Cited by 265Sleep and related disordersAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and Applications

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A Comparison of Rates of Residual Insomnia Symptoms Following Pharmacotherapy or Cognitive-Behavioral Therapy for Major Depressive Disorder

Carney, Colleen E., Segal, Zindel V., Edinger, Jack D., Krystal, Andrew D.·2007·The Journal of Clinical Psychiatry

DOI 10.4088/jcp.v68n0211

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Abstract

OBJECTIVE: A number of pharmacologic studies have documented that insomnia is among the most commonly reported residual symptoms after remission from depression. Residual symptoms after remission are particularly relevant because these symptoms confer greater risk for subsequent depression. This study was the first to date to examine residual insomnia after cognitive-behavioral therapy (CBT) for depression and to compare CBT with pharmacotherapy for depression on residual insomnia rates. METHOD: This naturalistic study examined rates of posttreatment insomnia complaints in patients (N = 94) who had been diagnosed with major depressive disorder (MDD), according to DSM-IV criteria, and who remitted from MDD after completing at least 20 weeks of either CBT or pharmacotherapy at an outpatient clinic specializing in mood disorders. Participants were randomly assigned to the treatment conditions, but only the data from those who completed treatment and remitted were analyzed. Primary outcome measure was the 17-item Hamilton Rating Scale for Depression. Data were collected from October 1, 1999, to September 23, 2003. Groups were compared using a chi(2) for nominal data. RESULTS: The rate of posttreatment insomnia was 22% for sleep-onset insomnia, 26% for sleep-maintenance insomnia, and 17% for early morning awakenings, and the rates did not statistically differ across the 2 treatment groups. CONCLUSION: Although CBT and pharmacotherapy effectively addressed depression in these patients and addressed insomnia symptoms for many, there were a number of patients with residual insomnia. Whereas there appears to be no difference between CBT and pharmacotherapy with regard to rates of residual insomnia, the rates of such insomnia remaining after these treatments suggest that adjunctive sleep treatment to specifically address insomnia may be necessary for some MDD patients.

