sleep? 11:30 PM 11:30 PM 10:45 PM 11:20 PM 10:30 PM 11 PM 11:10 PM 3. How long did it take you to fall asleep? 30 min. 20 min. 40 min. 5 min. 40 min. 30 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 2 1 2 1 1 5. In total, how long did these awakenings last? 60 min. 10 min. 40 min. 10 min. 40 min. 25 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6:15 AM 6:20 AM 6:40 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 0 15 min. 30 min. 45 min. 30 min. 1 hour 2 hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 5:30 AM 5:45 AM 6 AM 6:20 AM 6:45 AM 7:50 AM 9 AM 8. How would you rate the quality of your sleep? ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good ✓ Very poor  Poor  Fair  Good  Very good Figure 10.4 Consensus Sleep Diary © 2011

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 11/22/14 11/23/14 11/24/14 11/25/14 11/26/14 11/27/14 11/28/14 9a. How many times did you nap or doze? 0 0 1 1 1 0 1 9b. In total, how long did you nap or doze? 0 0 15 min. 25 min. 20 min. 0 20 min. 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 1 10b. What time was your last drink? N/A N/A N/A N/A N/A N/A 9:30 PM 11a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? 2 2 2 3 2 3 3 11b. What time was your last drink? 1 PM 12:45 PM 1:15 PM 4:10 PM 1 PM 4 PM 4:45 PM 12. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken Trazodone 50 mg 10:30 PM Trazodone 50 mg 11 PM Trazodone 50 mg 9:45 PM Trazodone 50 mg 11 PM Trazodone 50 mg 9:30 PM Trazodone 50 mg 10 PM Trazodone 50 mg 10 PM 13. Comments (if applicable) Figure 10.4 Continued

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 11/29/14 11/30/14 12/1/14 12/2/14 12/3/14 12/4/14 12/5/14 1. What time did you get into bed? 11:30 PM 11:30 PM 10:45 PM 11:20 PM 10:30 PM 11 PM 11:10 PM 2. What time did you try to go to sleep? 11:30 PM 11:30 PM 10:45 PM 11:20 PM 10:30 PM 11 PM 11:10 PM 3. How long did it take you to fall asleep? 5 min. 20 min. 30 min. 5 min. 40 min. 25 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 1 1 1 1 1 5. In total, how long did these awakenings last? 10 min. 20 min. 30 min. 10 min. 45 min. 20 min. 40 min. 6a. What time was your final awakening? 5:45 AM 5:50 AM 5:50 AM 5:35 AM 6:15 AM 6:40 AM 6:40 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 10 min. 15 min. 10 min. 45 min. 30 min. 2 hour 2 hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 6:15 AM 6 AM 6:20 AM 6:45 AM 8:50 AM 8:30 AM 8. How would you rate the quality of your sleep?  Very poor ✓ Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good  Very poor ✓ Poor  Fair  Good  Very good Figure 10.4 Continued

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 11/29/14 11/30/14 12/1/14 12/2/14 12/3/14 12/4/14 12/5/14 9a. How many times did you nap or doze? 0 0 1 1 1 1 1 9b. In total, how long did you nap or doze? 0 0 10 min. 15 min. 10 min. 10 min. 15 min. 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 1 0 10b. What time was your last drink? N/A N/A N/A N/A N/A 9 PM N/A 11a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? 2 2 2 3 2 4 3 11b. What time was your last drink? 1 PM 1 PM 1:15 PM 4 PM 1 PM 6 PM 4:35 PM 12. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken Trazodone 50 mg 10:30 PM Trazodone 50 mg 11 PM Trazodone 50 mg 9:45 PM Trazodone 50 mg 11 PM Trazodone 50 mg 9:30 PM Trazodone 50 mg 10 PM Trazodone 50 mg 10 PM 13. Comments (if applicable) Hot flash Figure 10.4 Continued

