Available online at www.sciencedirect.

com

ScienceDirect
Behavior Therapy 45 (2014) 430 442
www.elsevier.com/locate/bt

Predictors of Adherence to a Brief Behavioral Insomnia

Intervention: Daily Process Analysis
Megan E. Ruiter Petrov
Arizona State University
Kenneth L. Lichstein
University of Alabama
Carrie E. Huisingh
Center for Clinical and Translational Science, University of Alabama at Birmingham
Laurence A. Bradley
University of Alabama at Birmingham

Behavioral interventions for insomnia are effective in

improving sleep, yet adherence is variable, and predictors
of adherence have not been consistently replicated. The
relationships between daily variations in state factors at the
initiation of treatment and adherence have not been
investigated. Using 2-week, self-report online logs, this
study determined, among 53 college students with probable
insomnia, the associations of pretreatment factors and daily
factors during treatment on daily variations in adherence to
one session of behavioral treatments for insomnia. These
treatments included stimulus control therapy (SCT), sleep
restriction therapy (SRT), and sleep hygiene (SH). Low
self-efficacy was associated with poorer SCT and SH
adherence. Participants with a bed partner or pet at
least some of the time had better SCT adherence. Greater
total sleep time and poorer sleep quality were associated
with poor SCT and SRT adherence the following night.
Dr. Lichstein is a member of the Merck Insomnia Advisory
Board. The other authors have no conflicts of interest to report. We
would like to acknowledge the statistical consultation support
received by Dr. Gerald McGwin. Dr. Lichstein is a member of the
Merck Insomnia Advisory Board. The other authors have no conflicts
of interest to report.
Address correspondence to Megan E. Petrov, Ph.D., College
of Nursing and Health Innovation, Arizona State University,
500 North 3rd Street, MC: 3020, Phoenix, AZ 85004.;
e-mail: Megan.Petrov@asu.edu.
0005-7894/45/430-442/$1.00/0
2014 Association for Behavioral and Cognitive Therapies. Published by
Elsevier Ltd. All rights reserved.

Greater sleep efficiency was related to greater next night

SCT and SRT adherence. Alcohol consumption was related
to poorer SRT and SH adherence the following night.
Future studies should test the replicability of these findings.
Adherence trials may want to test whether discouraging
alcohol intake, enhancing treatment-related self-efficacy,
and monitoring and providing feedback on sleep, early in
treatment, affects adherence.

Keywords: adherence; insomnia; behavior therapy; self-efficacy;

alcohol

Sleep disorders, such as chronic insomnia, are

among medical conditions with the lowest treatment
adherence rates (DiMatteo, 2004). Chronic insomnia
is a costly public health problem afflicting 615%
of the general population (Lichstein, Durrence,
Riedel, Taylor, & Bush, 2004; Morin, LeBlanc,
Daley, Gregoire, & Mrette, 2006; Ohayon, 2002).
Stimulus control therapy (SCT) and sleep restriction therapy (SRT) are evidence-based, effective
treatments for chronic insomnia (Edinger &
Means, 2005; Morgenthaler et al., 2006). However, adherence rates to these interventions have
been highly variable and often suboptimal (Matthews,
Arnedt, McCarthy, Cuddihy, & Aloia, 2013). Adherence rates were likely variable across studies because
study duration and treatment components varied, and

adherence to insomnia intervention

different metrics to measure adherence (e.g., often
dichotomously vs. continuously) were used
(Matthews et al., 2013). Currently there is no
gold standard for measuring adherence to behavioral
treatments for insomnia. Examples of how adherence has been measured have ranged from calculating the amount of deviance from a prescribed sleep
schedule on a continuous scale (Riedel & Lichstein,
2001) to whether participants completed all treatment sessions (Vincent & Lionberg, 2001). Despite
differing conceptualizations, the data available
suggest that adherence, however it was defined,
could be improved. In order to boost adherence,
effective identification of patient and behavioral
factors that alter adherence rates is crucial.
Adherence to SCT, SRT, and general sleep
hygiene (SH) recommendations is significantly
linked to improvements in sleep (Harvey, Inglis, &
Espie, 2002; Riedel & Lichstein, 2001; Vincent &
Hameed, 2003; Vincent, Lewycky, & Finnegan,
2008). However, identifying replicable predictors
of adherence has been elusive. Factors identified
that are associated with improved adherence
were acceptance of the intervention (Vincent &
Lionberg, 2001), greater self and task-related
efficacy (Bouchard, Bastien, & Morin, 2003), higher
intentions to change sleep behavior (Hebert, Vincent,
Lewycky, & Walsh, 2010; Matthews et al., 2013),
lower fatigue (Matthews, Schmiege, Cook, Berger, &
Aloia, 2012), less pretreatment sleepiness (Vincent et
al., 2008), and greater pretreatment sleep disturbance
severity (Hebert et al., 2010; Matthews et al., 2012;
Morgan, Thompson, Dixon, Tomeny, & Mathers,
2003). Reported barriers to adherence were heightened psychopathological status (Dashevsky &
Kramer, 1997; Hebert et al., 2010; McChargue et
al., 2012; Vincent & Hameed, 2003), sleep concerns
(Dashevsky & Kramer, 1997), fatigue (Dashevsky &
Kramer, 1997), poor physical health (Hohagen et al.,
1993; Morgan et al., 2003), and reductions in sleep
disturbances (McChargue et al., 2012).
One of the major problems with these studies is
most if not all predictors were assessed at baseline
or at the exit interview. Little information has been
documented on the day-to-day factors that affect
adherence during the initial treatment engagement.
These factors may be more influential than those
measured prior to treatment because they may
affect subsequent adherence behavior or the decision to continue being engaged in treatment at all.
Furthermore, in a changing health care field that
increasingly emphasizes cost-effective, brief behavioral interventions, it is important to identify
predictors for treatment-planning purposes, especially if providerpatient contact is infrequent or
not feasible.

431

In the present study we sought to determine the

predictors of variations in daily adherence during
initial treatment engagement after one session of
behavioral therapy for insomnia among young adults
with probable insomnia. To do this we examined the
daily relationships between several literature-based
and exploratory factors and adherence to SCT, SRT,
and SH over a 14-day period using self-reported,
online daily diaries. The literature-based daily factors
that were measured were fatigue, mood, perceived
health status, and sleep quality, total sleep time, and
sleep efficiency (Hebert et al., 2010; Matthews et al.,
2012; McChargue et al., 2012; Morgan et al., 2003).
Exploratory factors were defined as daily experiences
known to affect sleep quality and were proposed in
the literature as potentially interfering with adherence,
yet have not been systematically investigated. The
exploratory factors measured were pain (Smith, Perlis,
Smith, Giles, & Carmody, 2000; Suh et al., 2011),
stress, daily exercise (Baron, Reid, & Zee, 2012;
Buman, Hekler, Bliwise, & King, 2011), and alcohol
intake (Ebrahim, Shapiro, Williams, & Fenwick,
2013; Singleton & Wolfson, 2009). For replication
purposes we also examined whether baseline sleepiness, self-efficacy, acceptance of treatment, intentions
to adhere, depressive or anxiety symptoms, general
health, insomnia symptom severity, and frequency of
sleeping with a bed partner or pet were also
associated with subsequent adherence rates. Bed
partner or pet status was of particular interest because
previous literature suggests involving a bed partner
affects adherence to treatment for other sleep
disorders (Baron et al., 2011; Cartwright, 2008).

