Randomized controlled trial of the effects of cognitive behavioral therapy for insomnia on sleep, impulsivity and aggression in forensic psychiatric patients

Background: Many patients with psychiatric disorders experience sleeping problems. Sleep disorders can be both cause and consequence of psychiatric disorders, and contribute strongly to daily dysfunction and diminished quality of life. Treating sleeping problems positively affects the course of psychiatric illness. In forensic psychiatric patients, treatment of sleeping disorders could be even more important, considering the association between quality and quantity of sleep on one hand, and impulsivity and aggression on the other. Poor sleep is a potential risk factor for impulsive and aggressive behavior. Our hypothesis is that treatment of sleeping problems in forensic psychiatric patients ameliorates sleep and general psychopathology, and reduces impulsivity and aggression.
Objective: Evaluating the effects of cognitive behavioral therapy for chronic insomnia (CBT-I) on sleep, general psychopathology, impulsivity and aggression in forensic psychiatric patients.
Study design: In this randomized controlled intervention study, subjects will undergo a 6-week protocolled treatment for insomnia. Criteria for chronic insomnia will be assessed during a diagnostic interview. Severity of insomnia, as well as the absence of other co-occurring sleeping disorders will be evaluated with the Sleep Diagnosis Questionnaire (SDQ). Furthermore, a minimum score of 1 is required on the impulsivity item and hostility item of the HKT-30 (a Dutch adaptation of the HCR-20, a risk taxation instrument), to be able to evaluate treatment effects. Additional information on psychiatric diagnosis and current use of (hypnotic) medication will be extracted from the medical files. Subsequently, subjects will be randomly assigned to either the intervention or a waiting list condition. Subjective evaluation of sleep, general psychopathology and level of impulsivity and aggression will be measured before and after treatment using four self report questionnaires: the Insomnia Severity Index (ISI), Symptom Checklist 90 (SCL-90), Barratt Impulsiveness Scale (BIS), and Aggression Questionnaire (AQ) respectively. Objective data on sleep characteristics and level of impulsivity will be obtained by actigraphy and two neuropsychological tests (Stop Signal Task and Iowa Gambling Task). Moreover, the treating physician will assess the possible occurrence of aggression by using the Short Term Assessment of Risk and Treatability (START, a risk taxation instrument). A follow-up evaluation will be carried out seven weeks post-intervention.

Poor sleep is a potential risk factor for impulsive and aggressive behavior. Our hypothesis is that treatment of sleeping problems in forensic psychiatric patients ameliorates sleep and general psychopathology, and reduces impulsivity and aggression.

weeks 0 ( pre-treatment), 7 (post-treatment), 14 (follow-up), (21 (only for waiting list: post-treatment))

Cognitive behavioral therapy for insomnia (CBT-i) versus waiting list