Dr. Rachel Manber is a behavioral sleep medicine specialist. She specializes in non-drug treatments of sleep problems in adults, youth, children, and infants. She has provided cognitive behavioral therapy (CBT) for patients with insomnia and other sleep disorders for more than 20 years. Dr. Manber has a special interest in the treating patients who have chronic long standing sleep difficulties, including those who wish to stop taking sleep medications.

Clinical Focus

  • Cognitive Behavioral Therapy for Insomnia
  • Sleep difficulties in children and teens
  • Adjustment to CPAP
  • Behavioral Sleep Medicine
  • Sleep Medicine

Academic Appointments

Professional Education

  • PhD Training:University of Arizona (1993) AZ
  • Board Certification: Sleep Medicine, American Board of Sleep Medicine
  • Internship:University of Washington School of Medicine (1993) WA
  • PhD, University of Arizona, Clinical Psychology (1993)

Community and International Work

  • Dissemination of CBT for Insomnia

    Partnering Organization(s)

    VA Health Care System

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

1) Insomnia during pregnancy
2) Acupuncture for chronic low back pain

Clinical Trials

  • Stanford Center for Back Pain Recruiting

    The purpose of the Stanford Center for Back Pain is to investigate and characterize the mechanisms of four treatments for chronic low back pain. These interventions (research treatment) include real-time fMRI neurofeedback, mindfulness based stress reduction, cognitive behavioral therapy, and acupuncture treatment. The investigators plan to characterize both mechanisms of treatment effects and efficacy.

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  • Treatments for Insomnia: Mediators, Moderators and Quality of Life Recruiting

    The purpose of this study is to evaluate the relative efficacy and effectiveness of specific components of cognitive behavioral therapies for insomnia: sleep restriction (SR) and cognitive therapy (CT) in comparison to combined SR and CT (SR+CT).

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  • Acupuncture and Massage for Depression During Pregnancy Not Recruiting

    This study evaluates the efficacy of acupuncture and massage for the treatment of depression during pregnancy. The study also examines differential effects of study treatments on delivery outcome and post partum depression.

    Stanford is currently not accepting patients for this trial.

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  • Acupuncture for Sleep Disruption in Cancer Survivors Not Recruiting

    The proposed study will recruit 60 women with breast cancer who finished undergoing treatment who complain of persistent insomnia problems that began with onset of their cancer diagnosis. The eligible women would be randomized and stratified by sleep problems to two arms: (Acupuncture Arm vs. Sham Acupuncture) with a goal of having 48 patients complete the study (we anticipate about 20% attrition rate). The study interventions will begin after patients completed their treatment. The placebo control for acupuncture will be a validated sham acupuncture control Assessments will be made with daily diaries and with weekly questionnaires. PSG data will be collected on the subsample of the population. Data will be gathered via pencil-and-paper measures before, during, immediately following, one month following the completion of treatment and six months after the conclusion of treatment. In addition, actigraphy data (objective sleep continuity data) will be acquired prior to and following treatment

    Stanford is currently not accepting patients for this trial. For more information, please contact David Spiegel, (650) 723 - 6421.

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  • Combining Antidepressant Medication and Psychotherapy for Insomnia to Improve Depression Outcome Not Recruiting

    This study will examine the effectiveness of a combination of antidepressant medication and sleep-focused psychotherapy to simultaneously treat sleep difficulties and depression.

    Stanford is currently not accepting patients for this trial.

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  • Treatment for Insomnia During Pregnancy Not Recruiting

    The aim of the study is to improve sleep during pregnancy and the postpartum period in women who are experiencing insomnia, using a brief non-pharmacological treatment.

    Stanford is currently not accepting patients for this trial. For more information, please contact Elizabeth Rangel, BSc, 650-723-2641.

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  • TRIAD - Treatment of Insomnia and Depression Not Recruiting

    The aim of the proposed three-site study is to increase the rate of full remission from major depressive disorder (MDD) at the end of 16 weeks of treatment for people who experience both major depressive disorder and insomnia.

    Stanford is currently not accepting patients for this trial.

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2017-18 Courses

Stanford Advisees

All Publications

  • Too Long, Too Short, or Too Variable? Sleep Intraindividual Variability and Its Associations With Perceived Sleep Quality and Mood in Adolescents During Naturalistically Unconstrained Sleep SLEEP Bei, B., Manber, R., Allen, N. B., Trinder, J., Wiley, J. F. 2017; 40 (2)


    Research has extensively examined the relationship between adolescents' mental health and average sleep duration/quality. Using rigorous methodology, this study characterized adolescents' objective sleep intraindividual variability (IIV) and examined its role on mood beyond the effects of their respective individual mean (IIM) values.One hundred forty-six community-dwelling adolescents (47.3% male) aged 16.2 ± 1.0 (M ± SD) years wore an actigraph that assessed bedtime, risetime, time-in-bed (TIB), and sleep onset latency (SOL) throughout a 15-day vacation with relatively unconstrained sleep opportunity. Self-report sleep quality (SSQ), negative mood (MOOD), and other covariates were assessed using questionnaires. For each sleep variable, individuals' mean values (IIM) and IIV were used to simultaneously predict MOOD with SSQ as a mediator. Models were estimated in a Bayesian IIV framework; both linear and quadratic effects of the IIM and IIV were examined.Longer and more variable TIB, as well as more variable SOL (but not mean SOL), were associated with poorer SSQ (ps < .01), which in turn, was associated with more negative MOOD (ps < .05). The indirect effect of SOL IIV was curvilinear, such that as SOL became more variable, the deteriorating effect of high SOL IIV accelerated. Neither bedtime nor risetime IIV was significantly associated with SSQ or MOOD.During relatively unconstrained sleep opportunity, more variable TIB and SOL were associated with more negative mood, mediated by poorer perceived sleep quality. Significant effects of IIV were over and above that of mean values, suggesting that unique aspects of sleep IIV are relevant to how adolescents perceive sleep quality and their mood.

    View details for DOI 10.1093/sleep/zsw067

    View details for Web of Science ID 000394129900025

    View details for PubMedID 28364491

  • 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 JOURNAL OF CLINICAL SLEEP MEDICINE Edinger, J. D., Manber, R., Buysse, D. J., Krystal, A. D., Thase, M. E., Gehrman, P., Fairholme, C. P., Luther, J., Wisniewski, S., Org, N. 2017; 13 (2): 205-213

    View details for DOI 10.5664/jcsm.6448

    View details for Web of Science ID 000397048800011

  • Objective and subjective sleep during pregnancy: links with depressive and anxiety symptoms. Archives of women's mental health Volkovich, E., Tikotzky, L., Manber, R. 2016; 19 (1): 173-181


    The aims of this paper are to study the associations between objective and subjective sleep in pregnant women, to examine which specific aspects of women's sleep are associated with depressive and anxiety symptoms and to test the moderating role of depressive and anxiety symptoms in the relations between objective and subjective sleep. The sample included 148 pregnant women. Objective sleep was measured by actigraphy for five nights at the participants' home, and subjective sleep was measured with the Pittsburgh sleep quality index. Depressive symptoms were assessed with the Edinburgh postnatal depression scale and anxiety symptoms with the Beck anxiety inventory. Significant associations were found between the subjective sleep measures and the depressive and anxiety scores, but there were no significant associations between actigraphic sleep measures and the depressive and anxiety scores. Depressive and anxiety scores emerged as significant moderators of the links between objective and subjective sleep. The findings suggest that emotional distress (i.e., depressive and anxiety symptoms severity) during pregnancy is associated with subjective sleep disturbances but not with objective sleep disturbances. Importantly, only among women with higher levels of emotional distress was subjective sleep quality associated with objective sleep quality. These findings may suggest that women with higher levels of emotional distress are not necessarily biased in their perception of sleep quality. However, they may perceive fragmented sleep as more detrimental to their wellbeing.

    View details for DOI 10.1007/s00737-015-0554-8

    View details for PubMedID 26250541

  • Effects of Cognitive Behavioral Therapy for Insomnia on Suicidal Ideation in Veterans SLEEP Trockel, M., Karlin, B. E., Taylor, C. B., Brown, G. K., Manber, R. 2015; 38 (2): 259-265


    To examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on suicidal ideation among Veterans with insomnia.Longitudinal data collected in the course of an uncontrolled evaluation of a large-scale CBT-I training program.Outpatient and residential treatment facilities.Four hundred five Veterans presenting for treatment of insomnia.Cognitive behavioral therapy for insomnia (CBT-I).At baseline, 32% of patients, compared with 21% at final assessment, endorsed some level of suicidal ideation [χ(2)(df = 1) = 125; P < 0.001]. After adjusting for demographic variables and baseline insomnia severity, each 7-point decrease in Insomnia Severity Index (ISI) score achieved during CBT-I treatment was associated with a 65% (OR = 0.35; 95% CI = 0.24 to 0.52) reduction in odds of suicidal ideation. The effect of change in insomnia severity on change in depression severity was also significant. After controlling for change in depression severity and other variables in the model, the effect of change in insomnia severity on change in suicidal ideation remained significant.This evaluation of the largest dissemination of CBT-I in the United States found a clinically meaningful reduction in suicidal ideation among Veterans receiving CBT-I. The mechanisms by which effective treatment of insomnia with CBT-I reduces suicide risk are unknown and warrant investigation. The current results may have significant public health implications for preventing suicide among Veterans.

    View details for DOI 10.5665/sleep.4410

    View details for Web of Science ID 000348757800014

    View details for PubMedID 25515115

  • A Randomized Controlled Trial of Mindfulness Meditation for Chronic Insomnia SLEEP Ong, J. C., Manber, R., Segal, Z., Xia, Y., Shapiro, S., Wyatt, J. K. 2014; 37 (9): 1553-U186


    To evaluate the efficacy of mindfulness meditation for the treatment of chronic insomnia.Three-arm, single-site, randomized controlled trial.Academic medical center.Fifty-four adults with chronic insomnia.Participants were randomized to either mindfulness-based stress reduction (MBSR), mindfulness-based therapy for insomnia (MBTI), or an eight-week self-monitoring (SM) condition.Patient-reported outcome measures were total wake time (TWT) from sleep diaries, the pre-sleep arousal scale (PSAS), measuring a prominent waking correlate of insomnia, and the Insomnia Severity Index (ISI) to determine remission and response as clinical endpoints. Objective sleep measures were derived from laboratory polysomnography and wrist actigraphy. Linear mixed models showed that those receiving a meditation-based intervention (MBSR or MBTI) had significantly greater reductions on TWT minutes (43.75 vs 1.09), PSAS (7.13 vs 0.16), and ISI (4.56 vs 0.06) from baseline-to-post compared to SM. Post hoc analyses revealed that each intervention was superior to SM on each of the patient-reported measures, but no significant differences were found when comparing MBSR to MBTI from baseline-to-post. From baseline to 6-month follow-up, MBTI had greater reductions in ISI scores than MBSR (P < 0.05), with the largest difference occurring at the 3-month follow-up. Remission and response rates in MBTI and MBSR were sustained from post-treatment through follow-up, with MBTI showing the highest rates of treatment remission (50%) and response (78.6%) at the 6-month follow-up.Mindfulness meditation appears to be a viable treatment option for adults with chronic insomnia and could provide an alternative to traditional treatments for insomnia.Mindfulness-Based Approaches to Insomnia:, identifier: NCT00768781.

    View details for DOI 10.5665/sleep.4010

    View details for Web of Science ID 000341512900017

    View details for PubMedID 25142566

  • National Dissemination of Cognitive Behavioral Therapy for Insomnia in Veterans: Therapist- and Patient-Level Outcomes JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Karlin, B. E., Trockel, M., Taylor, C. B., Gimeno, J., Manber, R. 2013; 81 (5): 912-917


    Objective: To evaluate the effects of national training in and implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I) in the U.S. Department of Veterans Affairs (VA) health care system on clinicians' competency and patients' insomnia severity, symptoms of depression, and quality of life. Method: A prospective cohort of 102 VA clinicians (including mental health staff in various mental health and primary care settings) participated in the VA CBT-I Training Program during 2011 and 2012. Patients included 182 veterans treated by clinicians enrolled in the training. Clinicians were rated on taped therapy sessions, using a standardized competency rating form. Patients' symptoms were assessed using the Insomnia Severity Index (ISI) and standardized measures of depression and quality of life. Results: Of 102 clinicians attending workshop training, 94 (92%) met all training requirements, including minimum competency score criteria. Of 182 patients, 122 (67%) completed treatment. The mixed effects model revealed significant reductions in average patient ISI score (from 19.9 to 10.2, standard error = 3.0). Patients also improved on measures of depression and quality of life. Conclusion: National training in and implementation of CBT-I resulted in a significant increase in therapist competency to deliver CBT-I for almost all clinicians and in a large reduction in insomnia severity and improvement in depression and quality of life among veterans. Observed effect sizes are comparable to results of randomized clinical trials. These results suggest CBT-I can be feasibly and effectively disseminated to routine clinical settings, with very favorable patient outcomes. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

    View details for DOI 10.1037/a0032554

    View details for Web of Science ID 000324780500017

    View details for PubMedID 23586730

  • Factors Associated with Clinically Significant Insomnia Among Pregnant Low-Income Latinas JOURNAL OF WOMENS HEALTH Manber, R., Steidtmann, D., Chambers, A. S., Ganger, W., Horwitz, S., Connelly, C. D. 2013; 22 (8): 694-701


    Abstract Background: Poor sleep, common during pregnancy, is associated with negative health risks. The study aimed to identify predictors of clinically significant insomnia among pregnant Latinas. Methods: A total of 1289 pregnant Latinas recruited from obstetric clinics completed the Insomnia Severity Index (ISI) and questions about demographics and sleep. Results: Clinically significant insomnia (ISI≥10) was present among 17% of participants. Significant correlates of clinically significant insomnia were higher scores on the Edinburgh Postnatal Depression Scale (EPDS) after removing the sleep item (47% of women with EPDS≥9 and 9% with EPDS<9), completing measures in English (rather than Spanish: 26% versus 13%), and income but not pregnancy week, age, highest education level, or marital status. The highest percentage of clinically significant insomnia (59%) was experienced by women with EPDS≥9 who completed measures in English. The lowest percentage of clinically significant insomnia (6.2%) was experienced by women with EPDS<9 who completed measures in Spanish. Conclusions: In this sample of low-income, mostly Spanish-speaking pregnant Latinas, rates of clinically significant insomnia appear to be higher than rates among nonpregnant Latinas. Rates of clinically significant insomnia are particularly high among Latinas with elevated depressive symptom severity, a known risk for insomnia. Acculturation, as indicated by completing measures in English, may be another risk specific to Latinas, possibly owing to loss of some ethnicity-specific protective factors (e.g., social support, strong family ties, and group identity). It will be important to directly test this explanation in future research.