Materials and Methods

design
The primary aim of the study was to identify
day-to-day factors that were associated with
adherence during behavioral insomnia treatment
initiation. We employed a one-group design to
determine daily factors experienced in the 2 weeks
after one, in-person treatment session. Insomnia
severity was assessed at baseline and after 2-week
follow-up.
participants
In an online survey study, 1,678 college students
participating in an introductory psychology course
research subject pool were screened for probable
insomnia. Those meeting study inclusion criteria
were invited to take part in one didactic session of
behavioral treatment for insomnia (n = 251). Participating in the study partially satisfied a course
requirement. Fifty-eight college students agreed to
participate in the study of those eligible (i.e., 23.5%
response rate). Five participants dropped out during

432

ruiter petrov et al.

the 2-week follow-up period. The final sample size

was 53 college students. These participants all
completed one session of behavioral treatment for
insomnia and at least 9 of the possible 14 daily online
diaries. These participants met two major inclusion
criteria: reported a clinical cutoff score of 8 on the
Insomnia Severity Index (ISI; Morin, 1993), and met
the International Classification of Sleep DisordersII
criteria for an insomnia disorder (ICSD-II; American
Academy of Sleep Medicine, 2005). Participants
were excluded if they were pregnant, employed in
shift work, or had other probable sleep disorders, as
determined by the Global Sleep Assessment
Questionnaire (GSAQ; Roth et al., 2002). Risk
for other sleep disorders was determined by responding usually or always to items on the GSAQ
indicating prominent symptoms of sleep apnea,
parasomnias, restless legs syndrome, and/or periodic
limb movement disorder. Based on clinical contraindications, participants were also excluded if they
reported any disabilities that severely restricted their
mobility, any severe unstable medical conditions, or
if they had a diagnosis of bipolar disorder, epilepsy,
orthostatic hypotension, or a parasomnia (Smith &
Perlis, 2006). The final sample was no different in
age, sex, ethnicity, or insomnia symptom severity,
frequency, or duration than those eligible in the
subject pool (data not presented).

met study criteria if they responded to having these

experiences at least sometimes in the past 4 weeks.
Participants also had to endorse experiencing at least
one of the following forms of daytime impairment
related to their nighttime sleep difficulty: fatigue/
malaise; attention concentration, or memory impairment; social/vocational dysfunction or poor school
performance; mood disturbance/irritability; daytime
sleepiness; motivation/energy/initiative reduction;
proneness for errors/accidents at work or while
driving; tension headaches and/or gastrointestinal
symptoms in response to sleep loss; and concerns or
worries about sleep.
Sleep Disorders Screener
The GSAQ (Roth et al., 2002) was distributed to all
potential participants to screen for individuals with
other sleep disorders. The questionnaire consists
of 11 items each with four response options
(i.e., never, sometimes, usually, always).
Sensitivity and specificity analyses revealed the
GSAQ differentiates insomnia from obstructive
sleep apnea, periodic limb movement, and parasomnias (Roth et al., 2002). Participants with scores
indicative of no sleep disorder (i.e., responding
never to all items) or any sleep disorder other
than insomnia (i.e., responding usually or
always to screening items) were excluded from
the study.

screening measures
Insomnia Severity Index
The ISI was used as a brief screening measure of
insomnia, and as an indicator of treatment outcome
2 weeks after one session of behavioral insomnia
treatment. The ISI is a valid and reliable tool that
quantifies perceived sleep difficulties and insomnia
severity (Morin, 1993; Morin, Belleville, Blanger,
& Ivers, 2011). It is a seven-item instrument with
ratings on a 0- to 4-point scale. A total composite
score is summed with higher scores indicating greater
insomnia severity. A clinical cutoff score of 8 was
used as an identifier of threshold insomnia because it
has optimal sensitivity and specificity in distinguishing people with insomnia from normal sleepers
(Savard, Savard, Simard, & Ivers, 2005).
ICSD-II Insomnia Screener
Participants responded to questions about ICSD-II
criteria for probable insomnia. The questions were
During the past 4 weeks did you have difficulty
falling asleep, staying asleep, waking up too early,
or feeling poorly rested in the morning? and Did
you have trouble sleeping despite having adequate
opportunity and circumstances to sleep? Response
choices for both questions included never,
sometimes, usually, or always. Participants

behavioral insomnia treatment

SCT (Bootzin, Epstein, & Ward, 1991) was used to
reestablish a consistent sleep/wake schedule, and
sleep-promoting associations with the bed/bedroom.
The participants were encouraged to follow six
instructions: discontinue all arousing activities conducted in the bed/bedroom except sex; go to bed only
when sleepy, get out of bed and engage in a quiet
activity in another room if they did not fall asleep
within 15 20 minutes, repeat the previous instruction for awakenings during the night, get up at the
same time every morning regardless of how much
sleep they obtained, and to not nap.
SRT (Spielman, Saskin, & Thorpy, 1987) was
used to increase sleep consolidation by creating a
state of partial sleep deprivation. SRT prescribes a
restricted amount of time spent in bed equal to the
average total sleep time (see Spielman et al., 1987).
In this study the participants were instructed to
restrict their time in bed to their typical total sleep
time plus a half hour. Time in bed and total sleep
time estimates were determined from recall of sleep
from the past 3 weekdays or the most recent 3
weekdays typical of their usual sleep pattern. Participants were encouraged to get up at a fixed wake-up
time regardless of the amount of sleep they obtained.

adherence to insomnia intervention

Participants were instructed to calculate their average
sleep efficiency (proportion of time slept to
time spent in bed) and were provided with
handouts on the method. Participants were told
how to alter their time in bed according to their
average sleep efficiency (i.e., by 15-minute increments) after the 2-week follow-up period if they
chose to do so.
SH (Lichstein & Morin, 2000) is a psychoeducational intervention consisting of five instructions
meant to discourage behaviors that influence sleep
quality and quantity. The instructions were to
avoid caffeine after noontime, and to avoid exercise,
nicotine, alcohol, and heavy meals within 2 hours of
bedtime.

independent variables
Potential Daily Assessed Predictors
All day-to-day factors were measured using an
online sleep diary (Perlis, Jungquist, Smith, &
Posner, 2005). Participants were asked to record
immediately prior to bed how they felt during the
day on the following variables: pain, fatigue, mood,
stress, perceived health status, amount of daily
exercise (in minutes), and number of alcoholic
beverages consumed. Pain and fatigue severity were
measured on a 05 scale from none to a lot. Mood
(affect) was assessed on a 05 scale from bad to
good. Perceived health status was measured on a 05
scale from felt fine to bad. Total sleep time, sleep
efficiency, and sleep quality (i.e., very poor, poor,
fair, good, or excellent) were recorded immediately
after the final awakening of each night.
Potential Baseline Predictors
Baseline, self-reported variables included perceived
health status, treatment-related self-efficacy, acceptance of treatment, intentions to adhere, ISI score,
GSAQ-measured excessive daytime sleepiness,
GSAQ-measured depressive and anxiety symptoms,
and frequency of sleeping with a bed partner or pet.
See Table 1 for an overview of how most of these
variables were measured. Treatment-related selfefficacy was measured with one item adapted from
Reed and Aspinwall (1998). The item read, If I
wanted to follow treatment recommendations it
would be easy for me to do so tonight, and was
measured on a 19 scale from totally disagree to
totally agree. Acceptance of treatment and intentions to adhere were assessed with the following
adapted questions from Sherman and colleagues
(2000): How important do you think it is that
people engage in the sleep-promoting behaviors
that were discussed to avoid the consequences of
poor and limited sleep? and How likely do you
think it is that you personally will actually follow