11/29/14–12/5/14 Dates Bedtime (Time went into bed) Lights out (Try to go to sleep) Latency to sleep (minutes to fall asleep) Minutes awake in middle of night (how long awakenings last) Wake time (time of final awakening) Mins awake too early (how many minutes earlier) Out of bed (out of bed for the day) Time in Bed (TIB) Total Sleep Time (TST) Sleep Efficiency (SE) % sample 1/1/2011 23:30 23:45 30 60 7:00 30 8:00 8.25 5.75 69.70% day 1 23:30 23:30 5.00 10.00 5:45 0.00 6:00 6.50 6.00 92.31% day 2 23:30 23:30 20.00 20.00 5:50 0.00 6:15 6.75 5.67 84.00% day 3 22:45 22:45 30.00 30.00 5:50 0.00 6:00 7.25 6.08 83.86% day 4 23:20 23:20 5.00 10.00 5:35 0.00 6:20 7.00 6.00 85.71% day 5 22:30 22:45 40.00 45.00 6:15 0.00 6:45 8.25 6.33 76.73% day 6 23:00 23:00 25.00 20.00 6:40 0.00 8:50 9.83 6.92 70.40% day 7 23:10 23:10 20.00 40.00 6:40 0.00 8:30 9.33 6.50 69.67% AVERAGE 23:06 23:08 20.71 25.00 6:05 0.00 6:57 7.84 6.21 80.38% Bedtime Lights out Latency to fall asleep Mins. awake in middle of night Wake time Minutes awake too early Out of bed for day Time in Bed Total Sleep Time Sleep Efficiency Figure 10.5 Kelly sleep diary calculations from week 2 of session 2

Assigned Homework: Session 2 • Complete two weeks of diaries. Follow the prescription on client summary (schedule is 11:30 PM–5:30 AM). • To address issues with feeling cold when getting up, place socks by bed and take blanket to a second location to transition. • Set alarm all 14 days. • Schedule some activities out of the house as well as some evening activities to minimize dozing, and track progress on activity monitoring form. • Return to clinic in two weeks. Session 3 Plan: • Review diaries, complement completion and/or troubleshoot incomplete sleep diaries. • Check-in on homework and troubleshoot any adherence issues. • Assess for whether sleep extension is warranted (i.e., a self-report of sleepiness or elevated mean sleep efficiency on the sleep diary). • Time permitting, add a mindfulness activity to help with repetitive thought. • Challenge perfectionistic thinking about functioning or sleep. • Check-in on thoughts and feelings about termination. • Assign Letter to Self for relapse prevention. Session 3 Notes The ISI was completed and the score was suggestive of moderate insomnia (ISI = 15). Suicidal ideation check revealed no current ideation. Her BDI score was suggestive of moderate level of depression (BDI-II = 17). She correctly and consistently completed the sleep diaries; the following mean sleep indices are calculated from the sleep diaries: mean sleep onset latency reduction from session 1 was maintained (M = 18 minutes) and within normal limits, WASO was again reduced from session 1 (M = 25 minutes) and is within normal limits, total sleep time remains around 6 hours and sleep efficiency was improved to 82 percent (61 percent at pre-treatment), and not suggestive of objective sleepiness. She reported that the diaries were representative of her sleep generally. The diaries and her self report revealed continued problems with adherence to the rise time prescription. Her average rise time was 6:40 AM; over an hour from the scheduled rise time. See Figures 10.6 and 10.7. Her final awakening was variable and the average time was 6:02 AM (30 minutes later than the scheduled alarm time). Followup inquiry confirmed that the client was not consistently setting an alarm. The solution proposed by the client was to keep a sticky note to remind herself to set the alarm. There were several instances during the session in which the client exhibited unhelpful thinking styles (e.g., perfectionism about sleep). These were challenged via Socratic questioning and also a thought record done in session. The client reported that the TR was helpful and agreed to complete TRs between sessions when encountering a troublesome thought. Similarly, the client reported that she ruminates less at night because she is sleepier but was distressed about rumination during the day this week. The therapist initiated an in-session behavioral experiment to test if rumination is helpful. The result was that thinking about concrete “what’s” of the situation worked Case Study 171

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/6/14 12/7/14 12/8/14 12/9/14 12/10/14 12/11/14 12/12/14 1. What time did you get into bed? 11:30 PM 11:30 PM 11:45 PM 11:30 PM 11:30 PM 11:20 PM 11:30 PM 2. What time did you try to go to sleep? 11:30 PM 11:30 PM 11:45 PM 11:30 PM 11:30 PM 11:20 PM 11:30 PM 3. How long did it take you to fall asleep? 30 min. 15 min. 10 min. 15 min. 10 min. 30 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 0 1 1 1 1 5. In total, how long did these awakenings last? 30 min. 10 min. 0 10 min. 40 min. 15 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 30 min. 15 min. 15 min. 15 min. 45 min. 1.5 hours 1.5 hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 5:45 AM 5:45 AM 5:50 AM 6:15 AM 7 AM 7 AM 8. How would you rate the quality of your sleep?  Very poor ✓ Poor  Fair  Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good Figure 10.6 Consensus Sleep Diary © 2011