    View details for DOI 10.1089/jwh.2012.4039

    View details for Web of Science ID 000322774400008

    View details for PubMedID 23863074

  • Improving sleep with mindfulness and acceptance: A metacognitive model of insomnia BEHAVIOUR RESEARCH AND THERAPY Ong, J. C., Ulmer, C. S., Manber, R. 2012; 50 (11): 651-660


    While there is an accumulating evidence to suggest that therapies using mindfulness and acceptance-based approaches have benefits for improving the symptoms of insomnia, it is unclear how these treatments work. The goal of this paper is to present a conceptual framework for the cognitive mechanisms of insomnia based upon mindfulness and acceptance approaches. The existing cognitive and behavioral models of insomnia are first reviewed and a two-level model of cognitive (primary) and metacognitive (secondary) arousal is presented in the context of insomnia. We then focus on the role of metacognition in mindfulness and acceptance-based therapies, followed by a review of these therapies in the treatment of insomnia. A conceptual framework is presented detailing the mechanisms of metacognition in the context of insomnia treatments. This model proposes that increasing awareness of the mental and physical states that are present when experiencing insomnia symptoms and then learning how to shift mental processes can promote an adaptive stance to one's response to these symptoms. These metacognitive processes are characterized by balanced appraisals, cognitive flexibility, equanimity, and commitment to values and are posited to reduce sleep-related arousal, leading to remission from insomnia. We hope that this model will further the understanding and impact of mindfulness and acceptance-based approaches to insomnia.

    View details for DOI 10.1016/j.brat.2012.08.001

    View details for Web of Science ID 000311178800001

    View details for PubMedID 22975073

  • PATIENT TREATMENT PREFERENCE AS A PREDICTOR OF RESPONSE AND ATTRITION IN TREATMENT FOR CHRONIC DEPRESSION DEPRESSION AND ANXIETY Steidtmann, D., Manber, R., Arnow, B. A., Klein, D. N., Markowitz, J. C., Rothbaum, B. O., Thase, M. E., Kocsis, J. H. 2012; 29 (10): 896-905


    Findings regarding the relationship between patient treatment preference and treatment outcome are mixed. This is a secondary data analysis investigating the relationship between treatment preference, and symptom outcome and attrition in a large two-phase depression treatment trial.Patients met DSM-IV criteria for chronic forms of depression. Phase I was a 12-week, nonrandomized, open-label trial in which all participants (n = 785) received antidepressant medication(s) (ADM). Phase I nonremitters were randomized to Phase II, in which they received 12 weeks of either cognitive-behavioral system of psychotherapy (CBASP) + ADM (n = 193), brief supportive psychotherapy (BSP) + ADM (n = 187), or ADM only (n = 93). Participants indicated their treatment preference (medication only, combined treatment or no preference) at study entry. Symptoms were measured at 2-week intervals with the 24-item Hamilton Rating Scale for Depression (HAM-D).A large majority of patients reported a preference for combined treatment. Patients who preferred medication only were more likely to endorse a chemical imbalance explanation for depression, whereas those desiring combined treatment were more likely to attribute their depression to stressful experiences. In Phase I, patients who expressed no treatment preference showed greater rates of HAM-D symptom reduction than those with any preference, and patients with a preference for medication showed higher attrition than those preferring combined treatment. In Phase II, baseline treatment preference was not associated with symptom reduction or attrition.Treatment preferences may moderate treatment response and attrition in unexpected ways. Research identifying factors associated with differing preferences may enable improved treatment retention and response.

    View details for DOI 10.1002/da.21977

    View details for Web of Science ID 000309394600009

    View details for PubMedID 22767424

  • Dissemination of CBTI to the Non-Sleep Specialist: Protocol Development and Training Issues JOURNAL OF CLINICAL SLEEP MEDICINE Manber, R., Carney, C., Edinger, J., Epstein, D., Friedman, L., Haynes, P. L., Karlin, B. E., Pigeon, W., Siebern, A. T., Trockel, M. 2012; 8 (2): 209-218


    Strong evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI). A significant barrier to wide dissemination of CBTI is the lack of qualified practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and flexibility of the treatment protocol. We developed a case conceptualization-driven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.

    View details for DOI 10.5664/jcsm.1786

    View details for Web of Science ID 000302862200017

    View details for PubMedID 22505869

  • An e-mail delivered CBT for sleep-health program for college students: effects on sleep quality and depression symptoms. Journal of clinical sleep medicine Trockel, M., Manber, R., Chang, V., Thurston, A., Taylor, C. B. 2011; 7 (3): 276-281


    We examined the effects of a cognitive behavioral self-help program (Refresh) to improve sleep, on sleep quality and symptoms of depression among first-year college students.Students in one residence hall (n = 48) participated in Refresh and students in another residence hall (n = 53) participated in a program of equal length (Breathe) designed to improve mood and increase resilience to stress. Both programs were delivered by e-mail in 8 weekly PDF files. Of these, 19 Refresh program participants and 15 Breathe program participants reported poor sleep quality at baseline (scores ≥ 5 on the Pittsburgh Sleep Quality Index [PSQI]). Participants completed the PSQI and the Center for Epidemiological Studies-Depression Scale (CES-D) at baseline and post-intervention.Among students with poor sleep (PSQI > 5) at baseline, participation in Refresh was associated with greater improvements in sleep quality and greater reduction in depressive symptoms than participation in Breathe. Among students with high sleep quality at baseline there was no difference in baseline to post-intervention changes in sleep (PSQI) or depressive symptom severity (CES-D).A cognitive behavioral sleep improvement program delivered by e-mail may be a cost effective way for students with poor sleep quality to improve their sleep and reduce depressive symptoms. An important remaining question is whether improving sleep will also reduce risk for future depression.

    View details for DOI 10.5664/JCSM.1072

    View details for PubMedID 21677898

  • CBT for Insomnia in Patients with High and Low Depressive Symptom Severity: Adherence and Clinical Outcomes JOURNAL OF CLINICAL SLEEP MEDICINE Manber, R., Bernert, R. A., Suh, S., Nowakowski, S., Siebern, A. T., Ong, J. C. 2011; 7 (6): 645-652


    To evaluate whether depressive symptom severity leads to poorer response and perceived adherence to cognitive behavioral therapy for insomnia (CBTI) and to examine the impact of CBTI on well-being, depressive symptom severity, and suicidal ideation.Pre- to posttreatment case replication series comparing low depression (LowDep) and high depression (HiDep) groups (based on a cutoff of 14 on the Beck Depression Inventory [BDI]).127 men and 174 women referred for the treatment of insomnia.Seven sessions of group CBTI.Improvement in the insomnia severity, perceived energy, productivity, self-esteem, other aspects of wellbeing, and overall treatment satisfaction did not differ between the HiDep and LowDep groups (p > 0.14). HiDep patients reported lower adherence to a fixed rise time, restricting time in bed, and changing expectations about sleep (p < 0.05). HiDep participants experienced significant reductions in BDI, after removing the sleep item. Levels of suicidal ideation dropped significantly among patients with pretreatment elevations (p < 0.0001).Results suggest that pre- to post CBTI improvements in insomnia symptoms, perceived energy, productivity, self-esteem, and other aspects of well-being were similar among patients with and without elevation in depressive symptom severity. Thus, the benefits of CBTI extend beyond insomnia and include improvements in non-sleep outcomes, such as overall well-being and depressive symptom severity, including suicidal ideation, among patients with baseline elevations. Results identify aspects of CBTI that may merit additional attention to further improve outcomes among patients with insomnia and elevated depressive symptom severity.

    View details for DOI 10.5664/jcsm.1472

    View details for Web of Science ID 000300161900012

    View details for PubMedID 22171204

  • An E-mail Delivered CBT for Sleep-Health Program for College Students: Effects on Sleep Quality and Depression Symptoms JOURNAL OF CLINICAL SLEEP MEDICINE Trockel, M., Manber, R., Chang, V., Thurston, A., Taylor, C. B. 2011; 7 (3): 273-278

    View details for DOI 10.5664/JCSM.1072

    View details for Web of Science ID 000292923600024

  • Maternal sleep and depressive symptoms Links with infant Negative Affectivity INFANT BEHAVIOR & DEVELOPMENT Tikotzky, L., Chambers, A. S., Gaylor, E., Manber, R. 2010; 33 (4): 605-612


    This study assessed whether elevated severities of maternal depression and disturbed maternal sleep would be associated with maternal perceptions of higher Negative Affectivity of her infant. Sixty-nine mothers participated in this study. The study was part of a larger randomized controlled study testing the efficacy of acupuncture as a treatment for depression during pregnancy. The present study focused on data collected at 6 months postpartum in a naturalistic follow-up design, using the Hamilton Rating Scale for Depression (HRSD), maternal sleep diaries (completed daily for 1 week), and the Infant Behavior Questionnaire-Revised (IBQ-R). Regression analyses revealed that (a) maternal depression severity was a significant predictor of the IBQ-R Distress and Falling Reactivity scales and (b) poor maternal sleep was a significant predictor of the IBQ-R Sadness scale. Our findings support previous findings of significant links between maternal emotional distress and perceived Negative Affectivity of her infant's temperament and provide a novel insight linking maternal poor sleep with perceived sadness of the infant.

    View details for Web of Science ID 000285857000024

    View details for PubMedID 20723998

  • Acupuncture for Depression During Pregnancy A Randomized Controlled Trial OBSTETRICS AND GYNECOLOGY Manber, R., Schnyer, R. N., Lyell, D., Chambers, A. S., Caughey, A. B., Druzin, M., Carlyle, E., Celio, C., Gress, J. L., Huang, M. I., Kalista, T., Martin-Okada, R., Allen, J. J. 2010; 115 (3): 511-520


    To estimate the efficacy of acupuncture for depression during pregnancy in a randomized controlled trial.A total of 150 pregnant women who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for major depressive disorder were randomized to receive either acupuncture specific for depression or one of two active controls: control acupuncture or massage. Treatments lasted 8 weeks (12 sessions). Junior acupuncturists, who were not told about treatment assignment, needled participants at points prescribed by senior acupuncturists. All treatments were standardized. The primary outcome was the Hamilton Rating Scale for Depression, administered by masked raters at baseline and after 4 and 8 weeks of treatment. Continuous data were analyzed using mixed effects models and by intent to treat.Fifty-two women were randomized to acupuncture specific for depression, 49 to control acupuncture, and 49 to massage. Women who received acupuncture specific for depression experienced a greater rate of decrease in symptom severity (P<.05) compared with the combined controls (Cohen's d=0.39, 95% confidence interval [CI] 0.01-0.77) or control acupuncture alone (P<.05; Cohen's d=0.46, 95% CI 0.01-0.92). They also had significantly greater response rate (63.0%) than the combined controls (44.3%; P<.05; number needed to treat, 5.3; 95% CI 2.8-75.0) and control acupuncture alone (37.5%; P<.05: number needed to treat, 3.9; 95% CI 2.2-19.8). Symptom reduction and response rates did not differ significantly between controls (control acupuncture, 37.5%; massage, 50.0%).The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during,, NCT00186654.

    View details for DOI 10.1097/AOG.0b013e3181cc0816

    View details for Web of Science ID 000275132300006

    View details for PubMedID 20177281

  • Maternal subjective sleep quality and nighttime infant care JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY Gress, J. L., Chambers, A. S., Ong, J. C., Tikotzky, L., Okada, R. L., Manber, R. 2010; 28 (4): 384-391
  • Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Manber, R., Kraemer, H. C., Arnow, B. A., Thase, M. E., Klein, D. N., Gelenberg, A. J., Trivedi, M. H., Rush, A. J., Rothbaum, B. O., Kocsis, J. H., Keller, M. E. 2008; 76 (3): 459-467


    The main aim of the present novel reanalysis of archival data was to compare the time to remission during 12 weeks of treatment of chronic depression following antidepressant medication (n = 218), psychotherapy (n = 216), and their combination (n = 222). Cox regression survival analyses revealed that the combination of medication and psychotherapy produced full remission from chronic depression more rapidly than either of the single modality treatments, which did not differ from each other. Receiver operating characteristic curve analysis was used to explore predictors (treatment group, demographic, clinical, and psychosocial) of remission. For those receiving the combination treatment, the most likely to succeed were those with low baseline depression (24-item Hamilton Rating Scale for Depression [HRSD; M. Hamilton, 1967] score < 26) and those with high depression scores but low anxiety (HRSD = 26 and Hamilton Anxiety Rating Scale [M. Hamilton, 1959] < 14). Both profiles were associated with at least 40% chance of attaining full remission. The model did not identify predictors for those receiving medication or psychotherapy alone, and it did not distinguish between the 2 monotherapies. The authors conclude that combined antidepressant medications and psychotherapy result in faster full remission of chronic forms of major depressive disorder.