433

the behavioral recommendations to treat your

insomnia? The questions were answered using a
09 scale, anchored from not important to very
important.

adherence measures
Adherence to sleep recommendations was measured with online sleep diaries and two adherence
logs specific to SH and SCT instructions. Sleep
diaries are a record of a participants sleep and
wake time each night for a period of 2 weeks. The
sleep diary used in the present study was by Perlis
and colleagues (2005). This particular diary was
used because it documents common sleep variables
and specific variables related to SCT and SRT
instructions. The primary dependent variable from
the sleep diary was the average of the time deviations
(in minutes) from the prescribed wake time. This
average was used as a measure of adherence to SRT.
This method is similar in approach to that by Riedel
and Lichstein (2001) who found that this method of
assessing SRT adherence through variations in
arising time is superior to other adherence measures in predicting treatment outcome. Specifically
they found that measures of time in bed and
bedtime reduction did not significantly correlate
with treatment outcomes, whereas lower variance
in arising time in the morning was significantly
correlated.
Two adherence logs were used to document
whether the participants were adherent to the six
instructions of SCT and the five instructions of
SH. The proportion of instructions the participants were compliant to each of the 14 days was
averaged. This method of measurement is similar
to that used in a previous study (McChargue et
al., 2012).
procedure
Didactic sessions were conducted in a university
building by a trained undergraduate honors research
assistant who was supervised on a weekly basis by a
certified behavioral sleep medicine specialist. Sessions were conducted at various times across the
2010 2011 academic year, but never between
semesters or during spring break. Each session was
delivered in an interactive, didactic format to small
groups of two to nine participants. The sessions were
not structured as group therapy. The treatment
session featured sleep and insomnia education, and
three behavioral treatment components: SCT, SRT,
and SH. The session lasted 1.5 hours. After the
treatment session, participants completed 14 days of
time-stamped, online sleep and adherence diaries. To
dampen any bias in the measurement of the studys

434

ruiter petrov et al.

Table 1

Sample Characteristics of Baseline and 14-Day Postbehavioral Insomnia Treatment Variables

Variable

# Log Entries

Mean or %

SD

Range

1.7

1725

Baseline Variables

Age (years)
Gender (% female)
Race/ethnicity
Non-Hispanic White
Non-Hispanic Black
Other Ethnic groups
Health status
Good, fair, or poor
Excellent or very good
Insomnia Severity Index
GSAQ excessive daytime sleepiness
Usually or always
Never or sometimes
Bed partner or pet frequency
At least sometimes
Never
GSAQ depressive or anxiety symptoms frequency
Usually or always
Never or sometimes
Self-efficacy
Low (15)
Moderate (67)
High (89)
Acceptance of treatment
Lower (57)
Higher (89)
Intentions to adhere
Lower (37)
Higher (89)

53
46

18.9
86.8

40
10
3

75.5
18.9
5.7

22
31
53

41.5
58.5
12.4

3.4

8.021.0

18
35

34.0
66.0

23
30

43.4
56.6

20
33

37.7
62.3

18
19
16

34.0
35.9
30.1

30
23

56.6
43.4

27
26

50.9
49.1

14-Day Postbehavioral Insomnia Treatment Variables

# Log Entries

Mean or %

SD

Range

Total sleep time (in minutes)

Sleep efficiency (%)
Sleep quality
Poor to very poor (12)
Fair to excellent quality (35)
Pain
None to low levels (01)
Moderate to high levels (25)
Fatigue
Low (01)
Moderate (23)
High (45)
Mood
Bad (01)
Fine (23)
Good (45)
Stress
None to low levels (02)
Moderate to high levels (35)
Health status
Good (01)
Fair (23)
Poor (45)

700
700
719
109
610
719
521
198
719
161
373
185
719
66
284
369
720
367
353
719
493
159
67

407.4
86.4
3.4
15.2
84.8
0.9
72.5
27.5
2.6
22.4
51.9
25.7
3.3
9.2
39.5
51.3
2.4
51.0
49.0
1.1
68.6
22.1
9.3

130.0
15.0
0.4
1.2
1.3
-

0857
0100
1.94.5
05
05
-

1.2
-

05
-

1.4
1.4
-

05
05
-

435

adherence to insomnia intervention

Table 1 (continued)
Variable

# Log Entries

Mean or %

SD

Range

35.9
1.37

0300
09

Baseline Variables

Exercise time (in minutes)

No. alcoholic beverages
None
1

718
718
631
87

24.8
0.6
87.9
12.1

Note. GSAQ = item derived from the Global Sleep Assessment Questionnaire; SD = standard deviation

objective (i.e., to assess adherence), participants were

informed the study was intended to discover what
aspects of behavioral insomnia treatment make it
effective. Participants were reminded by e-mail every
other day to complete the online logs no matter if
they utilized treatment recommendations or not. The
participants were informed that their ability to satisfy
the course requirement was not contingent on if they
followed the treatment recommendations. At the
completion of the study, the participants were
debriefed of the actual intent of the study. The
universitys Institutional Review Board reviewed and
approved of the study protocol.

Data Analysis
We computed descriptive statistics on all predictor
variables, covariates, and outcomes. A paired-samples t test was used to compare baseline and
posttreatment ISI scores. The continuous data for
the adherence outcome measures were not normally
distributed; therefore, they were collapsed into
ordinal variables. The average proportion of SCT
instructions followed over the 14-day follow-up
period was categorized into the following groups:
less than four out of six (b 0.67); four out of six
(0.67); five out of six (0.83); and six out of six
(1.00). The average proportion of SH instructions
followed over the 14-day follow-up period was
categorized into the following groups: 0.80; 0.80
0.90; and 1.00 (five out of five instructions). The
average deviation in minutes from the prescribed
wake time in SRT was converted into clinically
meaningful increments as follows: 0; 115; 1630;
3145; 4660; 6190; and N 90.
A proportional odds model (Scott, Goldberg &
Mayo, 1997) using generalized estimated equations
was used to analyze the ordinal outcome data and
produce odds ratios (ORs) and 95% confidence
intervals (CIs) for the association between the
baseline and daily assessed predictors with SCT,
SRT, and SH adherence scores. The use of
generalized estimated equations allowed for the
models to account for the clustering within study
participants. Daily assessed fatigue, mood, stress,
pain, sleep quality, and health status as well as
baseline self-efficacy, treatment acceptance, and