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Background
A two-phase, prescriptive comparative effectiveness study to optimize the treatment of co-occurring insomnia and depression with digital interventions
Pigeon, W. R., Bishop, T. M., Bossarte, R. M., Schueller, S. M., & Kessler, R. C. (2023) · Contemporary Clinical Trials · doi:10.1016/j.cct.2023.107306 · Cited by 6
Digital cognitive–behavioural therapy for insomnia compared with digital patient education about insomnia in individuals referred to secondary mental health services in Norway: protocol for a multicentre randomised controlled trial
Kallestad, H., Saksvik, S. B., Vedaa, Ø., Langsrud, K., Morken, G., Lydersen, S., Simpson, M. R., Dørheim, S. K., Holmøy, B., Selvik, S. G., et al. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-050661 · Cited by 7
Treatment-resistant residual insomnia in patients with recurrent major depressive episodes
IWAKI, S., Satoh, K., MATSUMOTO, Y., Echizenya, M., KATOH, T., Kusanagi, H., Kitamura, S., Shimizu, T., & Mishima, K. (2012) · Sleep and Biological Rhythms · doi:10.1111/j.1479-8425.2012.00564.x · Cited by 6
Insomnia treatments: moving from efficacy to effectiveness
Haynes, P. L., & Bootzin, R. R. (2010) · Journal of Clinical Psychology · doi:10.1002/jclp.20735 · Cited by 8
Are Patients with Childhood Onset of Insomnia and Depression More Difficult to Treat Than Are Those with Adult Onsets of These Disorders? A Report from the TRIAD Study
Edinger, J. D., Manber, R., Buysse, D. J., Krystal, A. D., Thase, M. E., Gehrman, P. R., Fairholme, C. P., Luther, J. F., & Wisniewski, S. R. (2017) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.6448 · Cited by 6
“7–11 Thus, when insomnia occurs comorbid to MDD it often requires separate treatment attention.”
Self-citation
Clinical feasibility of cognitive behavioural therapy for insomnia in a real-world mixed sample at a specialized psychiatric outpatient clinic
Cassel, M., Blom, K., Gatzacis, J., Renblad, P., Kaldo, V., & Jernelöv, S. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-04231-4 · Cited by 6
“In the scientific literature, residual symptoms of insomnia have been found after successful treatment for PTSD [9] and depression [10, 11] and treating depression does not necessarily alleviate insomnia symptoms [12, 13].”
Background
Changes in insomnia and binge‐eating symptom severity before and after treatment of eating disorders in individuals with non‐low‐weight binge‐spectrum disorders
Christensen, K. A., Chen, Y., Bottera, A. R., & Forbush, K. T. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14378 · Cited by 7
Cognitive behavioural therapy for insomnia as an early intervention of mood disorders with comorbid insomnia: A randomized controlled trial
Chung, K., Lee, C., Au, C. W., Kam, K., Lee, C., Yeung, W., Lau, E. Y. Y., Ho, F. Y., & Ho, L. (2023) · Early Intervention in Psychiatry · doi:10.1111/eip.13435 · Cited by 6
“Insomnia can occur before and represents a risk factor for new onset of mood disorders (Hertenstein et al., 2019), sometimes persists despite remission of mood symptoms (Carney et al., 2007), and is an independent factor influencing the course of mood disorders (Boland et al., 2020).”
Background
Integration of sleep and emotion treatment: a randomized trial of transdiagnostic CBT for comorbid insomnia
Jam, M. M., Rasouli, A., Soumee, Z. N., Vand, H. D. A., & Saed, O. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06832-1 · Cited by 5
“Studies demonstrate that even successful treatment of disorders where sleep disturbance is diagnostic (e.g., Post-Traumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD)) often fails to fully resolve insomnia symptoms [9].”
Lying awake in forensic hospitals: a multicenter, cross-sectional study on the prevalence of insomnia and contributing factors in forensic psychiatric patients
Mijnster, T., Boersma, G. J., Engberts, J., Vreugdenhil-Becherer, L., Vos, M. K., de Vogel, V., Bulten, E., & Lancel, M. (2022) · Journal of Forensic Psychiatry and Psychology · doi:10.1080/14789949.2022.2068451 · Cited by 6
“The insomnia symptoms frequently persist, even after remission of the mental disorder, and evolve into insomnia disorder (e.g., Carney et al., 2007; Germain, 2013; Lancel et al., 2020).”
Background
Psychological and Behavioral Treatments for Insomnia II
Edinger, J. D., Means, M. K., Carney, C. E., & Manber, R. (2011) · Elsevier eBooks · doi:10.1016/b978-1-4160-6645-3.00080-3 · Cited by 5
Self-citation
Нарушения сна и суицидальное поведение. Сообщение I: Распространённость, влияния и взаимосвязи
Любов, Е. Б., & Zotov, P. B. (2020) · Суицидология · doi:10.32878/suiciderus.20-11-01(38)-98-116 · Cited by 6
Efficacy and safety of lemborexant in subjects with insomnia disorder receiving medications for depression or anxiety symptoms
Krystal, A. D., Blier, P., Culpepper, L., Nierenberg, A. A., Takaesu, Y., Kubota, N., Moline, M. L., Malhotra, M., Pinner, K., & Yardley, J. (2024) · Neuropsychopharmacology Reports · doi:10.1002/npr2.12509 · Cited by 5
Self-citation
The Association Between the Sedative Loads and Clinical Severity Indicators in the First-Onset Major Depressive Disorder
Wang, Y.-C., Lin, H.-T., Lu, M., Huang, M., Chen, C.-H., Wu, T., Wang, S. Z., Mao, W., Kuo, P., & Chen, H. (2019) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00129 · Cited by 5
“Even during remission, almost 50% of patients with MDD suffer from sleep problems (17).”
Association between Depressed Mood and Sleep Duration among Various Ethnic Groups—The Helius Study
Anujuo, K. O., Stronks, K., Snijder, M. B., Lok, A., Jean‐Louis, G., & Agyemang, C. O. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18137134 · Cited by 4
“In addition, sleep problems and depression may also share common risk factors and biological features and the two conditions may respond to some of the same treatment strategies [10]. and sleep duration among six ethnic groups.”
Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis
Jensen, E. S., Ladegaard, N., Mellentin, A. I., Ebert, D. D., Titzler, I., Araya, R., Pashoja, A. C., Hazo, J., Holtzmann, J., Cieślak, R., et al. (2021) · Journal of Medical Internet Research · doi:10.2196/30231 · Cited by 5
“Furthermore, insomnia symptoms are among the most frequent residual symptoms following depression treatment [15-17].”
Background
Long-term efficacy of cognitive behavioural therapy for insomnia (CBT-I) on depressive symptoms: A systematic review and meta-analysis of randomised controlled trials
Fiori, V., Lombardo, C., Baglioni, C., & Ballesio, A. (2026) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2026.102339 · Cited by 3
Use of Sleep Aids in Insomnia
Dawson, S. C., Krakow, B. J., Haynes, P. L., Rojo‐Wissar, D. M., McIver, N. D., & Ulibarri, V. A. (2023) · The Primary Care Companion For CNS Disorders · doi:10.4088/pcc.22m03344 · Cited by 3
Effect of depression treatment on health behaviors and cardiovascular risk factors in primary care patients with depression and elevated cardiovascular risk: data from the eIMPACT trial
Schuiling, M. D., Shell, A. L., Callahan, C. M., Nürnberger, J. I., MacDonald, K. L., Considine, R. V., Wu, W., Hirsh, A. T., Crawford, C. A., Williams, M. K., et al. (2024) · Psychological Medicine · doi:10.1017/s0033291724001429 · Cited by 4
“It is often stated that sleep disturbance tends to linger following treatment for depression, which is true for some but not all cases of depression with sleep disturbance (Carney et al., 2007).”
Evaluation of alpha neurofeedback training to enhance sleep in remitted depression and anxiety sufferers with persistent insomnia
Lu, T., Hsieh, T.-H., Wang, Y.-H., Shaw, F., Chen, P. S., & Liang, S. (2025) · Psychiatry Research · doi:10.1016/j.psychres.2025.116401 · Cited by 5
The Temporal Dynamics of Sleep Disturbances, Depression, and Self-Injurious Thoughts and Behaviors in Preadolescents: A Year-Long Intensive Longitudinal Study
Hoyniak, C. P., Donohue, M. R., Tillman, R., Thompson, R. J., Going, B., Barch, D. M., & Luby, J. L. (2025) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-025-01326-w · Cited by 3
“…hypersomnia, and fatigue, are often conceptualized as a symptom of depression, increasing evidence suggests that sleep disturbances in the context of depression reflect a co-morbid condition (Lichstein, 2006) that may not improve with traditional depression treatment alone (Carney et al., 2007).”
Effects of a Multi-Component Behavioral Intervention (MCI) for Insomnia on Depressive and Insomnia Symptoms in Individuals with High and Low Depression
Johnson, K., Sidani, S., & Epstein, D. R. (2015) · Journal of Evidence-Informed Social Work · doi:10.1080/15433714.2013.873753 · Cited by 4
Sleep Dysregulation and Related Regulatory Models
Germain, A., & Thase, M. E. (2008) · Elsevier eBooks · doi:10.1016/b978-0-08-045078-0.00005-8 · Cited by 3
CBT‐I Protocol for Insomnia Co‐morbid with Affective Disorders
Blom, K., & Jernelöv, S. (2022) · doi:10.1002/9781119891192.ch12 · Cited by 3
Efficacy of cognitive behavioral therapy for insomnia and lemborexant medication for different subtypes of chronic insomnia: study protocol for a randomized controlled trial
Chen, S., Ivers, H., Dang‐Vu, T. T., Shapiro, C. M., Carney, C. E., Robillard, R., & Morin, C. M. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06878-1 · Cited by 2
“These patients often show elevated depressive and anxiety symptoms, increased worry about falling asleep and greater distress about daytime functioning (e.g., fatigue) [27, 33–35], which can be effectively addressed by CBT-I intervention [36, 37].”
Self-citation
A transdiagnostic sleep intervention for outpatients with sleep problems and comorbid mental health disorders, data from a Danish quality assurance project
Dyrberg, H., Kristiansen, S. T., Speed, M. S., Møller, D. S., & Kragh, M. (2025) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2025.2571217 · Cited by 2
“However, this is not always the case; for example, patients in remission from depression often continue to experience residual insomnia [9].”
A Qualitative Study of Sleep and Mood in Postpartum Women
Swanson, L. M., Arnedt, J. T., Armitage, R., Adams, J., & Adams, J. (2013) · The Open Sleep Journal · doi:10.2174/1874620901306010098 · Cited by 2
“In non-postpartum populations with depression, insomnia symptoms hinder treatment response [9-11] and commonly persist after remission from depression has been achieved [12-14].”
Background
The Effect of Sleep Disturbances on Major Depressive Disorder.
Pigeon, W. R. (2009) · PubMed · Cited by 2

