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Mental disorders are among the most common and burdensome conditions for individuals and society. One in five people has to deal with them. Frequent and often comorbid are anxiety disorders (14.0%), major depressive disorder (6.9%) and somatoform disorder (6.3%) [1]. Regular treatment does not suit everyone well, and after recovery relapse often occurs. Improvement of treatment and relapse prevention is urgent. Attention for insomnia offers the best chance to do so. Insomnia is the transdiagnostically most commonly shared complaint, while good sleep is essential for regulating emotions and learning new cognitions and behaviours: the core fundaments of regular treatments. The aim of this project is to improve treatment-effectiveness in people waiting for help for diverse mental health complaints, by first providing multifaceted lifestyle interventions that improve sleep, physical activity and rhythm regularity while decreasing stress, smoking and alcohol use.

 

Even in the general population, clinically significant insomnia is one of the most common health problems, with a prevalence of 10%. It affects 1.7 million Dutch citizens (CBS 2018), and already in puberty 1.4 times as many women than men [2,3]. Trimbos estimates direct costs of insomnia due to absenteeism, reduced performance, medical expenses, etc. at 10 billion/year [4]. Over recent years, the prevalence of insomnia in the general population increased strongly [5,6]. However, really alarmingly high is the prevalence of insomnia in the specific population of people suffering from a mental disorder. In fact, only few experience a good night’s sleep. Insomnia and mental disorders are strongly connected.

 

First, meta-analyses show that pre-existing insomnia is the primary risk factor predicting first onset anxiety disorders (OR 3.23) and depression (2.83) [7]. Pre-existing insomnia is also key to whether or not a traumatic experience elicits posttraumatic stress disorder (PTSD) [8-10].

 

Second, people with insomnia are respectively 10 and 17 times as likely to have clinically significant depression and anxiety [11]. Indeed, insomnia is common in the majority of people currently diagnosed with major depressive disorder (MDD) [12], PTSD [13-15] and generalized anxiety disorder (GAD) [16]. Estimates of comorbid insomnia easily reach 4 out of five patients [17].

 

Third, insomnia aggravates the disease state, worsens the prognosis, impedes treatment response, and promotes relapse after recovery [18-20].

 

Fourth, while the findings summarized above suggest that treatment of insomnia should be part and parcel of the regular treatment of mental disorders, insomnia symptoms are currently mostly neglected. A limited number of studies investigated the application of the guided eHealth intervention Cognitive Behavioral Therapy for Insomnia (CBTI) in people diagnosed with MDD, with most promising results. CBTI simultaneously addresses life style factors of sleep, physical activity, stress, smoking, use of alcohol and circadian rhythm regularity [21-23] and is as effective for comorbid insomnia [24-28]. Of note, when applied in people with MDD, CBTI not only ameliorated insomnia itself, but also depressive symptoms [24-29]. CBTI moreover lowered the risk of future depression [24], for meta-analysis see [30]. Unfortunately, CBTI studies are largely lacking for common mental disorders other than MDD. Our project will address this gap.

 

The literature thus indicates that insomnia contributes importantly to the risk, severity and treatment resilience of these other mental disorders. Therefore, the current project will transdiagnostically assess the efficacy of immediately applicable CBTI to improve sleep, physical activity, stress coping and circadian rhythm regularity while reducing smoking and alcohol use. We expect the intervention to improve physiological markers of overnight stress regulation and learning, and thereby the response to regular mental health interventions: faster, better and more enduring recovery. In order to optimally prepare for scalable widespread implementation in case of demonstrated effectiveness, the trial will be performed in real life situation, in the earliest possible stage and usual circumstances of current mental healthcare practice, and under the guidance of an implementation expert. At the onset of the project, these experts will make an implementation plan. They will perform process evaluation and problem analysis during the trial.

 

The trial will pragmatically take place during the unfortunately common =8 week waiting list-vacuum endured by patients with mental health complaints after referral by their general practitioner, before onset of regular treatment in generalistic basic mental healthcare. We thus utilize otherwise 'dead time' while patients seek help and are motivated. In line with patients' preferences and to prevent drug dependency [31], we employ a psychological intervention that addresses multiple life style factors.

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