intentions to adhere were measured on ordinal

scales. Bed partner or pet status, baseline health
status, sleepiness, and depressive and anxiety
symptoms were measured on categorical scales.
The sample sizes for some of the values on these
ordinal and categorical scales were low. Low
sample sizes per ordinal value or category can
lead to wide confidence intervals in generalized
estimated equations analysis. Therefore, these
variables were collapsed into categories based
on the frequency of endorsement for each value in
each predictor to improve the stability of the
estimates.
The number of predictors to be tested with the
three adherence outcome measures was large.
Rather than using a strict correction factor for
multiple comparisons, such as the Bonferroni,
which may increase our Type II error rate, the
following analyses were based on the stepwise
approach used by Fournier and colleagues (2009).
This stepwise approach was used to determine the
most salient predictors of adherence while minimizing the number of statistical tests conducted to
balance concerns about high rates of Type I and
Type II errors. First, each predictor variable was
assigned to one of seven domains based on content
and time of collection as follows: demographics
(age, gender, race/ethnicity), baseline sleep and
health (ISI score, excessive daytime sleepiness,
depressive and anxiety symptoms, and general
health status), baseline treatment perceptions (selfefficacy, acceptance of treatment, and intentions to
adhere), bed partner or pet status, nightly sleep
(total sleep time, sleep efficiency, and sleep quality),
daytime symptoms (pain, mood, fatigue, stress, and
health status), and daytime behaviors (alcohol
consumption and time spent exercising). To check
for issues with multicollinearity, the correlation
between total sleep time and sleep efficiency was
assessed (r = .68). Since the correlation was lower
than r b .75, both variables were placed in the same
domain. Second, six separate generalized estimated
equation models were constructed to identify
significant predictors within each domain in a
stepwise manner. In Step 1, any predictors within
each domain that attained significance values of

436

ruiter petrov et al.

p b 0.20 were retained in the model. At subsequent

Steps 2 and 3, predictors were only retained if they
achieved significance values of p b .10 and then
p b .05, respectively. All remaining significant
predictors were then included into a final, full
model to determine unique effects of each predictor
while controlling for the effects of the other
significant predictors. A cumulative logit distribution was used to estimate the model parameters. An
alpha level of p b .05 was considered statistically
significant. The generalized estimated equation
analyses were conducted using the PROC GENMOD statement in SAS 9.2 (SAS Institute, Inc.,
Cary, North Carolina).

Results
sample characteristics
Fifty-three participants completed the treatment
protocol and at least 9 days of sleep diaries and
adherence logs (M = 13.2, SD = 1.8, range: 9
14 days). Five additional participants completed
the treatment protocol but dropped out of the study
before providing any sleep diary or adherence log
information. These participants were significantly
older, M = 20.8, SD = 2.7 versus M = 18.9, SD =
1.7, t(56) = 2.3, p = .030, and had less treatmentrelated self-efficacy, M = 4.4, SD = 2.9 versus M =
6.3, SD = 1.8, t(56) = 2.1, p = .040, than the final
sample. They did not differ on any other baseline
variables. The most cited reason for dropping out
of the study was time commitment. The vast
majority of the final sample were full-time students
(98.1%), and 15.4% were employed part-time.
None of the participants reported being diagnosed
or treated for a mental disorder. Descriptive
statistics on all independent variables can be
found in Table 1.
treatment outcome
Baseline ISI scores (M = 12.4, SD = 3.4) compared
with 2-week follow-up ISI scores (M = 10.7, SD =
3.7) indicated a statistically significant reduction in
insomnia severity, t(50) = 3.51, p = .001.
missing data
Common to most studies conducting daily measurements, there were some missing data on the
daily assessed variables and adherence measures.
Missing data for the daily assessed variables from a
possible 742 entries (i.e., 53 participants 14 days)
ranged from 3.0 to 5.7%. Missing data for the daily
adherence measures ranged from 3.2 to 4.2%. Given
the small percentages of missing data, complete case
analyses were not employed to assess all relationships.

adherence to online diary entry

At the treatment session, participants were
instructed to complete online sleep and treatment
adherence logs each morning over the following
14 days. Of 727 time-stamped, online diary entries,
75.2% (n = 547) were entered within 1 day, and
85.4% (n = 621) were entered within 2 days of the
designated time. Treatment group size was not
related to any of the adherence variables (data not
presented).
treatment adherence
Table 2 displays the descriptive information on the
adherence scores for each treatment component.
Participants, on average, followed four to five of the
six SCT instructions and five SH recommendations
per night. In contrast, only 46.7% of the participants followed SRT recommendations fairly well
(i.e., only deviated from their recommended wake
time on average by no more than 30 minutes).
relationships of baseline and daily
assessed factors to sct adherence
Table 3 presents Steps 1, 2, and the final model of
the stepwise procedure to identify baseline and
daily assessed variables associated with SCT
adherence. In the final model, the only baseline
Table 2

Level of Adherence of Study Participants Over the 14-Day

Follow-Up Period
Adherence Outcomes

# Log
Entries

Mean
or %

SD

Range

Stimulus Control (SC) a

b 0.67
0.67
0.83
1.0
Sleep Restriction
Therapy (SRT) b
0
115
1630
3145
4660
6190
91.0
Sleep Hygiene (SH) c
b 0.8
0.80.9
1.0

719
106
168
309
136
713

0.77
14.7
23.4
43.0
18.9
81.6

0.18

96.5

01

0540.0

207
71
55
22
62
55
241
720
122
247
351

29.0
10.0
7.7
3.1
8.7
7.7
33.3
0.85
16.9
34.3
48.8

0.18

01

Note. SD = standard deviation.

a
Adherence is the proportion of the six instructions followed
each day/night.
b
Adherence is the number of minutes discrepant from the
recommended wake time.
c
Adherence is the proportion of the five instructions followed
each day/night.

437

adherence to insomnia intervention

Table 3

Stepwise Approach to Final Model of Variables Associated With Adherence to Stimulus Control Therapy
Step 1: Retain Effects at p b .20
a

95% CI

Domain

Predictor

OR

Baseline sleep and health

Baseline treatment perceptions

Health (ref: excellent or very good; 01); good, fair, or poor (24)
Self-efficacy (ref: high; 89);
moderate (67)
Low (15)
Bed partner or pet (ref: never)
Total sleep time (15-min increments)
Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Pain (ref: none to low; 01);
moderate to high (25)
Health status (ref: good; 01);
fair health (23)
Poor health (45)
Exercise (30-min increments)

1.79
0.70
0.22
2.06
0.95
1.14
0.57
1.46
0.60
0.45
1.16

0.94, 3.41
0.31, 1.59
0.09, 0.55
1.14, 3.69
0.92, 0.98
1.03, 1.27
0.34, 0.98
1.02, 2.09
0.43, 0.85
0.23, 0.87
0.96, 1.41

Health (ref: excellent to very good; 01); good, fair, or poor (24)
Self-efficacy (ref: high; 89);
moderate (67)
Low (15)
Bed partner or pet (ref: never)
Total sleep time (15-min increments)
Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Pain (ref: none to low; 01);
moderate to high (25)
Health status (ref: good; 0-1);
fair health (23)
Poor health (45)

1.68
0.66
0.21
2.06
0.95
1.14
0.57
1.47
0.58
0.44

0.93,
0.33,
0.10,
1.14,
0.92,
1.03,
0.34,
1.01,
0.40,
0.24,

3.03
1.31
0.44
3.69
0.98
1.27
0.98
2.15
0.84
0.83

.085
.235
b .001
.016
.003
.007
.043
.043
.004
.011

0.79
0.25
2.57
0.95
1.14
0.56

0.39,
0.13,
1.53,
0.92,
1.03,
0.33,

1.58
0.46
4.33
0.98
1.25
0.94

.512
b .001
b .001
.003
.009
.006

Baseline bed partner or pet

Nightly sleep

Daytime symptoms

Daytime behaviors

.077
.392
.001
.016
.003
.007
.043
.041
.004
.018
.134

Step 2: Retain Effects at p b .10

Baseline sleep and health
Baseline treatment perceptions
Bed partner or pet
Nightly sleep