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/6/14 12/7/14 12/8/14 12/9/14 12/10/14 12/11/14 12/12/14 9a. How many times did you nap or doze? 0 0 0 0 0 0 0 9b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 0 10b. What time was your last drink? N/A N/A N/A N/A N/A N/A N/A 11a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? 2 2 2 2 2 2 2 11b. What time was your last drink? 1 PM 1:45 PM 1:15 PM 1 PM 1 PM 1 PM 12:45 PM 12. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken Trazodone 50 mg 10:30 PM Trazodone 50 mg 10:30 PM Trazodone 50 mg 10:45 PM Trazodone 50 mg 11 PM Trazodone 50 mg 10:30 PM Trazodone 50 mg 10 PM Trazodone 50 mg 10 PM 13. Comments (if applicable) Figure 10.6 Continued

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/13/14 12/14/14 12/15/14 12/16/14 12/17/14 12/18/14 12/19/14 1. What time did you get into bed? 11:30 PM 11:30 PM 11:45 PM 11:30 PM 11:30 PM 11:30 PM 11:30 PM 2. What time did you try to go to sleep? 11:30 PM 11:30 PM 11:45 PM 11:30 PM 11:30 PM 11:30 PM 11:30 PM 3. How long did it take you to fall asleep? 5 min. 20 min. 20 min. 5 min. 30 min. 25 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 1 1 1 1 1 5. In total, how long did these awakenings last? 10 min. 20 min. 30 min. 10 min. 45 min. 20 min. 40 min. 6a. What time was your final awakening? 5:30 AM 5:50 AM 5:50 AM 5:35 AM 6:15 AM 6:40 AM 6:40 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 10 min. 15 min. 10 min. 45 min. 30 min. 1 hour 1 hour 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 6:15 AM 6 AM 6:20 AM 6:45 AM 7:50 AM 7:30 AM 8. How would you rate the quality of your sleep?  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good Figure 10.6 Continued

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/13/14 12/14/14 12/15/14 12/16/14 12/17/14 12/18/14 12/19/14 10a. How many times did you nap or doze? 0 0 0 0 0 0 0 10b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 11a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 1 11b. What time was your last drink? N/A N/A N/A N/A N/A N/A 9:30 PM 12a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? 2 2 2 2 2 2 2 12b. What time was your last drink? 1 PM 1 PM 1:15 PM 1 PM 1 PM 1 PM 1:35 PM 13. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken Trazodone 50 mg 10:30 PM Don’t see the point of the trazodone —stopped No No No No No 14. Comments (if applicable) Figure 10.6 Continued

12/3/14–12/19/14 Dates Bedtime (Time went into bed) Lights out (Try to go to sleep) Latency to sleep (minutes to fall asleep) Minutes awake in middle of night (how long awakenings last) Wake time (time of final awakening) Mins awake too early (how many minutes earlier) Out of bed (out of bed for the day) Time in Bed (TIB) Total Sleep Time (TST) Sleep Efficiency (SE) % sample 1/1/2011 23:30 23:45 30 60 7:00 30 8:00 8.25 5.75 69.70% day 1 23:30 23:30 5.00 10.00 5:30 0.00 6:00 6.50 5.75 88.46% day 2 23:30 23:30 20.00 20.00 5:50 0.00 6:15 6.75 5.67 84.00% day 3 23:45 23:45 20.00 30.00 5:50 0.00 6:00 6.25 5.25 84.00% day 4 23:30 23:30 5.00 10.00 5:35 0.00 6:20 6.83 5.83 85.36% day 5 23:30 23:30 30.00 45.00 6:15 0.00 6:45 7.25 5.50 75.86% day 6 23:30 23:30 25.00 20.00 6:40 0.00 7:50 8.33 6.42 77.07% day 7 23:30 23:30 20.00 40.00 6:40 0.00 7:30 8.00 6.17 77.13% AVERAGE 23:32 23:32 17.86 25.00 6:02 0.00 6:40 7.13 5.80 81.70% Bedtime Lights out Latency to fall asleep Mins. awake in middle of night Wake time Minutes awake too early Out of bed for day Time in Bed Total Sleep Time Sleep Efficiency Figure 10.7 Kelly sleep diary calculations from week 2 of session 3

