Factors Influencing the Effectiveness of a One-Day CBT for Insomnia Workshop

Insomnia is highly prevalent and has severe negative consequences. Cognitive Behavioural Therapy for Insomnia (CBT-I) is an evidence-based treatment that is usually delivered individually. Given the high prevalence, accessible one-day CBT-I workshops (each for up to 30 people) were developed to be run in the community for the general public (1). These CBT-I workshops have been found to reduce levels of insomnia (2, 3) and are now run on a routine basis. As yet, little is known about the impact of factors such as comorbid depression or anxiety or receipt of previous treatment on the effectiveness of the CBT-I workshop. This study aimed to evaluate the accessibility and clinical effectiveness of a series of nine one-day CBT-I workshops (n=120) run in routine practice and to explore the impact of factors including co-morbid depression or anxiety and receipt of previous treatment, on the effectiveness of the CBT-I workshops. The CBT-I workshops were found to be effective at reducing insomnia at one-month follow-up and broadly accessible across a wide group of people in the community. In addition, significant reductions in depression and anxiety were found and the severity of depression or anxiety at baseline did not interfere with the effectiveness of the workshop. People with no previous experience of counselling or psychological therapy showed greater reduction of insomnia symptoms. It is concluded that the CBT-I workshop is an accessible and effective treatment for insomnia across a range of clinical severity and complexity. Further benefits include reductions in both depression and anxiety. DOI : 10.14302/issn.2574-4518jsdr-14-592 Corresponding author: Ann Steele, , Psychosis Research Unit, Rico House, Harrop House, Bury New Road, Prestwich, M25 3BL, United Kingdom, Email: ann.steele@gmw.nhs.uk


Introduction
Symptoms of insomnia are estimated at 38.6% of the United Kingdom (UK) adult population, with a clinical diagnosis of insomnia being present in 5.8% (4). The economic burden of insomnia is significant with 76% of the estimated cost being due to absence from work and reduced productivity in the workplace (5). It can therefore be seen as a major public health problem.
Cognitive Behavioural Therapy for Insomnia (CBT-I), which is usually offered to individuals, has been shown to be an effective and lasting treatment (6,7) which is superior to drug therapy in durability (8,9,10). Group CBT-I has also demonstrated efficacy (7,11). However, despite the high prevalence of insomnia, provision of CBT-I is still low. Furthermore, access to treatment for insomnia may be impacted by factors such as unwillingness to go to the General Practioner (GP) (12), or a lack of awareness of treatment options available (13,14).
One solution to these problems is an accessible brief community group treatment workshop, run at weekends. Brown and colleagues (1) developed a format offering self-referral one-day CBT workshops that are run in non-medical centres such as libraries and leisure centres for a range of different problems such as stress and self-confidence/depression. These CBT group workshops are effective in reducing depression and anxiety (1,15,16), with improvements being maintained two years after self-confidence workshops (17). More recently this model has been applied, with success, to the treatment of insomnia (2,3,18).
Espie (19) reported that individual CBT-I has an approximate 70% response rate regardless of severity and chronicity of presenting characteristics. However, the generalisability of group CBT-I workshops across different clinical groups has not yet been formally assessed. According to the 'Stepped Care' model (19), greater severity or complexity, such as comorbidity, may interfere with the benefits gained from group work-shops. In addition, other factors could indicate greater complexity and chronicity of insomnia such as nonresponse to prior psychological treatment. Examining the impact of these factors on the efficacy of group CBT-I workshops could contribute towards the identification of people who are more or less likely to benefit from oneday CBT-I workshops.
Finally, individual CBT-I has been reported to reduce symptoms of anxiety (e.g. 20,21) and depression (20,22,23); however, it is not yet known whether group CBT-I might also impact on reducing comorbid anxiety or depression (7).
The main objective of the current study was to evaluate the accessibility and clinical effectiveness of a series of large-scale one-day CBT-I workshops run in routine practice. A further aim was to explore the impact of factors such as co-morbid depression or anxiety or receipt of previous treatment on the effectiveness of the CBT-I workshops as well as to assess indirect impacts of group CBT-I on comorbid anxiety or depression. Interested individuals were invited to attend a one-hour introductory talk. During these talks, the format and content of the workshops were described, any questions arising were answered and baseline measures were completed.

Clinical effectiveness
Change in insomnia, depression and anxiety following the CBT-I workshop were examined using pairedsamples t-tests. Table 3

Discussion
The main aim of this study was to evaluate the accessibility and clinical effectiveness of a series of large  Table 3. Baseline and follow-up ISI, PHQ-9 and GAD-7 scores, statistical tests and effect sizes. In addition, significant reductions in both depression and generalised anxiety were found following the workshop.
Evidence has been presented for the additional benefit of individual CBT-I in treating depression (20,22) and anxiety (20,21). However, the impact of CBT-I delivered in a group workshop format on depression is less clear (2,3,18).

Conclusion
The current study has provided good evidence for the accessibility and application of one-day CBT-I workshops as an effective way to treat insomnia of varying severity as well as reducing co-morbid depression and anxiety across a wide range of people. This finding has broad implications for clinical practice given the current lack of