Daytime symptoms

Final Model With All Significant Predictors (p b .05) in Step 3: From All Domains
Baseline treatment perceptions

Self-efficacy (ref: high; 89);

moderate (67)
Low (15)

Bed partner or pet

Nightly sleep

Bed partner or pet (ref: none)

Total sleep time (15-min increments)
Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor

Note. OR = odds ratio; CI = confidence interval.

a
Odds ratios greater than 1.0 indicate greater treatment adherence; odds ratios less than 1.0 indicate poorer treatment adherence.

variables that were retained were bed partner or pet

status and treatment-related self-efficacy. Better
SCT adherence was associated with having a bed
partner or pet. Lower SCT adherence was associated with low self-efficacy. Odds of reporting good
SCT adherence were also decreased by 44% for
reporting poor to very poor sleep quality when
compared with fair to excellent sleep quality. An
increase in total sleep time by 15 minutes was
associated with a 5% decrease in adherence, whereas
an increase in sleep efficiency by 5% was related to a
14% increase in adherence.

relationships of baseline and daily

assessed factors to srt adherence
Table 4 presents Steps 1, 2, and the final model of
the stepwise procedure to identify baseline and
daily assessed variables associated with adherence
to SRT wake time recommendations. None of the

baseline variables assessed from any of the domains

were significantly related to nightly variations in
SRT adherence. Daily assessed variables that were
significantly related to SRT adherence in the final
model were alcohol consumption, total sleep time,
sleep efficiency, and sleep quality. Any alcoholic
beverages consumed were related to greater odds of
poorer SRT adherence compared with no alcoholic
beverages consumed. Increases in total sleep time
and poorer sleep quality were also related to next
night poorer SRT adherence, whereas increases
in sleep efficiency were related to greater SRT
adherence.

relationships of baseline and daily

assessed factors to sh adherence
Table 5 displays Steps 1, 2, and the final model of
the stepwise procedure to identify baseline and
daily assessed variables associated with SH

438

ruiter petrov et al.

Table 4

Stepwise Approach to Final Model of Variables Associated With Adherence to Sleep Restriction Therapy
Step 1: Retain Effects at p b .20
Domain

Predictor

OR a

95% CI

Nightly sleep

Total sleep time (15-min increments)

Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Mood (ref: good; 45);
fine (23)
Bad (01)
Alcohol consumption (ref: 0 drinks)

0.78
1.51
0.46
0.70
0.62
0.39

0.72,
1.34,
0.29,
0.49,
0.40,
0.22,

0.83
1.70
0.74
0.99
0.96
0.70

b .001
b .001
.001
.043
.033
.002

0.78
1.51
0.46
0.68
0.59
0.38

0.72,
1.34,
0.29,
0.47,
0.37,
0.21,

0.83
1.70
0.73
0.99
0.93
0.68

b .001
b .001
.001
.049
.023
.001

0.77
1.53
0.46
0.38

0.72,
1.36,
0.29,
0.17,

0.83
1.72
0.74
0.84

b .001
b .001
.001
.017

Daytime symptoms
Daytime behaviors

Step 2: Retain Effects at p b .10

Nightly sleep

Daytime symptoms
Daytime behaviors

Total sleep time (15-min increments)

Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Mood (ref: good; 01);
fine (23)
Bad (45)
Alcohol consumption (ref: 0 drinks)

Final Model With All Significant Predictors (p b .05) in Step 3: From All Domains
Nightly sleep

Daytime behaviors

Total sleep time (15-min increments)

Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Alcohol consumption (ref: 0 drinks)

Note. OR = odds ratio; CI = confidence interval.

a
Odds ratios greater than 1.0 indicate greater treatment adherence; odds ratios less than 1.0 indicate poorer treatment adherence.

adherence. In the final model, low treatment-related

self-efficacy (compared to high self-efficacy) and
any alcohol use were significantly associated with
poorer SH adherence.

Discussion
Daily variations in adherence, during the 2 weeks
after one session of behavioral therapy for insomnia,
were associated with several pretreatment participant
factors and during treatment state factors. Lower
baseline treatment-related self-efficacy was related to
lower SCT and SH adherence. Sharing a bed with a
partner or pet was related to better SCT adherence.
Poor sleep quality, greater total sleep time, and less
sleep efficiency were associated with poorer SCT and
SRT adherence the following night. Consumption of
alcoholic beverages was related to poorer SRT and
SH adherence on the following night.
The association between low self-efficacy and
poorer adherence to SCT and SH recommendations is in concordance with a previous study. That
study found that greater global, treatment-related
self-efficacy was related to better weekly adherence
to cognitive-behavioral therapy for insomnia,
particularly during the first week of treatment
(Bouchard et al., 2003). In the present study,
self-efficacy accounted for more of the variability

in SCT and SH adherence than acceptance of

treatment and intentions to adhere, suggesting that
gauging or enhancing patients self-efficacy may be
particularly important during the initial introduction to treatment for successful subsequent treatment adherence and response.
Our results suggest that poor sleep quality and
sleep efficiency as well as greater total sleep time on
one night were predictive of nonadherence to SCT
and SRT the next night. The total sleep time result is
similar to that found by McChargue and colleagues
(2012). Their study found that decreasing sleep
disturbances over the course of treatment was
related to lower adherence to relaxation therapy
for insomnia among women with breast cancer. In
the present study it follows that if participants are
experiencing greater sleep durations, they may not
feel the need to engage in further treatment having
perceived that their sleep is improved. However,
this relationship also may be seen as evidence that
the participant is not engaging in treatment from
the very beginning of treatment. Behavioral treatments of insomnia when followed usually result in
lower total sleep times during the early treatment
phase and then increase over time. Poor sleep
quality, low sleep efficiency, and greater total sleep
time within the first few nights of treatment may

439

adherence to insomnia intervention

Table 5

Stepwise Approach to Final Model of Variables Associated With Adherence to Sleep Hygiene Recommendations
Step 1: Retain Effects at p b .20
p

1.10
1.94
0.58
0.58
1.28
0.40
1.67
0.67
0.50
0.61
0.11

0.96,
0.84,
0.26,
0.27,
0.46,
0.12,
0.79,
0.37,
0.30,
0.30,
0.06,

1.25
4.47
1.32
1.25
3.51
1.34
3.54
1.20
0.80
1.23
0.20

.189
.121
.195
.162
.637
.138
.181
.173
.004
.167
b .001

1.11
0.31
0.75
0.51
0.64
0.11

0.42,
0.12,
0.34,
0.30,
0.32,
0.07,

2.95
0.81
1.66
0.87
1.26
0.19

.827
.016
.480
.014
.194
b .001

0.93
0.25
0.11

0.38, 2.30
0.10, 0.63
0.06, 0.21

.882
.004
b .001

Predictor

OR

Baseline sleep and health

Insomnia Severity Index

Health (ref: excellent to very good; 01); good, fair, or poor (24)
EDS (ref: never or sometimes); usually or always
Intentions (ref: lower; 37); higher (89)
Self-efficacy (ref: high; 89);
moderate (67)
Low (15)
Bed partner or pet (ref: never)
Sleep quality (ref: fair to excellent); poor to very poor
Health status (ref: good 01);
fair health (23)
Poor health (45)
Alcohol consumption (ref: 0 drinks)

