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BACKGROUND: Patient adherence has been identified as an important barrier to the implementation of evidence-based psychological treatments. OBJECTIVE: In cognitive behavioral treatments (CBT) for insomnia, the current study examined (a) the validity of therapist ratings of patient agreement and adherence against an established behavioral measure of adherence, and (b) the relationship between treatment agreement, adherence, and outcome. METHOD: Participants were 188 adults meeting DSM-IV-TR criteria for chronic insomnia who were randomized to receive behavior therapy, cognitive therapy, or CBT for insomnia. Treatment agreement/adherence was measured by (a) weekly therapist ratings of patient agreement and homework completion, and (b) adherence to behavioral strategies (ABS) derived from patient-reported sleep diary. Outcome measures were Insomnia Severity Index and insomnia remission (Insomnia Severity Index

OBJECTIVE: To examine the mediators and the potential of treatment matching to improve outcome for cognitive behavior therapy (CBT) for insomnia. METHOD: Participants were 188 adults (117 women; Mage = 47.4 years, SD = 12.6) meeting the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) diagnostic criteria for chronic insomnia (Mduration: 14.5 years, SD: 12.8). Participants were randomized to behavior therapy (BT; n = 63), cognitive therapy (CT; n = 65), or CBT (n = 60). The outcome measure was the Insomnia Severity Index (ISI). Hypothesized BT mediators were sleep-incompatible behaviors, bedtime variability (BTv), risetime variability (RTv) and time in bed (TIB). Hypothesized CT mediators were worry, unhelpful beliefs, and monitoring for sleep-related threat. RESULTS: The behavioral processes mediated outcome for BT but not CT. The cognitive processes mediated outcome in both BT and CT. The subgroup scoring high on both behavioral and cognitive processes had a marginally significant better outcome if they received CBT relative to BT or CT. The subgroup scoring relatively high on behavioral but low on cognitive processes and received BT or CBT did not differ from those who received CT. The subgroup scoring relatively high on cognitive but low on behavioral processes and received CT or CBT did not differ from those who received BT. CONCLUSION: The behavioral mediators were specific to BT relative to CT. The cognitive mediators were significant for both BT and CT outcomes. Patients exhibiting high levels of both behavioral and cognitive processes achieve better outcome if they receive CBT relative to BT or CT alone. (PsycINFO Database Record

ObjectiveSleep prepares key neural structures for next-day learning, and sleep obtained after learning promotes subsequent memory consolidation supporting long-term retention. This study examined whether sleep the night before and after a therapy session predicts aspects of treatment adherence.MethodAs part of a randomized clinical trial, 188 adults (62.7% female, mean age = 47.5, 80.5% Caucasian) with persistent insomnia received cognitive-behavioral therapy for insomnia. Patients completed a sleep diary before and after treatment sessions. Minutes spent awake during the night (total wake time; TWT) and total sleep time (TST) were used as measures of sleep disturbance. At each treatment session, therapists rated participant understanding of the session and homework compliance from the previous session.ResultsCompared to longer TWT, before session shorter TWT was associated with increased treatment understanding the next day. After session shorter TWT was also associated with increased understanding, but not homework compliance the subsequent session compared to participants with longer TWT. Similar results were obtained for TST.ConclusionsImproving sleep may benefit patient adherence to treatment. Sleep may influence processes related to initial learning and subsequent consolidation of treatment information. Future studies should examine whether improved sleep within other psychiatric disorders is also an ingredient to the successful outcome of psychosocial interventions. (PsycINFO Database Record