better than thinking about the “whys”. The client agreed it was not helpful and agreed on a plan to use rumination as a cue for getting out of the bed at night, and BA during the day. During this conversation, the client reported attending a Mindfulness Based Stress Reduction group in the past. She stated that it was helpful for her rumination but had since stopped mindfulness practice. The therapist explored ways in which mind - fulness may allow her to take a step back from thoughts that excessively draw her attention. The client agreed to reintroduce mindfulness to her life by adding mindful - ness to her early evening walk. Assigned Homework: Session 3 • Complete two weeks of diaries. Follow the prescription on client summary (schedule is 11:30 PM–5:30 AM). • Continue to place socks by bed and take blanket to a second location to transition. • Continue to set alarm all 14 days; put sticky note on alarm clock to remember to set each night. • Schedule some activities (e.g., evening walk, joining the weekend card game) out of the house as well as some evening activities to minimize dozing, and track progress on activity monitoring form. • Add mindfulness to evening walk. • Write “Note to Self” for Relapse Prevention. • Return to clinic in two weeks. Session 4 Plan • Review diaries, complement completion and/or troubleshoot incomplete sleep diaries. • Check-in on homework and troubleshoot any adherence issues. • Assess for whether sleep extension is warranted (i.e., a self-report of sleepiness or elevated mean sleep efficiency on the sleep diary). • Challenge perfectionistic thinking about functioning or sleep. • Check-in on thoughts and feelings about termination. • Review Letter to Self; relapse prevention. • Enter ISI score into spreadsheet and share progress with client (see Figure 10.10). Session 4 Notes The ISI was 9 suggestive of mild sub-syndromal symptoms. In reviewing the ISI graph (Figure 10.10), the client expressed that the graph matched her experience of gradual improvement and being satisfied with her sleep currently. She had one remaining complaint: daytime sleepiness. There were notable improvements in her depression symptoms (BDI-II = 13), beliefs about sleep (DBAS16 = 2.7; below the clinical cutoff for the measure), fatigue (FSS = 3.4), and rumination in response to feeling tired (DISRS = 39). Of note, the BDI-II score at pre-treatment was in the moderately severe range and is now below the clinical cutoff for the measure (BDI-II = 13). The client remains Case Study 177

on citalopram. She voluntarily discontinued nightly trazodone use 3 weeks ago without any rebound or other discontinuation issues. A review of her sleep diaries (see Figure 10.8 for diaries and Figure 10.9 for a summary) revealed 8.57 minutes in wakefulness during the night, a sleep efficiency just above 90 percent, and a sleep onset latency of 10 minutes. The therapist and client discussed whether the time-in-bed prescription should be increased. It was agreed that the client should try a 15 minute extension and assess sleepiness after the period. The client demonstrated a good understanding of how to make the sleep diary calculations and how to assess whether an extension is needed. Both the diaries and self-report suggest that the client is now adherent to the rise time schedule; she reported that the sticky note reminder to set her alarm was helpful. The client read aloud her Letter to Self. She stated the following changes were particularly helpful: setting an alarm to maintain a regular rise time, scheduling activities so that she is not bored and prone to dozing, getting out of bed when she cannot sleep, particularly when she has a hot flash, and accepting the experience of fatigue. The client reported that the mindful walk has been helpful and she has instigated a 20 minute mindfulness practice with her colleagues over the lunch hour. The client expressed gratitude that she feels able to connect with her valued life and said that she feels confident that she could enact these strategies in the future if the insomnia returned. It should be noted that based on the remaining adherence issues in Session 3, an extra session could have been added. Based on the notable improvements (e.g., steadily falling ISI score and a sleep efficiency above 80 percent) and the fact that the therapist was confident that the remaining adherence would be improved in time for the last session, the therapist kept to a typical 4-session protocol. Assigned Homework: Session 4 • Continue with diary monitoring to assess the impact of the 15-minute sleep extension on current sleepiness. Extend an additional 15 minutes if sleepiness unresolved. Provided her with link for sleep diaries: www.drcolleencarney.com. • Continue with treatment plan including the prescription (schedule is 11:15 PM5:30 AM), socks by the bed, alarm 7 days a week, mindfulness evening walks and scheduling activities. • Follow-up with clinic in the future if sleep extension does not resolve the sleepiness or if new sleep symptoms arise, particularly, excessive daytime sleepiness, breathing-related symptoms such as loud snoring, choking; repeated urges to move the legs in the evening. In most cases, four sessions (sometimes less) is sufficient to resolve insomnia symptoms. At the end of the four sessions, there may be planned adjustments to time-in-bed for the upcoming weeks and months after treatment (most commonly extending timein-bed). Thus, it is important to have a written plan and decision guide for the client to make adjustments. A primary goal in CBT-I is to increase sleep self-efficacy, so it is important that the client receive training in how to make calculations and adjustments to their time-in-bed so that they can confidently change their sleep habits independently. 178 Case Study