Self-efficacy (ref: high; 89);

Baseline treatment perceptions

Bed partner or pet

Nightly sleep
Daytime symptoms
Daytime behaviors

95% CI

Domain

Step 2: Retain effects at p b .10

Baseline treatment perceptions
Nightly sleep
Daytime symptoms
Daytime behaviors

moderate (67)
Low (15)
Sleep quality (ref: fair to excellent); poor to very poor
Health status (ref: good 01);
fair health (23)
Poor health (45)
Alcohol (ref: 0 drinks)

Final Model With All Significant Predictors (p b .05) in Step 3: From All Domains
Baseline treatment perceptions

Self-efficacy (ref: high; 89);

Daytime behaviors

Alcohol (ref: 0 drinks)

moderate (67)
Low (15)

Note. OR = odds ratio; CI = confidence interval; EDS = excessive daytime sleepiness.

a
Odds ratios greater than 1.0 indicate greater treatment adherence; odds ratios less than 1.0 indicate poorer treatment adherence.

simply be indicators that the participant is struggling

to engage with the treatment, which is predictive of a
continuing struggle throughout treatment. Careful
monitoring of sleep by the therapist within the first
few nights of treatment engagement may be crucial
for successful treatment adherence and response
thereafter.
Several literature-based predictors were not
replicated in this study, including pretreatment
depressive and anxiety symptoms, general health,
daytime sleepiness, and insomnia severity, as well as
daily assessed fatigue, mood, pain, exercise, and
health status. The baseline-assessed variables likely
were not replicated for the same reasons that so
many of the literature-based factors have not been
consistently replicated in other studies such as
differences in the measurement of predictors and
adherence outcomes, treatment components and
how they were delivered, and populations studied.
Without standardized methods of measuring variables in adherence trials and the delivery of
behavioral treatments of insomnia it is difficult to

compare results to previous studies. Regarding the

daily assessed variables, these factors were only
found to be significantly related to treatment
adherence in previous studies when they were
measured at baseline assessment, which may
explain why they were not found to be significantly
related in this study.
A novel predictor of SCT adherence was sharing
a bed with a bed partner or pet at least some of the
time. This result may be explained by the likely
situation that these participants lived in apartments
or homes, rather than a college dormitory where the
implementation of SCT may be more difficult.
However, an alternative explanation is that merely
the physical and social presence of another living
creature, whether human or animal in the bed, may
improve SCT and SH adherence. These participants
may have altered their sleep patterns more readily
because they felt accountable to the other person or
animal present in the bed. Another explanation, in
the case of a human bed partner, is social support
received from that bed partner may have influenced

440

ruiter petrov et al.

SCT adherence. Objective sleep data have revealed

sleepwake cycles among bed partners are often
interdependent (Meadows, Arber, Venn, Hislop, &
Stanley, 2009). We propose that social support
from a bed partner may have affected self-efficacy
in adhering to behavioral sleep treatment recommendations. The health behavior literature suggests
that relationship partners influence health behavior
change (Lewis et al., 2006), and a recent review
suggests bed partners may be an important
component for successful behavioral treatment for
insomnia (Rogojanski, Carney, & Monson, 2012).
However, extreme caution should be exercised with
this interpretation because the assessment of bed
partner or pet status was combined, therefore it is
unknown how many of these participants were
reporting on bed partners as opposed to pets. Future
studies should assess for bed partner status separate
from pets and reevaluate its relation to treatment
adherence.
Alcohol consumption was associated with poorer
next night SRT and SH adherence. The timing of this
consumption was not measured. However, if the
consumption occurred in the 2 hours prior to
bedtime in this sample, it may have directly or
indirectly affected sleepwake schedules. Alcohols
detrimental effects on sleep have been documented
among healthy, nonalcoholic participants (Roehrs &
Roth, 2001). Among college students, greater
alcohol consumption is associated with delays in
bedtimes and wake times, oversleeping, and desynchrony between weekday and weekend sleepwake
schedules (Singleton & Wolfson, 2009). These
previous studies along with our data indicate alcohol
may be a barrier to full adherence to behavioral
insomnia treatments. However, given that a large
proportion of the study participants were under the
legal drinking age, another interpretation is that
these participants who did not adhere to drinking
regulations may also be prone not to adhere to a
behavioral treatment program. Nonetheless, clinicians may opt to educate their patients on the effects
of alcohol on sleep, and monitor consumption.
Future research should investigate whether education and monitoring would promote adherence and
lead to more favorable treatment outcomes than not
adding these components.
The meaningfulness of these data are bolstered by
the studys strengths, including the use of ICSD-II
criteria to identify participants with probable
insomnia, obtaining daily online data, and analyzing these data from a daily process framework.
However, the study has limitations. Notably, our
sample size was small and confined to mostly
female and non-Hispanic White college undergraduates with mild insomnia, thus limiting generaliz-

ability to other ethnic groups, young adults, and

patients with severe insomnia. Therefore, the
findings from the final regression models may not
generalize to men or to nonstudents with insomnia
who are seeking treatment. Nonetheless, this
population is important to investigate because
many insomnia sufferers report their symptoms
began during their older adolescence and young
adult years (Bixler, Kales, Soldatos, Kales, &
Healey, 1979; Singareddy et al., 2012), and the
transition to college often heralds changes in sleep
patterns that have been associated with poor
academic performance and psychopathology
(Gaultney, 2010; Taylor et al., 2011).
Further limitations of the study were the lack of
psychometrically validated and standardized daily
assessed predictor variables and the lack of verified
clinical diagnoses of insomnia. While the questions
used to determine whether the participants had
insomnia conformed to ICSD-II diagnostic criteria,
the questions had not been previously validated and
therefore the participants could only be determined
to have probable insomnia. This is in contrast to the
literature that mostly reports on the adherence to
behavioral insomnia treatment by participants with
verified, chronic insomnia. Future research should
work to standardize self-report screening measures
for insomnia according to ICSD-II criteria and
daytime symptoms and behaviors related to behavioral treatments for insomnia. A final limitation
was that the study utilized a didactic, single session
of behavioral insomnia treatment adapted from
cognitive-behavioral therapy for insomnia, which
differs from this evidence-based treatments optimal
treatment duration of four weekly sessions
(Edinger, Wohlgemuth, Radtke, Coffman, &
Carney, 2007). However, the original intent of the
present study was to capture adherence at the early
stages of treatment initiation because delivery of
four sessions of behavioral insomnia treatment in a
modern health care system is not always feasible.