    View details for DOI 10.1037/0022-006X.76.3.459

    View details for Web of Science ID 000256326700010

    View details for PubMedID 18540739

  • Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia SLEEP Manber, R., Edinger, J. D., Gress, J. L., Pedro-Salcedo, M. G., Kuo, T. F., Kalista, T. 2008; 31 (4): 489-495


    Insomnia impacts the course of major depressive disorder (MDD), hinders response to treatment, and increases risk for depressive relapse. This study is an initial evaluation of adding cognitive behavioral therapy for insomnia (CBTI) to the antidepressant medication escitalopram (EsCIT) in individuals with both disorders.A randomized, controlled, pilot study in a single academic medical center.30 individuals (61% female, mean age 35 +/- 18) with MDD and insomnia.EsCIT and 7 individual therapy sessions of CBTI or CTRL (quasi-desensitization). Measurements and results: Depression was assessed with the HRSD17 and the depression portion of the SCID, administered by raters masked to treatment assignment, at baseline and after 2, 4, 6, 8, and 12 weeks of treatment. The primary outcome was remission of MDD at study exit, which required both an HRSD17 score < or =7 and absence of the 2 core symptoms of MDD. Sleep was assessed with the insomnia severity index (ISI), daily sleep diaries, and actigraphy. EsCIT + CBTI resulted in a higher rate of remission of depression (61.5%) than EsCIT + CTRL (33.3%). EsCIT + CBTI was also associated with a greater remission from insomnia (50.0%) than EsCIT + CTRL (7.7%) and larger improvement in all diary and actigraphy measures of sleep, except for total sleep time.This pilot study provides evidence that augmenting an antidepressant medication with a brief, symptom focused, cognitive-behavioral therapy for insomnia is promising for individuals with MDD and comorbid insomnia in terms of alleviating both depression and insomnia.

    View details for Web of Science ID 000254936400008

    View details for PubMedID 18457236

  • Depression symptoms during pregnancy ARCHIVES OF WOMENS MENTAL HEALTH Manber, R., Blasey, C., Allen, J. J. 2008; 11 (1): 43-48


    Pregnancy impacts common symptoms of major depressive disorder (MDD), such as energy, appetite, weight change, and sleep and somatic complaints. However, it is not known whether the presentation of depression during pregnancy is different from that at other times in women's lives. This study compares the severity of symptoms of depression in 61 pregnant women with MDD (PD), 50 nonpregnant women with MDD (D), and 41 pregnant women without MDD (P). Despite equivalent overall depression severity, PD women had lower scores on suicidality, guilt, and early insomnia and higher scores on psychomotor retardation than D women. The severity of other depressive symptoms was similar in the two depressed groups. As expected on the basis of the selection criteria, overall depression severity and the severity of individual symptoms were significantly higher in the PD group than in the P group but effect sizes for somatic symptoms were smaller than for psychological symptoms. The results suggest that the profile of depression symptoms of women with MDD who are pregnant does not differ much from that of depressed nonpregnant women. Depressive symptoms, particularly psychological symptoms of depression, during pregnancy should be taken seriously and not be dismissed as a normal part of the pregnancy experience.

    View details for DOI 10.1007/s00737-008-0216-1

    View details for Web of Science ID 000253695000006

    View details for PubMedID 18270654

  • Characteristics of insomniacs with self-reported morning and evening chronotypes. Journal of clinical sleep medicine Ong, J. C., Huang, J. S., Kuo, T. F., Manber, R. 2007; 3 (3): 289-294


    This study examines the relevance of self-reported morning and evening chronotypes in treatment-seeking insomniacs presenting to a tertiary sleep clinic setting.Using a cross-sectional design, patients were categorized as morning, intermediate, and evening chronotypes based upon scores on the Morningness-Eveningness Composite Scale (MECS). Group comparisons were made on self-report measures of nocturnal sleep, sleep period variability, and waking correlates and consequences of insomnia.Sleep disorders clinicThe sample consisted of 312 patients who presented to a group cognitive-behavior therapy for insomnia (CBT-I) at the sleep clinic.Participants completed the MECS, Beck Depression Inventory (BDI), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), and one week of sleep diary prior to treatment. Even after adjusting for total wake time as an index of insomnia severity, differences between the three chronotypes were present on several measures. Compared to the morning and intermediate types, evening types reported more total sleep time, more time in bed, greater variability in the time out of bed, and higher levels of distress on the DBAS and BDI.These results indicate that insomniacs presenting to a sleep specialist who endorse an evening chronotype report sleep/wake irregularities and waking distress greater than expected in association with the level of insomnia severity. These factors may serve to perpetuate the insomnia disorder and might be particularly important to consider when treating this subgroup of insomniacs.

    View details for PubMedID 17561599

  • Assessing insomnia severity in depression: comparison of depression rating scales and sleep diaries JOURNAL OF PSYCHIATRIC RESEARCH Manber, R., Blasey, C., Arnow, B., Markowitz, J. C., Thase, M. E., Rush, A. J., Dowling, F., Koscis, J., Trivedi, M., Keller, M. B. 2005; 39 (5): 481-488


    Depression and sleep researchers typically assess insomnia severity differently. Whereas depression researchers usually assess insomnia with items on depression symptom inventories, sleep researchers usually assess the subjective experience of insomnia with sleep diaries. The present manuscript utilizes baseline data from 397 participants in a large multi-site chronic depression study to assess agreement between these two methodologies. The results indicate that the early, middle, and late insomnia items of the Hamilton Rating Scale for Depression (HRSD(24)) and the Inventory of Depression Symptoms - Self Report (IDS-SR(30)) are highly correlated with the weekly mean values of time to sleep onset, time awake after sleep onset, and time awake prior to the planned wake-up obtained from prospective sleep diaries. Results also reveal significant correspondence between the weekly-mean of daily sleep efficiency, an accepted measure of sleep continuity (the ratio between reported time asleep and time in bed), and the insomnia scale scores of the HRSD(24) and the IDS-SR(30) (the mean score on the three insomnia items of each depression measure). Unit increments in HRSD(24) scores for early, middle and late insomnia were associated with significant increases in unwanted minutes awake for corresponding periods on sleep diaries. Similar relationships were found for early insomnia on the IDS-SR(30) but not for middle and late insomnia. Overall, with few exceptions, findings revealed substantial agreement between the HRSD(24), IDS-SR(30) and prospective sleep diary data. The study supports the validity of the sleep items and sleep subscales of the HRSD(24) and the IDS-SR(30) as global measures of insomnia severity in depression. Conventional sleep assessment procedures can complement depression scales by providing additional information about specific aspects of sleep in depression.

    View details for DOI 10.1016/j.jpsychires.2004.12.003

    View details for Web of Science ID 000231579300005

    View details for PubMedID 15992557

  • Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders CLINICAL PSYCHOLOGY REVIEW Smith, M. T., Huang, M. I., Manber, R. 2005; 25 (5): 559-611


    Insomnia is a pervasive problem for many patients suffering from medical and psychiatric conditions. Even when the comorbid disorders are successfully treated, insomnia often fails to remit. In addition to compromising quality of life, untreated insomnia may also aggravate and complicate recovery from the comorbid disease. Cognitive behavior therapy for insomnia (CBT-I) has an established efficacy for primary insomnia, but less is known about its efficacy for insomnia occurring in the context of medical and psychiatric conditions. The purpose of this article is to present a rationale for using CBT-I in medical and psychiatric disorders, review the extant outcome literature, highlight considerations for adapting CBT-I procedures in specific populations, and suggest directions for future research. Outcome studies were identified for CBT-I in mixed medical and psychiatric conditions, cancer, chronic pain, HIV, depression, posttraumatic stress disorder, and alcoholism. Other disorders discussed include: bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder. The available data demonstrate moderate to large treatment effects (Cohen's d, range=0.35-2.2) and indicate that CBT-I is a promising treatment for individuals with medical and psychiatric comorbidity. Although the literature reviewed here is limited by a paucity of randomized, controlled studies, the available data suggest that by improving sleep, CBT-I might also indirectly improve medical and psychological endpoints. This review underscores the need for future research to test the efficacy of adaptations of CBT-I to disease specific conditions and symptoms.

    View details for DOI 10.1016/j.cpr.2005.04.004

    View details for Web of Science ID 000230812200003

    View details for PubMedID 15970367

  • Acupuncture: a promising treatment for depression during JOURNAL OF AFFECTIVE DISORDERS Manber, R., Schnyer, R. N., Allen, J. J., Rush, A. J., Blasey, C. M. 2004; 83 (1): 89-95


    Few medically acceptable treatments for depression during pregnancy are available. The aim of this randomized controlled pilot study was to determine whether acupuncture holds promise as a treatment for depression during pregnancy.Sixty-one pregnant women with major depressive disorder and a 17-item Hamilton Rating Scale for Depression (HRSD17) score >or=14 were randomly assigned to one of three treatments, delivered over 8 weeks: an active acupuncture (SPEC, N=20), an active control acupuncture (NSPEC, N=21), and massage (MSSG, N=20). Acupuncture treatments were standardized, but individually tailored, and were provided in a double-blind fashion. Responders to acute phase treatment (HRSD17 score<14 and >or=50% reduction from baseline) continued the treatment they were initially randomized to until 10 weeks postpartum.Response rates at the end of the acute phase were statistically significantly higher for SPEC (69%) than for MSSG (32%), with an intermediate NSPEC response rate (47%). The SPEC group also exhibited a significantly higher average rate of reduction in BDI scores from baseline to the end of the first month of treatment than the MSSG group. Responders to the acute phase of all treatments combined had significantly lower depression scores at 10 weeks postpartum than nonresponders.Generalizability is limited by the small sample and its relative homogeneity.Acupuncture holds promise for the treatment of depression during pregnancy.

    View details for DOI 10.1016/j.jad.2004.05.009

    View details for Web of Science ID 000225913900012

    View details for PubMedID 15546651

  • Patients' perception of their depressive illness JOURNAL OF PSYCHIATRIC RESEARCH Manber, R., Chambers, A. S., Hitt, S. K., McGahuey, C., Delgado, P., Allen, J. J. 2003; 37 (4): 335-343


    Perception of illness has been described as an important predictor in the medical health psychology literature, but has been given little attention in the domain of mental disorders. The patient's Perception of Depression Questionnaire (PDIQ) is a newly developed measure whose factor structure and psychometric properties were evaluated on a sample of 174 outpatients meeting criteria for major depressive disorder. The clinical utility of the questionnaire was assessed on a sub-sample of 121 participants in a study of acupuncture treatment for depression. The questionnaire has four subscales, each with high internal consistency and high test-retest reliability. These four subscales are: Self-Efficacy, which reflects perceived controllability of the illness, Externalizing, which reflects attributing the illness to external causes, Hopeless/Flawed, which reflect a belief that depression is a personal trait and therefore there is little hope for cure, and Holistic, which reflects a belief in alternative therapies. Although the PDIQ did not predict outcome, its subscales were related to adherence to treatment, treatment preference, expectations, and therapeutic alliance. The subscales have adequate convergent/discriminant validity and are clinically relevant to aspects of treatment provision.

    View details for DOI 10.1016/S0022-3956(03)00019-0

    View details for Web of Science ID 000183215100008

    View details for PubMedID 12765856

  • Patient's therapeutic skill acquisition and response to psychotherapy, alone or in combination with medication PSYCHOLOGICAL MEDICINE Manber, R., Arnow, B., Blasey, C., Vivian, D., McCullough, J. P., Blalock, J. A., Klein, D. N., Markowitz, J. C., Riso, L. P., Rothbaum, B., Rush, A. J., Thase, M. E., Keller, M. B. 2003; 33 (4): 693-702


    We tested the hypotheses that the addition of medication to psychotherapy enhances participation in the latter by: (1) speeding the acquisition of the psychotherapy's targeted skill; and (2) facilitating higher skill level acquisition.Participants were 431 chronically depressed patients who received Cognitive Behavioral Analysis System of Psychotherapy (CBASP), alone (N=214) or in combination with nefazodone (N=217), as part of a randomized chronic depression study (Keller et al. 2000). CBASP, developed specifically to treat chronic depression, uses a specific procedure, 'situational analysis' to help patients engage in more effective goal-oriented interpersonal behaviours. At the end of each session, therapists rated patients on their performance of situational analysis. Outcome on depressive symptoms was assessed with the 24-item Hamilton Rating Scale for Depression.Although reductions in depression were significantly greater in combined treatment compared to CBASP alone, there were no between-group differences in either the rate of skill acquisition or overall skill level at the end of treatment. Proficiency in the use of the main skill taught in psychotherapy at treatment midpoint predicted outcome independently of medication status and of baseline depressive severity.Effective participation in CBASP, as reflected by proficiency in the compensatory skill taught in psychotherapy, is not enhanced by the addition of medication and does not mediate the between-group difference in depression outcome.