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/20/14 12/21/14 12/22/14 12/23/14 12/24/14 12/25/14 12/26/14 1. What time did you get into bed? 11:30 PM 11:30 PM 11:45 PM 11:30 PM 11:30 PM 11:20 PM 11:30 PM 2. What time did you try to go to sleep? 11:30 PM 11:30 PM 11:45 PM 11:30 PM 11:30 PM 11:20 PM 11:30 PM 3. How long did it take you to fall asleep? 30 min. 15 min. 10 min. 15 min. 10 min. 30 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 0 1 1 1 1 5. In total, how long did these awakenings last? 30 min. 10 min. 0 10 min. 40 min. 15 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 30 min. 15 min. 15 min. 15 min. 45 min. 1.5 hours 1.5 hours 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 6 AM 5:45 AM 5:45 AM 5:50 AM 6:15 AM 7 AM 7 AM 8. How would you rate the quality of your sleep?  Very poor ✓ Poor  Fair  Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good Figure 10.8 Consensus Sleep Diary © 2011

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/20/14 12/21/14 12/22/14 12/23/14 12/24/14 12/25/14 12/26/14 9a. How many times did you nap or doze? 0 0 0 0 0 0 0 9b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 10a. How many drinks containing alcohol did you have? 0 0 0 0 0 0 0 10b. What time was your last drink? N/A N/A N/A N/A N/A N/A N/A 11a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? 2 2 2 2 2 2 2 11b. What time was your last drink? 1 PM 1:45 PM 1:15 PM 1 PM 1 PM 1 PM 12:45 PM 12. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken Trazodone 50 mg 10:30 PM Trazodone 50 mg 10:30 PM Trazodone 50 mg 10:45 PM Trazodone 50 mg 11 PM Trazodone 50 mg 10:30 PM Trazodone 50 mg 10 PM Trazodone 50 mg 10 PM 13. Comments (if applicable) Figure 10.8 Continued

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/27/14 12/28/14 12/29/14 12/30/14 12/31/14 1/1/15 1/2/15 1. What time did you get into bed? 11:30 PM 11:30 PM 11:30 PM 11:30 PM 1:00 AM 11:30 PM 11:30 PM 2. What time did you try to go to sleep? 11:30 PM 11:30 PM 11:30 PM 11:30 PM 1:00 AM 11:30 PM 11:30 PM 3. How long did it take you to fall asleep? 5 min. 10 min. 10 min. 5 min. 5 min. 15 min. 20 min. 4. How many times did you wake up, not counting your final awakening? 1 1 1 1 0 1 1 5. In total, how long did these awakenings last? 10 min. 15 min. 10 min. 10 min. 0 5 min. 10 min. 6a. What time was your final awakening? 5:30 AM 5:30 AM 5:30 AM 5:30 AM 5:30 AM 6:20 AM 5:30 AM 6b. After your final awakening, how long did you spend in bed trying to sleep? 15 min. 15 min. 15 min. 30 min. 30 min. 1 hour 1 hour 6c. Did you wake up earlier than you planned? No No No No No No No 6d. If yes, how much earlier? N/A N/A N/A N/A N/A N/A N/A 7. What time did you get out of bed for the day? 5:45 AM 5:45 AM 5:45 AM 5:40 AM 6:00 AM 6:20 AM 5:30 AM 8. How would you rate the quality of your sleep?  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor  Fair ✓ Good  Very good  Very poor  Poor ✓ Fair  Good  Very good  Very poor  Poor  Fair ✓ Good  Very good Figure 10.8 Continued