Conclusions
We discovered several pretreatment participant
factors as well as daily experienced factors during
treatment engagement were related to daily variations in adherence to a brief behavioral intervention
for insomnia. The results suggest interventions
designed to enhance self-efficacy in conjunction
with behavioral therapies for insomnia may be
worthy of further testing, particularly if this finding
is replicated in future studies. We recommend that in
research and clinical settings, the presence of another
person or pet in the bedroom ought to be assessed to
determine whether it may be an important factor in a
given patients treatment engagement and response.

adherence to insomnia intervention

Comprehensive monitoring of alcohol intake and
sleep during the first few nights of treatment may also
prove to be clinically important and predictive of
adherence if replicated.
Conflict of Interest Statement
Dr. Lichstein is a member of the Merck Insomnia Advisory
Board. The other authors have no conflicts of interest to report.
We would like to acknowledge the statistical consultation
support received by Dr. Gerald McGwin. Dr. Lichstein is a
member of the Merck Insomnia Advisory Board. The other
authors have no conflicts of interest to report.

References
American Academy of Sleep Medicine. (2005). The international classification of sleep disorders and diagnostic and
coding manual (2nd ed.). Westchester, IL: Author.
Baron, K. G., Reid, K. J., & Zee, P. C. (2012). Exercise to
improve sleep in insomnia: Exploration of the bidirectional
effects. Journal of Clinical Sleep Medicine, 9(8), 819824.
http://dx.doi.org/10.5664/jcsm.2930
Baron, K. G., Smith, T. W., Berg, C. A., Czajkowski, L. A.,
Gunn, H., & Jones, C. R. (2011). Spousal involvement in
CPAP adherence among patients with obstructive sleep apnea.
Sleep and Breathing, 15(3), 525534. http://dx.doi.org/
10.1007/s11325-010-0374-z
Bixler, E. O., Kales, A., Soldatos, C. R., Kales, J. D., & Healey,
S. (1979). Prevalence of sleep disorders in the Los Angeles
metropolitan area. American Journal of Psychiatry, 136,
12571262.
Bootzin, R. R., Epstein, D., & Ward, J. M. (1991). Stimulus
control instructions. In P. Hauri (Ed.), Case studies in
insomnia (pp. 1928). New York, NY: Plenum Press.
Bouchard, S., Bastien, C., & Morin, C. M. (2003). Self-efficacy
and adherence to cognitive-behavioral treatment of insomnia.
Behavioral Sleep Medicine, 1(4), 187199. http://dx.doi.org/
10.1207/S15402010BSM0104_2
Buman, M. P., Hekler, E. B., Bliwise, D. L., & King, A. C. (2011).
Exercise effects on night-to-night fluctuations in self-rated
sleep among older adults with sleep complaints. Journal of
Sleep Research, 20(1), 2837. http://dx.doi.org/
10.1111/j.1365-2869.2010.00866.x
Cartwright, R. (2008). Sleeping together: A pilot study of the
effects of shared sleeping on adherence to CPAP treatment in
obstructive sleep apnea.Journal of Clinical Sleep Medicine,
4(2), 123127 (Retrieved from www.ncbi.nlm.nih.gov/pmc/
articles/PMC2335391).
Dashevsky, B., & Kramer, M. (1997). Patients who discontinue
combined behavioral and medicinal treatment of insomnia.
Sleep Research, 26, 350.
DiMatteo, R. M. (2004). Variations in patients adherence to
medical recommendations: A quantitative review of 50 years
of research. Medical Care, 42(3), 200209. http://dx.doi.org/
10.1097/01.mlr.0000114908.90348.f9
Ebrahim, I. O., Shapiro, C. M., Williams, A. J., & Fenwick, P.
B. (2013). Alcohol and sleep I: Effects on normal sleep.
Alcoholism: Clinical and Experimental Research, 37(4),
539549. http://dx.doi.org/10.1111/acer.12006
Edinger, J. D., & Means, M. K. (2005). Cognitive-behavioral
therapy for primary insomnia. Clinical Psychology Review,
25(5), 539558. http://dx.doi.org/10.1016/j.cpr.2005.
04.003
Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Coffman, C.
J., & Carney, C. E. (2007). Dose-response effects of
cognitive-behavioral insomnia therapy: A randomized clinical

441

trial. Sleep, 30(2), 203212. http://dx.doi.org/10.1016/j.cpr.

2005.04.003.
Fournier, J. C., DeRubeis, R. J., Shelton, R. C., Hollon, S. D.
Amsterdam, J. D., & Gallop, R. (2009). Prediction of response
to medication and cognitive therapy in the treatment of
moderate to severe depression. Journal of Consulting and
Clinical Psychology, 77(4), 775787. http://dx.doi.org/
10.1037/a0015401
Gaultney, J. F. (2010). The prevalence of sleep disorders in college
students: Impact on academic performance. Journal of
American College Health, 59(2), 9197. http://dx.doi.org/
10.1080/07448481.2010.483708
Harvey, L., Inglis, S. J., & Espie, C. A. (2002). Insomniacs
reported use of CBT components and relationship to long-term
clinical outcome. Behaviour Research and Therapy, 40, 7583.
http://dx.doi.org/10.1016/S0005-7967(01)00004-3
Hebert, E. A., Vincent, N., Lewycky, S., & Walsh, K. (2010).
Attrition and adherence in the online treatment of
chronic insomnia. Behavioral Sleep Medicine, 8, 141150.
http://dx.doi.org/10.1080/15402002.2010.487457
Hohagen, F., Rink, K., Kppler, C., Schramm, E., Riemann, D.,
Weyerer, S., & Berger, M. (1993). Prevalence and treatment
of insomnia in general practice: A longitudinal study.
European Archives of Psychiatry and Clinical Neuroscience,
242(6), 329336. http://dx.doi.org/10.1007/BF02190245
Lewis, M. A., McBride, C. M., Pollack, K. I., Puleo, E.,
Butterfield, R. M., & Emmons, K. M. (2006). Understanding
health behavior change among couples: An interdependence
and communal coping approach. Social Science and Medicine,
62(6), 13691380. http://dx.doi.org/10.1016/j.socscimed.
2005.08.006
Lichstein, K. L., Durrence, H. H., Riedel, B. W., Taylor, D. J., &
Bush, A. J. (2004). Epidemiology of sleep: Age, gender, and
ethnicity. Mahwah, NJ: Erlbaum.
Lichstein, K. L., & Morin, C. M. (2000). Treatment of late-life
insomnia. Thousand Oaks, CA: Sage.
Matthews, E. E., Arnedt, J. T., McCarthy, M. S., Cuddihy, L. J.,
& Aloia, M. S. (2013). Adherence to cognitive behavioral
therapy for insomnia: A systematic review. Sleep Medicine
Reviews. http://dx.doi.org/10.1016/j.smrv.2013.01.001
Matthews, E. E., Schmiege, S. J., Cook, P. F., Berger, A. M., &
Aloia, M. S. (2012). Adherence to cognitive behavioral
therapy for insomnia (CBTI) among women following
primary breast cancer treatment: A pilot study. Behavioral
Sleep Medicine, 10(3), 217229. http://dx.doi.org/10.1080/
15402002.2012.666220
McChargue, D. E., Sankaranarayanan, J., Visovsky, C. G.,
Matthews, E. E., Highland, K. B., & Berger, A. M. (2012).
Predictors of adherence to a behavioral therapy sleep
intervention during breast cancer chemotherapy. Supportive
Care in Cancer: Official Journal of the Multinational
Association of Supportive Care in Cancer, 20(2), 245252.
http://dx.doi.org/10.1007/s00520-010-1060-1
Meadows, R., Arber, S., Venn, S., Hislop, J., & Stanley, N. (2009).
Exploring the interdependence of couples rest-wake cycles: An
actigraphic study. Chronobiology International, 26(1), 8092.
http://dx.doi.org/10.1080/07420520802678452
Morgan, K., Thompson, J., Dixon, S., Tomeny, M., &
Mathers, N. (2003). Predicting longer-term outcomes
following psychological treatment for hypnotic-dependent
chronic insomnia. Journal of Psychosomatic Research,
54(1), 2129. http://dx.doi.org/10.1016/S0022-3999(02)
00569-X
Morgenthaler, T., Kramer, M., Alessi C, Friedman, L.,
Boehlecke, B., Brown, T., Swick, T. (2006). Practice
parameters for the psychological and behavioral treatment
of insomnia: An update. An American Academy of Sleep

442

ruiter petrov et al.