    View details for DOI 10.1017/S0033291703007608

    View details for Web of Science ID 000183495600013

    View details for PubMedID 12785471

  • Side Effects to Antidepressant Treatment in Patients With Depression and Comorbid Panic Disorder. journal of clinical psychiatry Shankman, S. A., Gorka, S. M., Katz, A. C., Klein, D. N., Markowitz, J. C., Arnow, B. A., Manber, R., Rothbaum, B. O., Thase, M. E., Schatzberg, A. F., Keller, M. B., Trivedi, M. H., Kocsis, J. H. 2017


    Side effects to antidepressant medication can affect the efficacy of treatment, but few predictors foretell who experiences side effects and which side effects they experience. This secondary data analysis examined whether depressed patients with comorbid panic disorder were more likely to experience side effects than those without panic disorder. The study also examined whether greater burden of side effects predicted a poorer treatment course for patients with panic disorder than those without panic disorder. To examine the specificity of these effects, analyses also examined 2 other anxiety disorders-social phobia and generalized anxiety disorder (GAD).Between 2002 and 2006, a large sample (N = 808) of chronically depressed individuals (assessed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders [SCID-IV]) received antidepressants according to a predetermined algorithm for 12 weeks. Every 2 weeks, depressive symptoms (per the Hamilton Depression Rating Scale) and side effects (specific side effects as well as several indicators of side effect burden) were assessed.Lifetime diagnosis of panic disorder (assessed using the SCID-IV) at baseline was associated with higher likelihood of gastrointestinal (OR = 1.6 [95% CI, 1.0-2.6]), cardiac (OR = 1.8 [95% CI, 1.1-3.1]), neurologic (OR = 2.6 [95% CI, 1.6-4.2]), and genitourinary side effects (OR = 3.0 [95% CI, 1.7-5.3]) during treatment. Increases in side effect frequency, intensity, and impairment over time were more strongly associated with increases in depressive symptoms for patients with panic disorder compared to those without panic disorder. Neither social phobia nor GAD was associated with these effects.Potentially due to heighte​ned interoceptive awareness of changes in their body, chronically depressed individuals with panic disorder may be at greater risk than those without panic disorder for antidepressant side effects and to experience a worsening of depressive symptoms as a result of these side effects over identifier: NCT00057551​.

    View details for DOI 10.4088/JCP.15m10370

    View details for PubMedID 28068460

  • Change in Patients' Interpersonal Impacts as a Mediator of the Alliance-Outcome Association in Treatment for Chronic Depression JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Constantino, M. J., Laws, H. B., Coyne, A. E., Greenberg, R. P., Klein, D. N., Manber, R., Rothbaum, B. O., Arnow, B. A. 2016; 84 (12): 1135-1144


    Theories posit that chronically depressed individuals have hostile and submissive interpersonal styles that undermine their interpersonal effectiveness and contribute to the cause and maintenance of their depression. Recent findings support this theory and demonstrate that chronically depressed patients' interpersonal impacts on their therapist become more adaptive (i.e., less hostile and submissive, and more friendly and assertive) during a targeted chronic depression treatment: cognitive-behavioral analysis system of psychotherapy (CBASP). In this study, the authors examined whether such changes in interpersonal impacts (as rated by clinicians' experiences of interacting with their patients) mediated the association between early patient-rated alliance quality and final session depression.Data derived from a large trial for chronic depression that compared the efficacy of CBASP, nefazodone, and their combination. The current subsample (N = 220) included patients in the CBASP and combined conditions who completed at least 1 depression assessment and the alliance measure, and whose therapists completed at least 1 interpersonal impacts assessment. Mediation models were fit using a bootstrapping procedure for assessing indirect effects.As hypothesized, results supported a mediating effect; higher early alliance predicted decreases in patient hostile-submissiveness during therapy, which in turn related to lower final session depression (indirect effect B = -.02, 95% confidence interval: -.07, -.001). This indirect effect accounted for 13% of the total effect of alliance on depression. There was no moderating effect of treatment condition on the indirect effect.Results further support CBASP change theory and suggest a candidate mechanism of the alliance's effect on outcome. (PsycINFO Database Record

    View details for DOI 10.1037/ccp0000149

    View details for Web of Science ID 000389304500010

    View details for PubMedID 27748609

  • 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. Journal of clinical sleep medicine Edinger, J. D., Manber, R., Buysse, D. J., Krystal, A. D., Thase, M. E., Gehrman, P., Fairholme, C. P., Luther, J., Wisniewski, S. 2016


    To determine if patients with childhood onsets (CO) of both major depression and insomnia disorder show blunted depression and insomnia treatment responses to concurrent interventions for both disorders compared to those with adult onsets (AO) of both conditions.A secondary analysis of data obtained from a multisite randomized clinical trial designed to test the efficacy of combining a psychological/behavior insomnia therapy with antidepressant medication to enhance depression treatment outcomes in patients with comorbid major depression and insomnia.27 adults with CO of depression and insomnia and 77 adults with AO of both conditions.A 16-week treatment including: (1) a standardized two-step pharmacotherapy for depression algorithm, consisting of escitalopram, sertraline, and desvenlafaxine in a prescribed sequence; and (2) either cognitive behavioral insomnia therapy (CBT-I) or a quasi-desensitization control (CTRL) therapy.The 17-item Hamilton Rating Scale for Depression (HRSD-17) and the Insomnia Severity Index (ISI) completed pre-treatment and every 2 weeks thereafter.The AO and CO groups did not differ significantly in regard to their pre-treatment HRSD-17 and ISI scores. Mixed model analyses that adjusted for the number of insomnia treatment sessions attended showed that the AO group achieved significantly lower, subclinical scores on the HRSD-17 and ISI than did the CO group by the time of study exit. Moreover, a significant group by treatment arm interaction suggested that HRSD-17 scores at study exit remained significantly higher in the CO group receiving the CTRL therapy than was the case for the participants in the CO group receiving CBT-I. Greater proportions of the AO group achieved a priori criteria for remission of insomnia (49.3% vs. 29.2%, p = 0.04) and depression (45.5% vs. 29.6%, p = 0.07) than did those in the CO group.Patients with comorbid depression and insomnia who experienced the first onset of both disorders in childhood are less responsive to the treatments offered herein than are those with adult onsets of these comorbid disorders. Further research is needed to identify therapies that enhance the depression and insomnia treatment responses of those with childhood onsets of these two conditions.

    View details for PubMedID 27784414

  • Efficacy of Cognitive-Behavioral Therapy for Insomnia Combined With Antidepressant Pharmacotherapy in Patients With Comorbid Depression and Insomnia: A Randomized Controlled Trial. journal of clinical psychiatry Manber, R., Buysse, D. J., Edinger, J., Krystal, A., Luther, J. F., Wisniewski, S. R., Trockel, M., Kraemer, H. C., Thase, M. E. 2016; 77 (10): e1316-e1323


    The Treatment of Insomnia and Depression (TRIAD) study evaluated the efficacy of combining depression pharmacotherapy (using MED, an ecologically valid and generalizable antidepressant medication algorithm) with cognitive-behavioral therapy for insomnia (CBT-I) among individuals with comorbid insomnia and major depressive disorder (MDD) to determine if change in insomnia severity mediates antidepressant outcome.This 16-week, 3-site, randomized controlled trial (RCT) randomly assigned 150 participants (recruited between March 2009 and August 2013), who met DSM-IV-TR criteria for insomnia and MDD and were not receiving treatment for either, to receive depression pharmacotherapy plus 7 sessions of either CBT-I or a credible control therapy for insomnia (CTRL). Depression pharmacotherapy followed a standardized 2-step algorithm, which included escitalopram, sertraline, and desvenlafaxine in a prescribed sequence. Primary measures were the Hamilton Depression Rating Scale and the depression module of the Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Nonpatient Edition, administered by raters masked to treatment assignment, and the self-administered Insomnia Severity Index (ISI).CBT-I was superior to CTRL in reducing insomnia severity (P = .028). The overall difference in depression remission between the treatments was not statistically significant (44% in CBT-I and 36% in CTRL; number needed to treat = 15). However, planned secondary analysis revealed that improvements in insomnia at week 6 mediated eventual remission from depression, with early change in ISI predicting depression remission in the CBT-I (P = .0002) but not in the CTRL arm (P = .26).CBT-I is an efficacious treatment for insomnia comorbid with MDD among patients treated with antidepressant medications. Improvement in insomnia may be related to the change in depression. Future studies should identify which patients are most likely to benefit from the addition of an insomnia-focused therapy to standard antidepressant identifier NCT00767624.

    View details for DOI 10.4088/JCP.15m10244

    View details for PubMedID 27788313

  • Beyond the mean: A systematic review on the correlates of daily intraindividual variability of sleep/wake patterns SLEEP MEDICINE REVIEWS Bei, B., Wiley, J. F., Trinder, J., Manber, R. 2016; 28: 108-124


    Features of an individual's sleep/wake patterns across multiple days are governed by two dimensions, the mean and the intraindividual variability (IIV). The existing literature focuses on the means, while the nature and correlates of sleep/wake IIV are not well understood. A systematic search of records in five major databases from inception to November 2014 identified 53 peer-reviewed empirical publications that examined correlates of sleep/wake IIV in adults. Overall, this literature appeared unsystematic and post hoc, with under-developed theoretical frameworks and inconsistent methodologies. Correlates most consistently associated with greater IIV in one or more aspects of sleep/wake patterns were: younger age, non-White race/ethnicity, living alone, physical health conditions, higher body mass index, weight gain, bipolar and unipolar depression symptomatology, stress, and evening chronotype; symptoms of insomnia and poor sleep were associated with higher sleep/wake IIV, which was reduced following sleep interventions. The effects of experimentally reduced sleep/wake IIV on daytime functioning were inconclusive. In extending current understanding of sleep/wake patterns beyond the mean values, IIV should be incorporated as an additional dimension when sleep is examined across multiple days. Theoretical and methodological shortcomings in the existing literature, and opportunities for future research are discussed.

    View details for DOI 10.1016/j.smrv.2015.06.003

    View details for Web of Science ID 000378966800010

    View details for PubMedID 26588182

  • Convergence in patient-therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment. Psychotherapy research Laws, H. B., Constantino, M. J., Sayer, A. G., Klein, D. N., Kocsis, J. H., Manber, R., Markowitz, J. C., Rothbaum, B. O., Steidtmann, D., Thase, M. E., Arnow, B. A. 2016: 1-15


    This study tested whether discrepancy between patients' and therapists' ratings of the therapeutic alliance, as well as convergence in their alliance ratings over time, predicted outcome in chronic depression treatment.Data derived from a controlled trial of partial or non-responders to open-label pharmacotherapy subsequently randomized to 12 weeks of algorithm-driven pharmacotherapy alone or pharmacotherapy plus psychotherapy. The current study focused on the psychotherapy conditions (N = 357). Dyadic multilevel modeling was used to assess alliance discrepancy and alliance convergence over time as predictors of two depression measures: one pharmacotherapist-rated (Quick Inventory of Depressive Symptoms-Clinician; QIDS-C), the other blind interviewer-rated (Hamilton Rating Scale for Depression; HAMD).Patients' and therapists' alliance ratings became more similar, or convergent, over the course of psychotherapy. Higher alliance convergence was associated with greater reductions in QIDS-C depression across psychotherapy. Alliance convergence was not significantly associated with declines in HAMD depression; however, greater alliance convergence was related to lower HAMD scores at 3-month follow-up.The results partially support the hypothesis that increasing patient-therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.

    View details for PubMedID 26829714

  • Examining the Variability of Sleep Patterns during Treatment for Chronic Insomnia: Application of a Location-Scale Mixed Model JOURNAL OF CLINICAL SLEEP MEDICINE Ong, J. C., Hedeker, D., Wyatt, J. K., Manber, R. 2016; 12 (6): 797-804


    The purpose of this study was to introduce a novel statistical technique called the location-scale mixed model that can be used to analyze the mean level and intra-individual variability (IIV) using longitudinal sleep data.We applied the location-scale mixed model to examine changes from baseline in sleep efficiency on data collected from 54 participants with chronic insomnia who were randomized to an 8-week Mindfulness-Based Stress Reduction (MBSR; n = 19), an 8-week Mindfulness-Based Therapy for Insomnia (MBTI; n = 19), or an 8-week self-monitoring control (SM; n = 16). Sleep efficiency was derived from daily sleep diaries collected at baseline (days 1-7), early treatment (days 8-21), late treatment (days 22-63), and post week (days 64-70). The behavioral components (sleep restriction, stimulus control) were delivered during late treatment in MBTI.For MBSR and MBTI, the pre-to-post change in mean levels of sleep efficiency were significantly larger than the change in mean levels for the SM control, but the change in IIV was not significantly different. During early and late treatment, MBSR showed a larger increase in mean levels of sleep efficiency and a larger decrease in IIV relative to the SM control. At late treatment, MBTI had a larger increase in the mean level of sleep efficiency compared to SM, but the IIV was not significantly different.The location-scale mixed model provides a two-dimensional analysis on the mean and IIV using longitudinal sleep diary data with the potential to reveal insights into treatment mechanisms and outcomes.

    View details for DOI 10.5664/jcsm.5872

    View details for Web of Science ID 000378334500005

    View details for PubMedID 26951414

  • CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia JOURNAL OF CLINICAL SLEEP MEDICINE Kuhn, E., Weiss, B. J., Taylor, K. L., Hoffman, J. E., Ramsey, K. M., Manber, R., Gehrman, P., Crowley, J. J., Ruzek, J. I., Trockel, M. 2016; 12 (4): 597-606


    This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176).VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released.Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes.Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.

    View details for DOI 10.5664/jcsm.5700

    View details for Web of Science ID 000374140000019

    View details for PubMedID 26888586

    View details for PubMedCentralID PMC4795288

  • Insomnia disorder NATURE REVIEWS DISEASE PRIMERS Morin, C. M., Drake, C. L., Harvey, A. G., Krystal, A. D., Manber, R., Riemann, D., Spiegelhalder, K. 2015; 1


    Insomnia disorder affects a large proportion of the population on a situational, recurrent or chronic basis and is among the most common complaints in medical practice. The disorder is predominantly characterized by dissatisfaction with sleep duration or quality and difficulties initiating or maintaining sleep, along with substantial distress and impairments of daytime functioning. It can present as the chief complaint or, more often, co-occurs with other medical or psychiatric disorders, such as pain and depression. Persistent insomnia has been linked with adverse long-term health outcomes, including diminished quality of life and physical and psychological morbidity. Despite its high prevalence and burden, the aetiology and pathophysiology of insomnia is poorly understood. In the past decade, important changes in classification and diagnostic paradigms have instigated a move from a purely symptom-based conceptualization to the recognition of insomnia as a disorder in its own right. These changes have been paralleled by key advances in therapy, with generic pharmacological and psychological interventions being increasingly replaced by approaches that have sleep-specific and insomnia-specific therapeutic targets. Psychological and pharmacological therapies effectively reduce the time it takes to fall asleep and the time spent awake after sleep onset, and produce a modest increase in total sleep time; these are outcomes that correlate with improvements in daytime functioning. Despite this progress, several challenges remain, including the need to improve our knowledge of the mechanisms that underlie insomnia and to develop more cost-effective, efficient and accessible therapies.