Consensus Sleep Diary-M (Please Complete Upon Awakening) ID/NAME: Kelly Today’s Date 12/27/14 12/28/14 12/29/14 12/30/14 12/31/14 1/1/15 1/2/15 9a. How many times did you nap or doze? 0 0 0 0 0 0 0 9b. In total, how long did you nap or doze? 0 0 0 0 0 0 0 10a. How many drinks containing alcohol did you have? 0 0 0 0 2 0 1 10b. What time was your last drink? N/A N/A N/A N/A 12 AM N/A N/A 11a. How many caffeinated drinks (coffee, tea, soda, energy drinks) did you have? 2 2 2 2 2 2 2 11b. What time was your last drink? 1 PM 1 PM 1:15 PM 1 PM 1 PM 1 PM 1:35 PM 12. Did you take any over-the-counter or prescription medication(s) to help you sleep? If so, list medication(s), dose, and time taken No No No No No No No 13. Comments (if applicable) New Year’s Eve Figure 10.8 Continued

Dates Bedtime (Time went into bed) Lights out (Try to go to sleep) Latency to sleep (minutes to fall asleep) Minutes awake in middle of night (how long awakenings last) Wake time (time of final awakening) Mins awake too early (how many minutes earlier) Out of bed (out of bed for the day) Time in Bed (TIB) Total Sleep Time (TST) Sleep Efficiency (SE) % sample 1/1/2011 23:30 23:45 30 60 7:00 30 8:00 8.25 5.75 69.70% day 1 23:30 23:30 5.00 10.00 5:30 0.00 5:45 6.25 5.75 92.00% day 2 23:30 23:30 10.00 15.00 5:30 0.00 5:45 6.25 5.58 89.28% day 3 23:30 23:30 10.00 10.00 5:30 0.00 5:45 6.25 5.67 90.72% day 4 23:30 23:30 5.00 10.00 5:30 0.00 5:40 6.17 5.75 93.19% day 5 1:00 1:00 5.00 0.00 5:30 0.00 6:00 5.00 4.42 88.40% day 6 23:30 23:30 15.00 5.00 6:20 0.00 6:20 6.83 6.50 95.16% day 7 23:30 23:30 20.00 10.00 5:30 0.00 5:30 6.00 5.50 91.67% AVERAGE 23:34 23:34 10.00 8.57 8:52 0.00 5:49 6.11 5.60 91.49% Bedtime Lights out Latency to fall asleep Mins. awake in middle of night Wake time Minutes awake too early Out of bed for day Time in Bed Total Sleep Time Sleep Efficiency Figure 10.9 Kelly sleep diary calculations from week 2 of session 4

Lastly, it is important that the therapist models a curious, open stance to problem-solving so that the client can remain confident, when troubleshooting independently. When clients understand their sleep system and experience improvements based on imple - menting their behavioral change strategies, they will be confident in the post-treatment phase. CBT-I is a robust, durable treatment, and effective insomnia treatment may have preventative or ameliorative effects on the depression; thus, CBT-I is an easy and important clinical endeavor. 0 5 10 15 20 25 30 35 Assessment Session 1 Session 2 Session 3 Session 4 Figure 10.10 Kelly’s Insomnia Severity Index scores throughout treatment

Appendix A: Core Sleep Diary General Instructions What is a Sleep Diary? A sleep diary is designed to gather information about your daily sleep pattern. How often and when do I fill out the sleep diary? It is necessary for you to complete your sleep diary every day. If possible, the sleep diary should be completed within one hour of getting out of bed in the morning. What should I do if I miss a day? If you forget to fill in the diary or are unable to finish it, leave the diary blank for that day. What if something unusual affects my sleep or how I feel in the daytime? If your sleep or daytime functioning is affected by some unusual event (such as an illness, or an emergency) you may make brief notes on your diary. What do the words ‘bed’ and ‘day’ mean on the diary? This diary can be used for people who are awake or asleep at unusual times. In the sleep diary, the word ‘day’ is the time when you choose or are required to be awake. The term ‘bed’ means the place where you usually sleep. Will answering these questions about my sleep keep me awake? This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate.

