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Behav Res Ther. 2014 Feb;53:41-6. doi: 10.1016/j.brat.2013.11.006. Epub 2013 Dec 15.

Cognitive Behavioral Therapy for insomnia with Veterans: evaluation of effectiveness and correlates of treatment outcomes.

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Sierra-Pacific Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Health Care System, USA; Stanford University School of Medicine, USA.
Mental Health Services, U.S. Department of Veterans Affairs Central Office, USA; Bloomberg School of Public Health, Johns Hopkins University, USA. Electronic address:


This paper examines the effectiveness of Cognitive Behavioral Therapy for insomnia (CBT-I) in Veterans and the effects of two process measures on CBT-I outcomes: 1) therapist ratings of patient adherence and 2) patient ratings of therapeutic alliance. Data are from 316 therapists in the Department of Veterans Affairs CBT-I Training Program and 696 patients receiving CBT-I from therapists undergoing training. Mixed effects model results indicate Insomnia Severity Index scores decreased from 20.7 at baseline to 10.9 (d = 2.3) during a typical course of CBT-I. Patients with highest tercile compared to those with lowest tercile adherence achieved, on average, 4.1 points greater reduction in ISI scores (d = 0.95). The effect of therapeutic alliance on change in insomnia severity was not significant after adjusting for adherence to CBT-I. These results support the effectiveness and feasibility of large-scale training in and implementation of CBT-I and indicate that greater focus on patient adherence may lead to enhanced outcomes. The current findings suggest that CBT-I therapists and training programs place greater emphasis on attending to and increasing patient adherence.


Adherence; Alliance; Cognitive Behavioral Therapy; Dissemination; Insomnia; Veterans

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