    View details for DOI 10.1038/nrdp.2015.26

    View details for Web of Science ID 000381313400001

    View details for PubMedID 27189779

  • National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans. International journal of geriatric psychiatry Karlin, B. E., Trockel, M., Spira, A. P., Taylor, C. B., Manber, R. 2015; 30 (3): 308-315


    Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18-64 years) veterans receiving CBT-I nationally in nonsleep specialty settings.Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.A total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups.Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings. Copyright © 2014 John Wiley & Sons, Ltd.

    View details for DOI 10.1002/gps.4143

    View details for PubMedID 24890708

  • Vii. Infant sleep development from 3 to 6 months postpartum: links with maternal sleep and paternal involvement. Monographs of the Society for Research in Child Development Tikotzky, L., Sadeh, A., Volkovich, E., Manber, R., Meiri, G., Shahar, G. 2015; 80 (1): 107-124


    The aims of this longitudinal study were to examine (a) development of infant sleep and maternal sleep from 3 to 6 months postpartum; (b) concomitant and prospective links between maternal sleep and infant sleep; and (c) triadic links between paternal involvement in infant caregiving and maternal and infant sleep. The study included 57 families that were recruited during pregnancy. Maternal and infant sleep was assessed using actigraphy and sleep diaries for 5 nights. Both fathers and mothers completed a questionnaire assessing the involvement of fathers relative to mothers in infant caregiving. The results demonstrated moderate improvement in infant and maternal sleep percent between 3 and 6 months. Maternal sleep percent at 3 months significantly predicted infant sleep percent at 6 months. Greater paternal involvement in infant daytime and nighttime caregiving at 3 months significantly predicted more consolidated maternal and infant sleep at 6 months. These findings suggest that maternal sleep is an important predictor of infant sleep and that increased involvement of fathers in infant caregiving responsibilities may contribute to improvements in both maternal and infant sleep during the first 6 months postpartum.

    View details for DOI 10.1111/mono.12147

    View details for PubMedID 25704738

  • SMART DOCS: A New Patient-Centered Outcomes and Coordinated-Care Management Approach for the Future Practice of Sleep Medicine SLEEP Kushida, C. A., Nichols, D. A., Holmes, T. H., Miller, R., Griffin, K., Cardell, C., Hyde, P. R., Cohen, E., Manber, R., Walsh, J. K. 2015; 38 (2): 315-?

    View details for DOI 10.5665/sleep.4422

    View details for Web of Science ID 000348757800020

    View details for PubMedID 25409112

  • The Relationship Between Beliefs About Sleep and Adherence to Behavioral Treatment Combined With Meditation for Insomnia BEHAVIORAL SLEEP MEDICINE Cvengros, J. A., Crawford, M. R., Manber, R., Ong, J. C. 2015; 13 (1): 52-63


    This study examined beliefs about sleep, as measured by the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale, as predictors of adherence to 3 specific insomnia treatment recommendations: restriction of time spent in bed, maintenance of a consistent rise time, and completion of daily meditation practice. Higher DBAS scores predicted poorer adherence to restriction of time spent in bed and to maintenance of a prescribed rise time. DBAS scores were not associated with completion of daily meditation. These preliminary findings suggest that pre-treatment beliefs about sleep may impact patient engagement with behavioral recommendations regarding time in bed and consistent rise time during treatment for insomnia.

    View details for DOI 10.1080/15402002.2013.838767

    View details for Web of Science ID 000345147800004

    View details for PubMedID 24354360

  • SMART DOCS: a new patient-centered outcomes and coordinated-care management approach for the future practice of sleep medicine. Sleep Kushida, C. A., Nichols, D. A., Holmes, T. H., Miller, R., Griffin, K., Cardell, C., Hyde, P. R., Cohen, E., Manber, R., Walsh, J. K. 2015; 38 (2): 315-326


    The practice of medicine is currently undergoing a transformation to become more efficient, cost-effective, and patient centered in its delivery of care. The aim of this article is to stimulate discussion within the sleep medicine community in addressing these needs by our approach as well as other approaches to sleep medicine care. The primary goals of the Sustainable Methods, Algorithms, and Research Tools for Delivering Optimal Care Study (SMART DOCS) are: (1) to introduce a new Patient-Centered Outcomes and Coordinated-Care Management (PCCM) approach for the future practice of sleep medicine, and (2) to test the PCCM approach against a Conventional Diagnostic and Treatment Outpatient Medical Care (CONV) approach in a randomized, two-arm, single-center, long-term, comparative effectiveness trial. The PCCM approach is integrated into a novel outpatient care delivery model for patients with sleep disorders that includes the latest technology, allowing providers to obtain more accurate and rapid diagnoses and to make evidence-based treatment recommendations, while simultaneously enabling patients to have access to personalized medical information and reports regarding their diagnosis and treatment so that they can make more informed health care decisions. Additionally, the PCCM approach facilitates better communication between patients, referring primary care physicians, sleep specialists, and allied health professionals so that providers can better assist patients in achieving their preferred outcomes. A total of 1,506 patients 18 y or older will be randomized to either the PCCM or CONV approach and will be followed for at least 1 y with endpoints of improved health care performance, better health, and cost control., NCT02037438.

    View details for DOI 10.5665/sleep.4422

    View details for PubMedID 25409112

  • Chronotype and Improved Sleep Efficiency Independently Predict Depressive Symptom Reduction after Group Cognitive Behavioral Therapy for Insomnia JOURNAL OF CLINICAL SLEEP MEDICINE Bei, B., Ong, J. C., Rajaratnam, S. M., Manber, R. 2015; 11 (9): 1021-1027

    View details for DOI 10.5664/jcsm.5018

    View details for Web of Science ID 000366292600009

    View details for PubMedID 25845891

  • Response to Kawada. Sleep medicine Suh, S., Kraemer, H. C., Yang, H., Fairholme, C. P., Manber, R., Shin, C. 2014; 15 (11): 1428-1429

    View details for DOI 10.1016/j.sleep.2014.05.032

    View details for PubMedID 25192674

  • Safety behaviors and sleep effort predict sleep disturbance and fatigue in an outpatient sample with anxiety and depressive disorders JOURNAL OF PSYCHOSOMATIC RESEARCH Fairholme, C. P., Manber, R. 2014; 76 (3): 233-236


    Theoretical and empirical support for the role of dysfunctional beliefs, safety behaviors, and increased sleep effort in the maintenance of insomnia has begun to accumulate. It is not yet known how these factors predict sleep disturbance and fatigue occurring in the context of anxiety and mood disorders. It was hypothesized that these three insomnia-specific cognitive-behavioral factors would be uniquely associated with insomnia and fatigue among patients with emotional disorders after adjusting for current symptoms of anxiety and depression and trait levels of neuroticism and extraversion.Outpatients with a current anxiety or mood disorder (N=63) completed self-report measures including the Dysfunctional Beliefs About Sleep Scale (DBAS), Sleep-Related Safety Behaviors Questionnaire (SRBQ), Glasgow Sleep Effort Scale (GSES), Pittsburgh Sleep Quality Index (PSQI), NEO Five-Factor Inventory (FFI), and the 21-item Depression Anxiety and Stress Scale (DASS). Multivariate path analysis was used to evaluate study hypotheses.SRBQ (B=.60, p<.001, 95% CI [.34, .86]) and GSES (B=.31, p<.01, 95% CI [.07, .55]) were both significantly associated with PSQI. There was a significant interaction between SRBQ and DBAS (B=.25, p<.05, 95% CI [.04, .47]) such that the relationship between safety behaviors and fatigue was strongest among individuals with greater levels of dysfunctional beliefs.Findings are consistent with cognitive behavioral models of insomnia and suggest that sleep-specific factors might be important treatment targets among patients with anxiety and depressive disorders with disturbed sleep.

    View details for DOI 10.1016/j.jpsychores.2014.01.001

    View details for Web of Science ID 000331925500008

    View details for PubMedID 24529043

  • Cognitive Behavioral Therapy for insomnia with veterans: Evaluation of effectiveness and correlates of treatment outcomes. Behaviour research and therapy Trockel, M., Karlin, B. E., Taylor, C. B., Manber, R. 2014; 53: 41-46


    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.

    View details for DOI 10.1016/j.brat.2013.11.006

    View details for PubMedID 24412462

  • Who is at risk for having persistent insomnia symptoms? A longitudinal study in the general population in Korea. Sleep medicine Suh, S., Yang, H., Fairholme, C. P., Kim, H., Manber, R., Shin, C. 2014; 15 (2): 180-186


    Our study had three goals: (1) to investigate the longitudinal course of insomnia symptoms over 4years (3 time points) by analyzing the trajectory of insomnia symptoms for all participants, (2) to compare persistent insomnia symptom to nonpersistent insomnia symptom groups on mental health and quality of life (QoL), and (3) to conduct exploratory analyses on the relative contribution of multiple factors to persistence of insomnia symptoms.Our population-based longitudinal study utilized a community-based sample from the Korean Genome and Epidemiology study (KoGES). Participants were 1247 individuals (40.1% men; mean age, 54.3±7.1years). Insomnia, QoL (measured by 12-item Short-Form health survey [SF-12]), sleep-interfering behaviors, and depression (measured by the Beck Depression Inventory [BDI]) were followed with biennial examinations at 3 data points spaced 2years apart (baseline, time 1, and time 2).Among individuals experiencing insomnia symptoms at baseline, the most common trajectory was to experience persistent nocturnal insomnia symptoms across all 3 time points. Those with persistent insomnia symptoms had significantly lower physical and mental QoL (measured by SF-12) and higher depression (measured by BDI) at time points compared to those without persistent nocturnal insomnia symptoms. A follow-up exploratory receiver operating characteristic curve (ROC) analysis identified poor sleep quality, frequent sleep-interfering behaviors, and low mental health QoL as the strongest predictors of persistent insomnia symptoms above other well-known risk factors.In particular, an interaction between poor sleep quality, sleep-interfering behaviors, and mental health QoL appeared to be the strongest risk factor for persistent insomnia symptoms.

    View details for DOI 10.1016/j.sleep.2013.09.024

    View details for PubMedID 24457162

  • Detecting critical decision points in psychotherapy and psychotherapy + medication for chronic depression. Journal of consulting and clinical psychology Steidtmann, D., Manber, R., Blasey, C., Markowitz, J. C., Klein, D. N., Rothbaum, B. O., Thase, M. E., Kocsis, J. H., Arnow, B. A. 2013; 81 (5): 783-792


    Objective: We sought to quantify clinical decision points for identifying depression treatment nonremitters prior to end-of-treatment. Method: Data came from the psychotherapy arms of a randomized clinical trial for chronic depression. Participants (n = 352; 65.6% female; 92.3% White; mean age = 44.3 years) received 12 weeks of cognitive behavioral analysis system of psychotherapy (CBASP) or CBASP plus an antidepressant medication. In half of the sample, receiver operating curve analyses were used to identify efficient percentage of symptom reduction cut points on the Inventory of Depressive Symptoms-Self-Report (IDS-SR) for predicting end-of-treatment nonremission based on the Hamilton Rating Scale for Depression (HRSD). Sensitivity, specificity, predictive values, and Cohen's kappa for identified cut points were calculated using the remaining half of the sample. Results: Percentage of IDS-SR symptom reduction at Weeks 6 and 8 predicted end-of-treatment HRSD remission status in both the combined treatment (Week 6 cut point = 50.0%, Cohen's κ = .42; Week 8 cut point = 54.3%, Cohen's κ = .45) and psychotherapy only (Week 6 cut point = 60.7%, Cohen's κ = .41; Week 8 cut point = 48.7%, Cohen's κ = .49). Status at Week 8 was more reliable for identifying nonremitters in psychotherapy-only treatment. Conclusions: Those with chronic depression who will not remit in structured, time-limited psychotherapy for depression, either with therapy alone or in combination with antidepressant medication, are identifiable prior to end of treatment. Findings provide an operationalized strategy for designing adaptive psychotherapy interventions. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

    View details for DOI 10.1037/a0033250

    View details for PubMedID 23750462

  • The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression. Journal of consulting and clinical psychology Arnow, B. A., Steidtmann, D., Blasey, C., Manber, R., Constantino, M. J., Klein, D. N., Markowitz, J. C., Rothbaum, B. O., Thase, M. E., Fisher, A. J., Kocsis, J. H. 2013; 81 (4): 627-638


    Objective: This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP). Method: 395 adults (57% female; Mage = 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16-20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change. Results: A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) = 62.48, p < .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) = 8.31, p = .004. Conclusions: The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

    View details for DOI 10.1037/a0031530

    View details for PubMedID 23339536

  • Dysfunctional attitudes as a moderator of pharmacotherapy and psychotherapy for chronic depression JOURNAL OF PSYCHIATRIC RESEARCH Shankman, S. A., Campbell, M. L., Klein, D. N., Leon, A. C., Arnow, B. A., Manber, R., Keller, M. B., Markowitz, J. C., Rothbaum, B. O., Thase, M. E., Kocsis, J. H. 2013; 47 (1): 113-121


    Individuals with chronic depression exhibit heterogeneous responses to treatment. Important individual differences may therefore exist within this particularly difficult to treat population that act as moderators of treatment response.The present study examined whether pretreatment levels of dysfunctional attitudes (DA) moderated treatment response in a large sample of chronically depressed individuals. Data were taken from the Research Evaluating the Value of Augmenting Medication with Psychotherapy (REVAMP) treatment study--a multi-site treatment and augmentation study of 808 chronically depressed individuals. REVAMP comprised two phases: 1) a 12-week open-label antidepressant trial and 2), a subsequent phase, in which phase 1 non-remitters (N = 491) were randomized to either receive an ongoing medication algorithm alone, medication plus cognitive behavioral analysis system of psychotherapy, or medication plus brief supportive psychotherapy.In phase 1, compared to the pharmacotherapy response of patients with lower DA scores, the response for patients with higher DA scores was steeper, but leveled off toward the end of the phase. In phase 2, DA predicted a differential response in the medication only arm, but not in the two psychotherapy + medication conditions. Specifically, in the phase 2 medication only condition, patients with higher DA improved while those with lower DA scores did not.These results indicate that the relation between DA and treatment response in chronic depression is complex, but suggest that greater DA may be associated with a steeper reduction and/or better response to pharmacotherapy.