Authors: Carney, C. E., Segal, Z. V., Edinger, J. D., & Krystal, A. D.
Affiliations: Duke Medical Center (US)
ORCID: Carney, Colleen E.
Segal, Zindel V.
Edinger, Jack D.
Krystal, Andrew D.
Venue: The Journal of Clinical Psychiatry
Publisher: Physicians Postgraduate Press, Inc
Published: 2007-02-15
Volume: 68
Issue: 02
Pages: 254-260
ISSN: 0160-6689 (ISSN-L)
DOI: 10.4088/jcp.v68n0211
OpenAlex: W2027041440
Cited by: 265
References: 0
Citations by year: 2026: 6 · 2025: 12 · 2024: 13 · 2023: 15 · 2022: 19 · 2021: 18 · 2020: 14 · 2019: 18 · 2018: 14 · 2017: 8 · 2016: 13 · 2015: 12 · 2014: 22 · 2013: 13 · 2012: 18
FWCI: 14.98
Type: journal article
Language: en
Open access: closed
Locations: The Journal of Clinical Psychiatry (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (5r01ar052368-05)
National Institute of Mental Health (R01MH067057)
National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR052368-01A1)
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords: major depressive disorder, antidepressant treatment, sleep onset insomnia, sleep maintenance insomnia, early morning awakening
MeSH terms: Adult, Aged, Clinical Trials as Topic, Major Depressive Disorder, Depressive Disorder, Major, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Retrospective Studies, Antipsychotic Agents, Cognitive Behavioral Therapy, Incidence, Treatment Outcome

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A Comparison of Rates of Residual Insomnia Symptoms Following Pharmacotherapy or Cognitive-Behavioral Therapy for Major Depressive Disorder

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