OBJECTIVE: To evaluate the impact of comorbid anxiety or depressive disorders on treatment response to cognitive-behavior therapy (CBT) for insomnia, behavior therapy (BT), or cognitive therapy (CT). METHOD: Participants were 188 adults (117 women; Mage = 47.4 years) with chronic insomnia, including 45 also presenting a comorbid anxiety or mild to moderate depressive disorder. They were randomized to BT (n = 63), CT (n = 65), or CBT (n = 60). Outcome measures were the proportion of treatment responders (decrease of ≥8 points on the Insomnia Severity Index; ISI) and remissions (ISI score < 8) and depression and anxiety symptoms. RESULTS: Proportion of treatment responders and remitters in the CBT condition was not significantly different between the subgroups with and without comorbidity. However, the proportion of responders was lower in the comorbidity subgroup compared to those without comorbidity in both the BT (34.4% vs. 81.6%; p = .007) and CT (23.6% vs. 57.6%; p = .02) alone conditions, although remission rates and prepost ISI change scores were not. Pre to post change scores on the depression (-10.6 vs. -3.9; p < .001) and anxiety measures (-9.2 vs. -2.5; p = .01) were significantly greater in the comorbidity subgroup relative to the subgroup without comorbidity but only for those treated with the full CBT; no difference was found for those treated with either BT or CT alone. CONCLUSIONS: The presence of a comorbid anxiety or mild to moderate depressive disorder did not reduce the efficacy of CBT for insomnia, but it did for its single BT and CT components when used alone. (PsycINFO Database Record

OBJECTIVE: To examine the unique contribution of behavior therapy (BT) and cognitive therapy (CT) relative to the full cognitive behavior therapy (CBT) for persistent insomnia. METHOD: Participants were 188 adults (117 women; M age = 47.4 years, SD = 12.6) with persistent insomnia (average of 14.5 years duration). They were randomized to 8 weekly, individual sessions consisting of BT (n = 63), CT (n = 65), or CBT (n = 60). RESULTS: Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%). Remission rates followed a similar trajectory, with higher remission rates at post treatment in CBT (57.3%) relative to CT (30.8%), with BT falling in between (39.4%); CT made further gains from post treatment to follow up (30.9% to 51.6%). All 3 therapies produced improvements of daytime functioning at both post treatment and follow up, with few differential changes across groups. CONCLUSIONS: Full CBT is the treatment of choice. Both BT and CT are effective, with a more rapid effect for BT and a delayed action for CT. These different trajectories of changes provide unique insights into the process of behavior change via behavioral versus cognitive routes.

Summary: Background: Despite widespread recognition of the undeniable impact of nurses on patient safety, important barriers relating to the organization of health systems still hinder the full expansion of the role of these professionals. In Quebec (Canada), nurses work overtime and increased adverse events are preoccupying and point to a possible lack of contemporary tools for continuous professional development. Innovative training tools should foster a more reflective practice focused on a holistic view of the patient in order to support the full scope of nursing practice and ensure continuous improvement in the quality of care. Such tools would make it possible to better understand their practice, according to their own perception, as well as its applicability in the emergence of a professional conscience which is essential to lasting safety competencies. This study's overarching goal was to propose a model and a portfolio prototype to support nurses’ training. Method: Based on a humanistic and reflective perspective on patient care and safety competencies, a design approach was used to develop a portfolio prototype. Ethnography was used to collect and analyse data using shadowing observations of 10 nurse/patient dyads, followed by interviews about their care experience. The research was conducted in acute and long-term care settings of the Quebec City area. The iteration process resulted in a first version of the prototype that was then presented to various stakeholders during a co-design workshop aimed at better understanding the clinical applicability of this prototype. Findings: The INSÉPArable project is illustrated in two interrelated figures, which reflects a complete inductive representation supporting sustainable patient safety from nursing practice experience. First, nursing practice status has been depicted as an iceberg metaphor where the essence of care, the « art of nursing » is hidden. Second, a sphere illustrates the direction to the full emergence of nursing practice that helps to enhance the hidden “art of nursing” by leading nurses towards optimal conditions conscience. Discussion: INSÉPArable turned out to be more than an individual reflective tool as it also highlights the need for collective awareness among nurse managers regarding their responsibility in implementing and sustaining healthy work environments, in which optimal conditions are better supported. This also implies a renewed mode of governance and the implementation of more humanistic processes that redefine the contemporary professionalism of nurses, which are closely linked to patient safety.