    View details for DOI 10.1016/j.jpsychires.2012.09.018

    View details for Web of Science ID 000312354400015

    View details for PubMedID 23102821

  • Lessons Learned from the National Dissemination of Cognitive Behavioral Therapy for Insomnia in the Veterans Health Administration: Impact of Training on Therapists' Self-Efficacy and Attitudes Sleep Medicine Clinics Manber, R., Trockel, M., Batdorf, W., Siebern, A. T., Taylor, B., Gimeno, J., Karlin, B. 2013; 8: 399–405
  • Antenatal identification of major depressive disorder: a cohort study AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Lyell, D. J., Chambers, A. S., Steidtmann, D., Tsai, E., Caughey, A. B., Wong, A., Manber, R. 2012; 207 (6)


    The purpose of this study was to estimate the frequency of identification of major depressive disorder by providers during prenatal care.A cohort of pregnant women who were participating in a randomized controlled trial and who had received a diagnosis of major depressive disorder was examined. Women were included in the current study if prenatal clinic records were available and legible.Clinical depression was noted in 56% of prenatal charts and on 24% of problem lists. Physicians and certified nurse midwives noted depression equally (P = .935); physicians more frequently noted mental health referral (23% vs 0%; P = .01), and midwives more frequently included depression on the problem list (P = .01). Recent medication use, which was stopped before conception or study participation, predicted notation of depression in the chart (P = .001).Depression frequently is missed during pregnancy and, when identified, is underacknowledged as a problem. Women who have not recently used antidepressant medication are more likely to be missed. Better screening and acknowledgment are needed.

    View details for DOI 10.1016/j.ajog.2012.09.030

    View details for Web of Science ID 000311483300030

    View details for PubMedID 23099192

  • Postpartum maternal sleep and mothers' perceptions of their attachment relationship with the infant among women with a history of depression during pregnancy INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT Tikotzky, L., Chambers, A. S., Kent, J., Gaylor, E., Manber, R. 2012; 36 (6): 440-448
  • Impact of paroxetine on sleep problems in 426 cancer patients receiving chemotherapy: A trial from the University of Rochester Cancer Center Community Clinical Oncology Program SLEEP MEDICINE Palesh, O. G., Mustian, K. M., Peppone, L. J., Janelsins, M., Sprod, L. K., Kesler, S., Innominato, P. F., Roth, T., Manber, R., Heckler, C., Fiscella, K., Morrow, G. R. 2012; 13 (9): 1184-1190


    Sleep problems are a frequent distressing symptom in cancer patients, yet little is known about their treatment. Sleep problems and depression frequently co-occur, leading healthcare professionals to treat depression with the expectation that sleep problems will also improve. The purpose of this study was to compare the effect of paroxetine to placebo on sleep problems via a secondary data analysis of a RCT designed to compare the effects of paroxetine to placebo on fatigue in cancer patients undergoing chemotherapy. A previously published report found a significant effect of paroxetine on depression in this cohort.A total of 426 patients were randomized following Cycle 2 of chemotherapy to receive either 20mg of paroxetine or placebo. Sleep problems were assessed using questions from the Hamilton Depression Inventory three times during chemotherapy.A total of 217 patients received paroxetine and 209 received placebo. Significantly fewer patients taking paroxetine reported sleep problems compared to patients on placebo (Paroxetine 79% versus Placebo 88%; p<0.05). These differences remained significant even after controlling for baseline sleep problems and depression (p<0.05).Paroxetine had a significant benefit on sleep problems in both depressed and non-depressed cancer patients. However, rates of sleep problems remained high even among those effectively treated for depression with paroxetine. There is a need to develop and deliver sleep-specific interventions to effectively treat sleep-related side effects of cancer treatments. These findings suggest that sleep problems and depression are prevalent and co-morbid. Cancer progression, its response to treatment, and overall patient survival are intricately linked to host factors, such as inflammatory response and circadian rhythms, including sleep/wake cycles. Sleep problems and depression are modifiable host factors that can influence inflammation and impact cancer progression and quality of life. Future research should focus on discovering the pathogenesis of sleep dysregulation and depression in cancer so that better treatment approaches can be developed to ameliorate these symptoms.

    View details for DOI 10.1016/j.sleep.2012.06.001

    View details for Web of Science ID 000311477200012

    View details for PubMedID 22858235

  • The Relation Between Changes in Patients' Interpersonal Impact Messages and Outcome in Treatment for Chronic Depression JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Constantino, M. J., Laws, H. B., Arnow, B. A., Klein, D. N., Rothbaum, B. O., Manber, R. 2012; 80 (3): 354-364


    Interpersonal theories posit that chronically depressed individuals have hostile and submissive styles in their social interactions, which may undermine their interpersonal effectiveness and maintain their depression. Recent findings support this theory and also show that patients' interpersonal impact messages, as perceived by their psychotherapists, change in theoretically predicted ways following cognitive-behavioral analysis system of psychotherapy (CBASP) alone or with medication. This study extended these previous findings by examining whether such changes were associated with their depression change and response status.Data derived from a large clinical trial for chronic depression compared the efficacy of CBASP, nefazodone, and their combination. To assess patients' impact messages, CBASP clinicians completed the Impact Message Inventory (IMI; Kiesler & Schmidt, 1993) following an early and late session. Our subsample (N = 259) consisted of patients in the CBASP and combined conditions who had depression severity data for at least 1 post-randomization visit and whose clinicians completed at least 1 IMI rating. We used hierarchical linear modeling (HLM) to calculate IMI change scores and to model depression change. We used HLM and logistic regression to test our predictor questions.As hypothesized, decreases in patients' hostile-submissive impact messages were significantly associated with depression reduction (γ = 0.27, 95% CI [0.11, 0.43], p < .01) and favorable treatment response (B = -0.05, 95% CI [-0.09, -0.01], p = .03), regardless of treatment condition.The findings support CBASP theory, suggesting that interpersonal change is related to depression reduction among chronically depressed patients.

    View details for DOI 10.1037/a0028351

    View details for Web of Science ID 000304508000004

    View details for PubMedID 22545738

  • Clinical significance of night-to-night sleep variability in insomnia SLEEP MEDICINE Suh, S., Nowakowski, S., Bernert, R. A., Ong, J. C., Siebern, A. T., Dowdle, C. L., Manber, R. 2012; 13 (5): 469-475


    To evaluate the clinical relevance of night-to-night variability of sleep schedules and insomnia symptoms.The sample consisted of 455 patients (193 men, mean age=48) seeking treatment for insomnia in a sleep medicine clinic. All participants received group cognitive behavioral therapy for insomnia (CBTI). Variability in sleep parameters was assessed using sleep diary data. Two composite scores were computed, a behavioral schedule composite score (BCS) and insomnia symptom composite score (ICS). The Insomnia Severity Index, the Beck Depression Inventory, and the Morningness-Eveningness Composite Scale were administered at baseline and post-treatment.Results revealed that greater BCS scores were significantly associated with younger age, eveningness chronotype, and greater depression severity (p<0.001). Both depression severity and eveningness chronotype independently predicted variability in sleep schedules (p<0.001). Finally, CBTI resulted in reduced sleep variability for all sleep diary variables except bedtime. Post-treatment symptom reductions in depression severity were greater among those with high versus low baseline BCS scores (p<0.001).Results suggest that variability in sleep schedules predict reduction in insomnia and depressive severity following group CBTI. Schedule variability may be particularly important to assess and address among patients with high depression symptoms and those with the evening chronotype.

    View details for DOI 10.1016/j.sleep.2011.10.034

    View details for Web of Science ID 000303346800004

    View details for PubMedID 22357064

  • Cognitions and Insomnia Subgroups COGNITIVE THERAPY AND RESEARCH Suh, S., Ong, J. C., Steidtmann, D., Nowakowski, S., Dowdle, C., Willett, E., Siebern, A., Manber, R. 2012; 36 (2): 120-128
  • Risk for Partner Victimization and Marital Dissatisfaction Among Chronically Depressed Patients JOURNAL OF FAMILY VIOLENCE Foran, H. M., Vivian, D., O'Leary, K. D., Klein, D. N., Rothbaum, B. O., Manber, R., Keller, M. B., Kocsis, J. H., Thase, M. E., Trivedi, M. H. 2012; 27 (1): 75-85
  • RELATIONSHIP BETWEEN CHANGES IN SELF-EFFICACY AND DEPRESSION FOLLOWING COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA 26th Annual Meeting of the Association-of-Professional-Sleep-Societies (APSS) Simpson, N., Nowakowski, S., Siebern, A. T., Manber, R. AMER ACAD SLEEP MEDICINE. 2012: A246–A247
  • Treatment of sleep disturbances in posttraumatic stress disorder: a review. Journal of rehabilitation research and development Schoenfeld, F. B., DeViva, J. C., Manber, R. 2012; 49 (5): 729-752


    Sleep disturbances are among the most commonly reported posttraumatic stress disorder (PTSD) symptoms. It is essential to conduct a careful assessment of the presenting sleep disturbance to select the optimal available treatment. Cognitive-behavioral therapies (CBTs) are at least as effective as pharmacologic treatment in the short-term and more enduring in their beneficial effects. Cognitive-behavioral treatment for insomnia and imagery rehearsal therapy have been developed to specifically treat insomnia and nightmares and offer promise for more effective relief of these very distressing symptoms. Pharmacotherapy continues to be an important treatment choice for PTSD sleep disturbances as an adjunct to CBT, when CBT is ineffective or not available, or when the patient declines CBT. Great need exists for more investigation into the effectiveness of specific pharmacologic agents for PTSD sleep disturbances and the dissemination of the findings to prescribers. The studies of prazosin and the findings of its effectiveness for PTSD sleep disturbance are examples of studies of pharmacologic agents needed in this area. Despite the progress made in developing more specific treatments for sleep disturbances in PTSD, insomnia and nightmares may not fully resolve.

    View details for PubMedID 23015583

  • A two-dimensional approach to assessing affective states in good and poor sleepers JOURNAL OF SLEEP RESEARCH Ong, J. C., Carde, N. B., Gross, J. J., Manber, R. 2011; 20 (4): 606-610


    This study examined a two-dimensional approach to assessing affective states among good and poor sleepers using the self-assessment manikin (SAM), a brief non-verbal self-report measure of affective states with separate ratings of valence and arousal. A sample of 286 undergraduate students completed the Pittsburgh Sleep Quality Index (PSQI) and the SAM. Participants were classified post hoc as either good (PSQI ≤ 5) or poor sleepers (PSQI > 5) using the PSQI and used the SAM to rate their current affective states (day) and their affective state at bedtime (night) the previous night. Compared to good sleepers, poor sleepers reported more negative affect and arousal at night and more negative affect during the day. Among poor sleepers, lower sleep quality and shorter sleep duration on the components of the PSQI were associated with more negative daytime valence. Among good sleepers, higher scores on the sleep medication and daytime dysfunction components of the PSQI were associated with more negative daytime valence. These findings indicate that the SAM appears to detect differences between good and poor sleepers on both valence and arousal of current daytime and retrospective night-time emotional states. This approach could be useful for the assessment of affective states related to sleep disturbance.

    View details for DOI 10.1111/j.1365-2869.2011.00907.x

    View details for Web of Science ID 000297412700017

    View details for PubMedID 21244540

  • Social Problem Solving and Depressive Symptoms Over Time: A Randomized Clinical Trial of Cognitive-Behavioral Analysis System of Psychotherapy, Brief Supportive Psychotherapy, and Pharmacotherapy JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Klein, D. N., Leon, A. C., Li, C., D'Zurilla, T. J., Black, S. R., Vivian, D., Dowling, F., Arnow, B. A., Manber, R., Markowitz, J. C., Kocsis, J. H. 2011; 79 (3): 342-352


    Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009).Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks.CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions.It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches.