Item Instructions Use the guide below to clarify what is being asked for each item of the Sleep Diary. Date: Write the date of the morning you are filling out the diary. 1. What time did you get into bed? Write the time that you got into bed. This may not be the time that you began ‘trying’ to fall asleep. 2. What time did you try to go to sleep? Record the time that you began ‘trying’ to fall asleep. 3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep? 4. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening? 5. In total, how long did these awakenings last? What was the total time you were awake between the time you first fell asleep and your final awakening? For example, if you woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20+35+15= 70 min or 1 hr. and 10 min). 6. What time was your final awakening? Record the last time you woke up in the morning. 7. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g. you may have woken up at 6:35 AM but did not get out of bed to start your day until 7:20 AM) 8. How would you rate the quality of your sleep? ‘Sleep Quality’ is your sense of whether your sleep was good or poor. 9. Comments If you have anything that you would like to say that is relevant to your sleep feel free to write it here. 186 Appendix A

Consensus Sleep Diary Core-M (Please Complete Upon Awakening) ID/NAME: ______________________________ Sample Today’s Date 4/5/11 1. What time did you get into bed? 10:15 PM 2. What time did you try to go to sleep? 11:30 PM 3. How long did it take you to fall asleep? 55 min. 4. How many times did you wake up, not counting your final awakening? 3 times 5. In total, how long did these awakenings last? 1 hour 10 min. 6. What time was your final awakening? 6:35 AM 7. What time did you get out of bed for the day? 7:20 AM 8. How would you rate the quality of your sleep?  Very poor ✓ Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good  Very poor  Poor  Fair  Good  Very good 9. Comments (if applicable) I have a cold

Appendix B: Expanded Sleep Diary General Instructions What is a Sleep Diary? A sleep diary is designed to gather information about your daily sleep pattern. How often and when do I fill out the sleep diary? It is necessary for you to complete your sleep diary every day. If possible, the sleep diary should be completed within one hour of getting out of bed in the morning. What should I do if I miss a day? If you forget to fill in the diary or are unable to finish it, leave the diary blank for that day. What if something unusual affects my sleep or how I feel in the daytime? If your sleep or daytime functioning is affected by some unusual event (such as an illness, or an emergency) you may make brief notes on your diary. What do the words ‘bed’ and ‘day’ mean on the diary? This diary can be used for people who are awake or asleep at unusual times. In the sleep diary, the word ‘day’ is the time when you choose or are required to be awake. The term ‘bed’ means the place where you usually sleep. Will answering these questions about my sleep keep me awake? This is not usually a problem. You should not worry about giving exact times, and you should not watch the clock. Just give your best estimate.

Sleep Diary Item Instructions Use the guide below to clarify what is being asked for each item of the Sleep Diary. Date: Write the date of the morning you are filling out the diary. 1. What time did you get into bed? Write the time that you got into bed. This may not be the time you began ‘trying’ to fall asleep. 2. What time did you try to go to sleep? Record the time that you began ‘trying’ to fall asleep. 3. How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep? 4. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening? 5. In total, how long did these awakenings last? What was the total time you were awake between the time you first fell asleep and your final awakening? For example, if you woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20+35+15= 70 min or 1 hr. and 10 min). 6a. What time was your final awakening? Record the last time you woke up in the morning. 6b. After your final awakening, how long did you spend in bed trying to sleep? After the last time you woke-up (Item #6a), how many minutes did you spend in bed trying to sleep? For example, if you woke up at 8 AM but continued to try and sleep until 9 AM, record 1 hour. 6c. Did you wake up earlier than you planned? If you woke up or were awakened earlier than you planned, check yes. If you woke up at your planned time, check no. 6d. If yes, how much earlier? If you answered ‘yes’ to question 6c, write the number of minutes you woke up earlier than you had planned on waking up. For example, if you woke up 15 minutes before the alarm went off, record 15 minutes here. 7. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g. you may have woken up at 6:35 AM but did not get out of bed to start your day until 7:20 AM) 8. In total, how long did you sleep? This should just be your best estimate, based on when you went to bed and woke up, how long it took you to fall asleep, and how long you were awake. You do not need to calculate this by adding and subtracting; just give your best estimate. 9. How would you rate the quality of your sleep? ‘Sleep Quality’ is your sense of whether your sleep was good or poor. 10. How restful or refreshed did you feel when you woke up for the day? This refers to how you felt after you were done sleeping for the night, during the first few minutes that you were awake. Appendix B 189