Medicine report. Sleep, 29(11), 14151419. Retrieved from

www.journalsleep.org/Articles/291105.pdf.
Morin, C. M. (1993). Insomnia: Psychological assessment and
management. New York, NY: Guilford Press.
Morin, C. M., Belleville, G., Blanger, L., & Ivers, H. (2011).
The Insomnia Severity Index: Psychometric indicators to
detect insomnia cases and evaluate treatment response.
Sleep, 34(5), 601608. Retrieved from www.ncbi.nlm.nih.
gov/pmc/articles/PMC3079939.
Morin, C. M., LeBlanc, M., Daley, M., Gregoire, J. P., &
Mrette, C. (2006). Epidemiology of insomnia: Prevalence,
self-help treatments, consultations, and determinants of
help-seeking behaviors. Sleep Medicine, 7(2), 123130.
http://dx.doi.org/10.1016/j.sleep.2005.08.008
Ohayon, M. M. (2002). Epidemiology of insomnia: What we
know and what we still need to learn. Sleep Medicine
Reviews, 6(2), 97111. http://dx.doi.org/10.1053/smrv.
2002.0186
Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005).
Cognitive behavioral treatment of insomnia: A session-bysession guide. New York, NY: Springer Science + Business
Media.
Reed, M. B., & Aspinwall, L. G. (1998). Self-affirmation
reduces biased processing of health risk information.
Motivation and Emotion, 22(2), 99131. http://dx.doi.org/
10.1023/A:1021463221281
Riedel, B. W., & Lichstein, K. L. (2001). Strategies for
evaluating adherence to sleep restriction treatment for
insomnia. Behaviour research and therapy, 39(2),
201212. http://dx.doi.org/10.1016/S0005-7967(00)
00002-4
Roehrs, T., & Roth, T. (2001). Sleep, sleepiness, and alcohol
use.Alcohol Research and Health, 25(2), 101109. Retrieved
from webapps.ou.edu/alcohol/docs/05SleepSleepinessandEton
Us101-109.pdf.
Rogojanski, J., Carney, C. E., & Monson, C. M. (2012).
Interpersonal factors in insomnia: A model for integrating
bed partners into cognitive behavioral therapy for insomnia.
Sleep Medicine Reviews, 17, 5564. http://dx.doi.org/
10.1016/j.smrv.2012.02.003
Roth, T., Zammit, G., Kushida, C., Doghramji, K.,
Mathias, S. D., Wong, J. M., & Buysse, D. J. (2002).
A new questionnaire to detect sleep disorders. Sleep
Medicine, 3(2), 99108. http://dx.doi.org/10.1016/
S1389-9457(01)00131-9
Savard, M. H., Savard, J., Simard, S., & Ivers, H. (2005).
Empirical validation of the insomnia severity index in cancer
patients. Psychooncology, 14(6), 429441. http://dx.doi.org/
10.1002/pon.860
Scott, S. C., Goldberg, M. S., & Mayo, N. E. (1997). Statistical
assessment of ordinal outcomes in comparative studies. Journal
of Clinical Epidemiology, 50(1), 4555. http://dx.doi.org/10.
1016/S0895-4356(96)00312-5
Sherman, D. K., Nelson, L. D., & Steele, C. M. (2000). Do
messages about health risks threaten the self? Increasing the

acceptance of threatening health messages via selfaffirmation.

Personality and Social Psychology Bulletin, 26, 10461058.
Singareddy, R., Vgontzas, A. N., Fernandez-Mendoza, J., Liao,
D., Calhoun, S., Shaffer, M. L., & Bixler, E. O. (2012). Risk
factors for incident chronic insomnia: A general population prospective study. Sleep Medicine, 13(4), 346353.
http://dx.doi.org/10.1016/j.sleep.2011.10.033
Singleton, R. A., & Wolfson, A. R. (2009). Alcohol consumption, sleep and academic performance among college
students. Journal of Studies on Alcohol and Drugs, 70(3),
355363 Retrieved from www.jsad.com/jsad/download
article/Alcohol_Consumption_Sleep_and_Academic_
Performance_Among_College_Students/4614.pdf.
Smith, M. T., & Perlis, M. (2006). Who is a candidate for
cognitive-behavioral therapy for insomnia? Health
Psychology, 25(1), 1519. http://dx.doi.org/10.1037/
0278-6133.25.1.15
Smith, M. T., Perlis, M. L., Smith, M. S., Giles, D. E., &
Carmody, T. P. (2000). Sleep quality and presleep arousal in
chronic pain. Journal of Behavioral Medicine, 23(1), 113.
http://dx.doi.org/10.1023/A:1005444719169
Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment
of chronic insomnia by restriction of time in bed. Sleep,
10(1), 4556 Retrieved from www.journalsleep.org/
ViewAbstract.aspx?pid=25195.
Suh, S., Dowdle, C. L., Willett, E. S., Nowakowski, S., Siebern,
A. T., Ong, J., Manber, R. (2011). Helpful components of
group cognitive behavioral therapy for insomnia (CBTI) for
patients who perceived pain to interfere with sleep. SLEEP,
34, A180 Retrieved from www.journalsleep.org/Resources/
Documents/2011abstractsupplement.pdf.
Taylor, D. J., Gardner, C. E., Bramoweth, A. D., Williams, J.
M., Roane, B. M., Grieser, E. A., & Tatum, J. I. (2011).
Insomnia and mental health in college students. Behavioral
Sleep Medicine, 9(2), 107116. http://dx.doi.org/10.
1080/15402002.2011.557992
Vincent, N., Lewycky, S., & Finnegan, H. (2008). Barriers to
engagement in sleep restriction and stimulus control in
chronic insomnia. Journal of Consulting and Clinical
Psychology, 76(5), 820828. http://dx.doi.org/10.
1037/0022-006X.76.5.820
Vincent, N., & Lionberg, C. (2001). Treatment preference and
patient satisfaction in chronic insomnia. Sleep, 24(4),
411417 Retrieved from www.ncbi.nlm.nih.gov/pubmed/
11403525.
Vincent, N. K., & Hameed, H. (2003). Relation between
adherence and outcome in the group treatment of insomnia.
Behavioral Sleep Medicine, 1(3), 125139. http://dx.doi.org/
10.1207/S15402010BSM0103_1

R E C E I V E D : April 10, 2013

A C C E P T E D : January 18, 2014
Available online 28 January 2014

All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.