    View details for DOI 10.1037/a0023208

    View details for Web of Science ID 000291129600008

    View details for PubMedID 21500885

  • CBT FOR INSOMNIA, PERCEPTION OF PAIN INTERFERING WITH SLEEP AND DEPRESSIVE SYMPTOM SEVERITY 25th Anniversary Meeting of the Associated-Professional-Sleep-Societies (APSS) Nowakowski, S., WILLETT, E. S., Dowdle, C. L., Suh, S., Ong, J., Siebern, A. T., Bernert, R. A., Manber, R. AMER ACAD SLEEP MEDICINE. 2011: A182–A182
  • PREGNANCY-RELATED SLEEP DISTURBANCES: A COMPARISON OF PREGNANT WOMEN WITH AND WITHOUT INSOMNIA DISORDER 25th Anniversary Meeting of the Associated-Professional-Sleep-Societies (APSS) Chambers, A. S., Manber, R. AMER ACAD SLEEP MEDICINE. 2011: A320–A320
  • HELPFUL COMPONENTS OF GROUP COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA (CBTI) FOR PATIENTS WHO PERCEIVED PAIN TO INTERFERE WITH SLEEP 25th Anniversary Meeting of the Associated-Professional-Sleep-Societies (APSS) Suh, S., Dowdle, C. L., WILLETT, E. S., Nowakowski, S., Siebern, A. T., Ong, J., Bernert, R. A., Manber, R. AMER ACAD SLEEP MEDICINE. 2011: A180–A180
  • AN OPEN TRIAL OF COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA (CBT-I) RESULTS IN SIGNIFICANT POSTTREATMENT REDUCTIONS IN SUICIDAL IDEATION 25th Anniversary Meeting of the Associated-Professional-Sleep-Societies (APSS) Bernert, R. A., Siebern, A. T., Suh, S., Ong, J., Manber, R. AMER ACAD SLEEP MEDICINE. 2011: A247–A247
  • Prefrontal brain asymmetry and pre-menstrual dysphoric disorder symptomatology JOURNAL OF AFFECTIVE DISORDERS Accortt, E. E., Stewart, J. L., Coan, J. A., Manber, R., Allen, J. J. 2011; 128 (1-2): 178-183


    Pre-menstrual dysphoric disorder (PMDD), a dysphoric form of pre-menstrual syndrome, is included as a diagnosis for further study in the DSM-IV-TR (APA, 2000). The present study investigated whether a marker of risk for major depressive disorder (MDD), prefrontal brain asymmetry, also characterizes women with PMDD.In a sample of 25 college women with PMDD symptomatology and 25 matched controls, resting frontal electroencephalographic (EEG) activity was assessed on four occasions within a two-week span.Across several frontal sites women with PMDD had relatively less left than right prefrontal brain activity, consistent with a diathesis-stress model for menstrual-related dysphoria.The findings suggest an overlap in the risk profile for MDD and PMDD.

    View details for DOI 10.1016/j.jad.2010.07.017

    View details for Web of Science ID 000286408600023

    View details for PubMedID 20833433

    View details for PubMedCentralID PMC2994967

  • New developments in cognitive behavioral therapy as the first-line treatment of insomnia. Psychology research and behavior management Siebern, A. T., Manber, R. 2011; 4: 21-28


    Insomnia is the most common sleep disorder. Psychological, behavioral, and biological factors are implicated in the development and maintenance of insomnia as a disorder, although the etiology of insomnia remains under investigation, as it is still not fully understood. Cognitive behavioral therapy for insomnia (CBTI) is a treatment for insomnia that is grounded in the science of behavior change, psychological theories, and the science of sleep. There is strong empirical evidence that CBTI is effective. Recognition of CBTI as the first-line treatment for chronic insomnia (National Institutes of Health consensus, British Medical Association) was based largely on evidence of its efficacy in primary insomnia. The aim of this article is to provide background information and review recent developments in CBTI, focusing on three domains: promising data on the use of CBTI when insomnia is experienced in the presence of comorbid conditions, new data on the use of CBTI as maintenance therapy, and emerging data on the delivery of CBTI through the use of technology and in primary care settings.

    View details for DOI 10.2147/PRBM.S10041

    View details for PubMedID 22114532

  • Differential Effects of Treatments for Chronic Depression: A Latent Growth Model Reanalysis JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Stulz, N., Thase, M. E., Klein, D. N., Manber, R., Crits-Christoph, P. 2010; 78 (3): 409-419


    Psychotherapy-pharmacotherapy combinations are frequently recommended for the treatment of chronic depressive disorders. Our aim in this novel reanalysis of archival data was to identify patient subgroups on the basis of symptom trajectories and examine the clinical significance of the resultant classification on basis of differential treatment effects to psychotherapy (cognitive behavioral analysis system of psychotherapy), pharmacotherapy (nefazodone), and their combination.We selected data for 504 patients diagnosed with chronic depression from archival data of a clinical trial (N = 681) and analyzed treatment courses (as assessed by the Hamilton Rating Scale for Depression) using growth mixture models, a contemporary exploratory analysis technique.Three patient subgroups were identified from the typical patterns of change of depression severity during 12-week acute-phase treatment. Within these patient subgroups, differential treatment effects were evident: combination treatment clearly outperformed the 2 monotherapies in the largest patient subgroup, characterized by moderate depression severity, but not in the remaining 2 subgroups, characterized by low and severe depression at baseline. Patient characteristics prior to initiation of treatment enabled allocation of 61% of patients to these subgroups.Research on patient subgroups with different change patterns may support classifications of patients that indicate which treatment is most effective for which type of patient.

    View details for DOI 10.1037/a0019267

    View details for Web of Science ID 000278412000012

    View details for PubMedID 20515216

  • Insomnia and Its Effective Non-pharmacologic Treatment MEDICAL CLINICS OF NORTH AMERICA Siebern, A. T., Manber, R. 2010; 94 (3): 581-?


    Emerging data underscores the public health and economic burden of insomnia evidenced by increased health risks; increased health care utilization; and work domain deficits (absenteeism and reduced productivity). Cognitive behavioral therapy for insomnia (CBTi) is a brief and effective non-pharmacologic treatment for insomnia that is grounded in the science of sleep medicine and the science of behavior change and psychological theory, and in direct comparisons with sleep medication in randomized control trials that demonstrate that CBTi has comparable efficacy with more durable long-term maintenance of gains after treatment discontinuation. The high level of empirical support for CBTi has led the National Institutes of Health Consensus and the American Academy of Sleep Medicine Practice Parameters to make the recommendation that CBTi be considered standard treatment. The aim of this report is to increase awareness and understanding of health care providers of this effective treatment option.

    View details for DOI 10.1016/j.mcna.2010.02.005

    View details for Web of Science ID 000278853600011

    View details for PubMedID 20451034

  • PSYCHOTHERAPIST MINDFULNESS AND THE PSYCHOTHERAPY PROCESS PSYCHOTHERAPY Bruce, N. G., Manber, R., Shapiro, S. L., Constantino, M. J. 2010; 47 (1): 83-97


    [Correction Notice: An erratum for this article was reported in Vol 47(2) of Psychotherapy: Theory, Research & Practice (see record 2010-13424-005). the order of authorship and the affiliations of the authors was incorrectly printed. The correct order and affiliations are as follows: Noah Bruce, Shauna L. Shapiro, Michael J. Constantino, and Rachel Manber; Kaiser Permanente, Santa Clara University, University of Massachusetts, Stanford University] A psychotherapist's ability to relate to his or her patients is essential for decreasing patient suffering and promoting patient growth. However, the psychotherapy field has identified few effective means for training psychotherapists in this ability. In this conceptual article, we propose that mindfulness practice may be a means for training psychotherapists to better relate to their patients. We posit that mindfulness is a means of self-attunement that increases one's ability to attune to others (in this case, patients) and that this interpersonal attunement ultimately helps patients achieve greater self-attunement that, in turn, fosters decreased symptom severity, greater well-being, and better interpersonal relationships.

    View details for DOI 10.1037/a0018842

    View details for Web of Science ID 000276141500010

    View details for PubMedID 22402003

  • Examining maladaptive beliefs about sleep across insomnia patient groups JOURNAL OF PSYCHOSOMATIC RESEARCH Carney, C. E., Edinger, J. D., Morin, C. M., Manber, R., Rybarczyk, B., Stepanski, E. J., Wright, H., Lack, L. 2010; 68 (1): 57-65


    Unhelpful beliefs about sleep have been linked to insomnia, and increasing one's cognitive flexibility about sleep has been linked to posttreatment sleep improvement. This study evaluated whether levels of such beliefs differ across insomnia groups and whether there are particular beliefs that differ for specific insomnia subtypes.Participants (N=1384) were people with insomnia and good sleepers ranging from 18 to 89 years old (mean=42.6; S.D.=19.4). Data from previous studies at five insomnia clinical sites were pooled to examine responses on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) across differing insomnia groups.Group analyses revealed that those from community-based insomnia clinics and those who are hypnotic-dependent generally had the highest levels of unhelpful sleep-related beliefs. With the exception of beliefs about sleep needs (wherein only community sleep clinic patients had high scores relative to good sleepers), all insomnia groups had higher scores on the 16-item DBAS (DBAS-16) than good sleepers. A validity analysis suggested that a DBAS-16 index score of >3.8 represented the level of unhelpful beliefs associated with clinically significant insomnia, although a slightly lower cutoff may be useful for identifying an unhelpful degree of sleep-related beliefs in highly screened primary-insomnia-only and medical patient groups.This study offers descriptive data for the use of DBAS-16 across insomnia subgroups, which will help the user understand what degree of maladaptive sleep beliefs is most strongly associated with clinically significant levels of insomnia. Results also may have implications for cognitive targeting during treatment for particular insomnia groups.

    View details for DOI 10.1016/j.jpsychores.2009.08.007

    View details for Web of Science ID 000273028700008

    View details for PubMedID 20004301

  • Insomnia and Depression: A Multifaceted Interplay CURRENT PSYCHIATRY REPORTS Manber, R., Chambers, A. S. 2009; 11 (6): 437-442


    Historically, insomnia has been viewed as a symptom of depressive illness that is expected to resolve with adequate treatment of the depressive disorder. This article reviews the evidence that increasingly challenges this simplistic view and summarizes research demonstrating the multifaceted interplay between insomnia and depression. It discusses the prevalence, clinical significance, and time course of insomnia, distinguishing between poor sleep and an insomnia disorder. The article also discusses abnormalities in sleep architecture in major depressive disorder and theories about the pathways connecting sleep and depression. It concludes with a discussion of issues related to treatment, including the effects of antidepressants on sleep and new evidence of the utility of adding an insomnia-specific therapy for improved management of depressed patients with comorbid insomnia.

    View details for Web of Science ID 000207903000003

    View details for PubMedID 19909664

  • Acupuncture for depression during pregnancy 30th Annual Clinical Meeting of the Society-for-Maternal-Fetal-Medicine Manber, R., Schnyer, R., Chambers, A., Lyell, D., Caughey, A., Carlyle, E., Druzin, M., Gress, J., Huang, M., Kalista, T., Okada, R., Allen, J. MOSBY-ELSEVIER. 2009: S19–S19
  • Antenatal recognition of major depressive disorder 30th Annual Clinical Meeting of the Society-for-Maternal-Fetal-Medicine Lyell, D., Chambers, A., Wong, A., Tsai, E., Caughey, A., Manber, R. MOSBY-ELSEVIER. 2009: S55–S55
  • Cognitive Behavioral Analysis System of Psychotherapy and Brief Supportive Psychotherapy for Augmentation of Antidepressant Nonresponse in Chronic Depression ARCHIVES OF GENERAL PSYCHIATRY Kocsis, J. H., Gelenberg, A. J., Rothbaum, B. O., Klein, D. N., Trivedi, M. H., Manber, R., Keller, M. B., Leon, A. C., Wisniewski, S. R., Arnow, B. A., Markowitz, J. C., Thase, M. E. 2009; 66 (11): 1178-1188


    Previous studies have found that few chronically depressed patients remit with antidepressant medications alone.To determine the role of adjunctive psychotherapy in the treatment of chronically depressed patients with less than complete response to an initial medication trial.This trial compared 12 weeks of (1) continued pharmacotherapy and augmentation with cognitive behavioral analysis system of psychotherapy (CBASP), (2) continued pharmacotherapy and augmentation with brief supportive psychotherapy (BSP), and (3) continued optimized pharmacotherapy (MEDS) alone. We hypothesized that adding CBASP would produce higher rates of response and remission than adding BSP or continuing MEDS alone.Eight academic sites.Chronically depressed patients with a current DSM-IV-defined major depressive episode and persistent depressive symptoms for more than 2 years.Phase 1 consisted of open-label, algorithm-guided treatment for 12 weeks based on a history of antidepressant response. Patients not achieving remission received next-step pharmacotherapy options with or without adjunctive psychotherapy (phase 2). Individuals undergoing psychotherapy were randomized to receive either CBASP or BSP stratified by phase 1 response, ie, as nonresponders (NRs) or partial responders (PRs).Proportions of remitters, PRs, and NRs and change on Hamilton Scale for Depression (HAM-D) scores.In all, 808 participants entered phase 1, of which 491 were classified as NRs or PRs and entered phase 2 (200 received CBASP and MEDS, 195 received BSP and MEDS, and 96 received MEDS only). Mean HAM-D scores dropped from 25.9 to 17.7 in NRs and from 15.2 to 9.9 in PRs. No statistically significant differences emerged among the 3 treatment groups in the proportions of phase 2 remission (15.0%), partial response (22.5%), and nonresponse (62.5%) or in changes on HAM-D scores.Although 37.5% of the participants experienced partial response or remitted in phase 2, neither form of adjunctive psychotherapy significantly improved outcomes over that of a flexible, individualized pharmacotherapy regimen alone. A longitudinal assessment of later-emerging benefits is ongoing.

    View details for Web of Science ID 000271427500004

    View details for PubMedID 19884606

  • Select comorbid personality disorders and the treatment of chronic depression with nefazodone, targeted psychotherapy, or their combination JOURNAL OF AFFECTIVE DISORDERS Maddux, R. E., Riso, L. P., Klein, D. N., Markowitz, J. C., Rothbaum, B. O., Arnow, B. A., Manber, R., Blalock, J. A., Keitner, G. I., Thase, M. E. 2009; 117 (3): 174-179


    Individuals with chronic depression respond poorly to both medication and psychotherapy. The reasons for the poorer response, however, remain unclear. One potential factor is the presence of comorbid Axis II personality disorders (PDs), which occur at high rates among these patients.This study examines the moderating influence of co-occurring PDs, primarily in cluster C, among 681 chronically depressed adult outpatients who were randomly assigned to 12 weeks of treatment with nefazodone, a specialized psychotherapy for chronic depression, or their combination.At baseline, 50.4% (n=343) of patients met criteria for one or more Axis II disorders. Following 12 weeks of treatment, patients with comorbid PDs had statistically lower depression scores (M=12.2, SD=+9.2) than patients without comorbid PDs (M=13.5, SD=+8.7). There was no differential impact of a comorbid PD on responsiveness to medication versus psychotherapy. The results did not change when the data were analyzed using an intent-to-treat sample or when individual personality disorders were examined separately.Patients with severe borderline, antisocial, and schizotypal PDs were excluded from study entry; therefore, these data primarily apply to patients with cluster C PDs and may not generalize to other Axis II conditions.Comorbid Axis II disorders did not negatively affect treatment outcome and did not differentially affect response to psychotherapy versus medication. Treatment formulations for chronically depressed patients with certain PDs may not need to differ from treatment formulations of chronically depressed patients without co-occurring PDs.

    View details for DOI 10.1016/j.jad.2009.01.010

    View details for Web of Science ID 000270245500008

    View details for PubMedID 19217168

  • Frequency and predictors of obstructive sleep apnea among individuals with major depressive disorder and insomnia JOURNAL OF PSYCHOSOMATIC RESEARCH Ong, J. C., Gress, J. L., Pedro-Salcedo, M. G., Manber, R. 2009; 67 (2): 135-141


    Disturbances in sleep continuity are common among individuals with major depressive disorder (MDD) and can impact the course of depression and response to treatment. Several studies have examined depressive symptom severity among sleep-disordered patients with obstructive sleep apnea (OSA). In contrast, little is known about OSA in patients with MDD. The goal of this study was to examine the frequency and predictors of OSA in a sample of individuals with comorbid MDD and insomnia.Participants were 51 individuals who enrolled in a treatment study on insomnia and depression, met criteria for MDD and comorbid insomnia, and underwent an overnight polysomnography evaluation. An apnea-hypopnea index >or=15 events per hour was used as a cutoff score for OSA. Regression analyses were conducted to examine clinical and demographic predictors of OSA severity as measured by the apnea-hypopnea index.The results revealed that 39% of the sample met criteria for OSA. The OSA group had significantly higher body mass index (BMI) scores and a significantly greater proportion of men. Regression analysis revealed that male sex, older age, and higher BMI were significant predictors of OSA severity. Neither depression severity nor insomnia severity was a significant predictor.These findings indicate that the frequency of OSA is higher among individuals with comorbid MDD and insomnia than was previously found among people with either MDD or insomnia alone. In addition, previously identified predictors of OSA (male sex, older age, and high BMI) also apply to this population.

    View details for DOI 10.1016/j.jpsychores.2009.03.011

    View details for Web of Science ID 000268603700005

    View details for PubMedID 19616140

  • EARLY ADVERSITY IN CHRONIC DEPRESSION: CLINICAL CORRELATES AND RESPONSE TO PHARMACOTHERAPY 115th Annual Convention of the American-Psychological-Association Klein, D. N., Arnow, B. A., Barkin, J. L., Dowling, F., Kocsis, J. H., Leon, A. C., Manber, R., Rothbaum, B. O., Trivedi, M. H., Wisniewski, S. R. WILEY-BLACKWELL. 2009: 701–10


    There is growing evidence suggesting that early adversity may be a marker for a distinct pathway to major depressive disorder (MDD). We examined associations between childhood adversity and a broad variety of clinical characteristics and response to pharmacotherapy in a large sample of patients with chronic forms of MDD.Subjects included 808 patients with chronic forms of MDD (chronic MDD, double depression, or recurrent MDD with incomplete recovery between episodes and a total continuous duration of >2 years) who were enrolled in a 12-week open-label trial of algorithm-guided pharmacotherapy. Baseline assessments included a semi-structured diagnostic interview, and clinician- and self-rated measures of depressive symptoms, social functioning, depressotypic cognitions, and personality traits, and childhood adversity. Patients were re-evaluated every 2 weeks.A longer duration of illness; earlier onset; greater number of episodes, symptom severity, self-rated functional impairment, suicidality, and comorbid anxiety disorder; and higher levels of dysfunctional attitudes and self-criticism were each associated with multiple forms of childhood adversity. A history of maternal overcontrol, paternal abuse, paternal indifference, sexual abuse, and an index of clinically significant abuse each predicted a lower probability of remission. Among patients completing the 12-week trial, 32% with a history of clinically significant abuse, compared to 44% without such a history, achieved remission.These findings indicate that a history of childhood adversity is associated with an especially chronic form of MDD that is less responsive to antidepressant pharmacotherapy.

    View details for DOI 10.1002/da.20577

    View details for Web of Science ID 000268736700002

    View details for PubMedID 19434623

  • Patient Preference as a Moderator of Outcome for Chronic Forms of Major Depressive Disorder Treated With Nefazodone, Cognitive Behavioral Analysis System of Psychotherapy, or Their Combination JOURNAL OF CLINICAL PSYCHIATRY Kocsis, J. H., Leon, A. C., Markowitz, J. C., Manber, R., Arnow, B., Klein, D. N., Thase, M. E. 2009; 70 (3): 354-361


    Little is known about moderators of response to psychotherapy, medication, and combined treatment for chronic forms of major depressive disorder (MDD). We hypothesized that patient preference at baseline would interact with treatment group to differentially affect treatment outcome.We report outcomes for 429 patients who participated in a randomized multicenter trial of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combination therapy for chronic forms of MDD (DSM-IV criteria) and who indicated their preference for type of treatment at study entry. The primary outcome measures were total scores on the 24-item Hamilton Rating Scale for Depression (HAM-D-24) and categorical definitions of remission or partial response. The patients were recruited between June 1996 and December 1997.There was an interactive effect of preference and treatment group on outcome. The treatment effect varied as a function of preference, and was particularly apparent for patients who initially expressed preference for one of the monotherapies. Patients who preferred medication had a higher remission rate (45.5%) and lower mean HAM-D-24 score (11.6) at study exit if they received medication than if they received psychotherapy (remission rate, 22.2%; mean HAM-D-24 score, 21.0). Patients who preferred psychotherapy had a higher remission rate (50.0%) and lower mean HAM-D-24 score (12.1) if they received psychotherapy than if they received medication (remission rate 7.7%, mean HAM-D-24 score 18.3). Nevertheless, treatment preference was not associated with risk of dropout from the study.These results suggest that patient preference is a potent moderator of treatment response for patients with chronic forms of MDD; however, relatively low proportions of the patient sample preferred one of the monotherapies, participants were not blinded to treatment assignment, and there was no placebo group.

    View details for Web of Science ID 000264735200007

    View details for PubMedID 19192474



    A unique intervention combining mindfulness meditation with cognitive behavioral therapy for insomnia (CBT-I) has been shown to have acute benefits at posttreatment in an open label study. The aim of the present study was to examine the long-term effects of this integrated intervention on measures of sleep and sleep-related distress in an attempt to characterize the natural course of insomnia following this treatment and to identify predictors of poor long-term outcome. Analyses were conducted on 21 participants, who provided follow-up data at six and 12 months posttreatment. At each time point, participants completed one week of sleep and meditation diaries and questionnaires related to mindfulness, sleep, and sleep-related distress, including the Pre-Sleep Arousal Scale, the Glasgow Sleep Effort Scale, the Kentucky Inventory of Mindfulness Skills, and the Insomnia Episode Questionnaire. Analyses examining the pattern of change across time (baseline, end of treatment, six months, and 12 months) revealed that several sleep-related benefits were maintained during the 12-month follow-up period. Participants who reported at least one insomnia episode (>or=1 month) during the follow-up period had higher scores on the Pre-Sleep Arousal Scale (P < .05) and the Glasgow Sleep Effort Scale (P < .05) at end of treatment compared with those with no insomnia episodes. Correlations between mindfulness skills and insomnia symptoms revealed significant negative correlations (P < .05) between mindfulness skills and daytime sleepiness at each of the three time points but not with nocturnal symptoms of insomnia. These results suggest that most sleep-related benefits of an intervention combining CBT-I and mindfulness meditation were maintained during the 12-month follow-up period, with indications that higher presleep arousal and sleep effort at end of treatment constitute a risk for occurrence of insomnia during the 12 months following treatment.

    View details for DOI 10.1016/j.explore.2008.10.004

    View details for Web of Science ID 000262826700009

    View details for PubMedID 19114261

  • THE CO-OCCURRENCE OF INSOMNIA AND DEPRESSION SYMPTOMS IN AN ADOLESCENT MEDICAL CLINIC: A PILOT STUDY 23rd Annual Meeting of the Associated-Professional-Sleep-Societies (APSS) Zitner, L., Wren, F. J., Golden, N. H., Horwitz, S., Manber, R. AMER ACAD SLEEP MEDICINE. 2009: A358–A359
  • PERSISTENT SLEEP DISTURBANCE DURING PREGNANCY PREDICTS REEMERGENCE OF A CORE SYMPTOM OF DEPRESSION IN THE POSTPARTUM 23rd Annual Meeting of the Associated-Professional-Sleep-Societies (APSS) Chambers, A. S., Manber, R., Siebern, A. T., Tkotzky, L. AMER ACAD SLEEP MEDICINE. 2009: A355–A355
  • INTERPERSONAL STYLES OF CHRONICALLY DEPRESSED OUTPATIENTS: PROFILES AND THERAPEUTIC CHANGE PSYCHOTHERAPY Constantino, M. J., Degeorge, J., Zuroff, D. C., Markowitz, J. C., Thase, M. E., Manber, R., Mcbride, C., Ravitz, P., Klein, D. N., Rothbaum, B. O., Arnow, B. A. 2008; 45 (4): 491-506


    Theoretical accounts posit that chronically depressed individuals are perceived as hostile and/or submissive, which compromises their ability to satisfy their interpersonal needs. The current study assessed the interpersonal tenets of McCullough's (2000) chronic depression theory and examined change in interpersonal functioning following McCullough's treatment for chronic depression (viz., Cognitive-Behavioral Analysis System of Psychotherapy; CBASP). Data derive from a randomized 12-week clinical trial that compared the efficacy of CBASP, nefazodone, and their combination for chronic depression. To assess patients' interpersonal impacts, CBASP therapists completed the Impact Message Inventory (IMI) following an early and a late session. IMI data were compared to normative and clinical comparison samples to assess depression-related interpersonal profiles and clinically significant change in interpersonal functioning. As predicted, chronically depressed patients were initially perceived as more submissive and hostile than the comparison groups. Patients' interpersonal impacts on their therapists changed in adaptive, theoretically predicted ways by the end of CBASP treatment, either with or without medication. Individual-level clinical significance data were less robust. The findings generally substantiate McCullough's interpersonal theory and provide preliminary evidence of change in interpersonal impacts following treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

    View details for DOI 10.1037/a0014335

    View details for Web of Science ID 000262213000006

    View details for PubMedID 22122536

  • Chronic forms of major depression are still undertreated in the 21st century: Systematic assessment of 801 patients presenting for treatment JOURNAL OF AFFECTIVE DISORDERS Kocsis, J. H., Gelenberg, A. J., Rothbaum, B., Klein, D. N., Trivedi, M. H., Manber, R., Keller, M. B., Howland, R., Thase, M. E. 2008; 110 (1-2): 55-61


    During a multisite, NIMH-sponsored clinical trial entitled, "Research Evaluating the Value of Augmentation of Medication by Psychotherapy" (REVAMP), we assessed the adequacy of prior antidepressant treatment in patients with chronic forms of major depressive disorder using the Antidepressant Treatment History Form (ATHF). We hypothesized that when compared to earlier studies treatment adequacy would not have increased over the past decade. We found that only 33% of the 801 subjects enrolled had ever had a prior adequate trial of antidepressant medication. Patients significantly more likely to have received prior adequate antidepressant trials were older, married, white, had a longer duration of illness, had more melancholic features or met criteria for the melancholic subtype or met lifetime criteria for panic disorder. The hypothesis that rates of treatment adequacy have not significantly increased over the past decade was supported. These results and the consistency of similar results over time point to the dire need for patient and provider education regarding the signs and symptoms of depression and its treatment.

    View details for DOI 10.1016/j.jad.2008.01.002

    View details for Web of Science ID 000258850600006

    View details for PubMedID 18272232

  • Combining mindfulness meditation with cognitive-behavior therapy for insomnia: A treatment-development study 20th Annual Meeting of the Associated-Professional-Sleep-Societies Ong, J. C., Shapiro, S. L., Manber, R. ASSOC ADV BEHAVIOR THERAPY. 2008: 171–82


    This treatment-development study is a Stage I evaluation of an intervention that combines mindfulness meditation with cognitive-behavior therapy for insomnia (CBT-I). Thirty adults who met research diagnostic criteria for Psychophysiological Insomnia (Edinger et al., 2004) participated in a 6-week, multi-component group intervention using mindfulness meditation, sleep restriction, stimulus control, sleep education, and sleep hygiene. Sleep diaries and self-reported pre-sleep arousal were assessed weekly while secondary measures of insomnia severity, arousal, mindfulness skills, and daytime functioning were assessed at pre-treatment and post-treatment. Data collected on recruitment, retention, compliance, and satisfaction indicate that the treatment protocol is feasible to deliver and is acceptable for individuals seeking treatment for insomnia. The overall patterns of change with treatment demonstrated statistically and clinically significant improvements in several nighttime symptoms of insomnia as well as statistically significant reductions in pre-sleep arousal, sleep effort, and dysfunctional sleep-related cognitions. In addition, a significant correlation was found between the number of meditation sessions and changes on a trait measure of arousal. Together, the findings indicate that mindfulness meditation can be combined with CBT-I and this integrated intervention is associated with reductions in both sleep and sleep-related arousal. Further testing of this intervention using randomized controlled trials is warranted to evaluate the efficacy of the intervention for this population and the specific effects of each component on sleep and both psychological and physiological arousal.

    View details for Web of Science ID 000257419100007

    View details for PubMedID 18502250

  • Who is at risk for dropout from group cognitive-behavior therapy for insomnia? JOURNAL OF PSYCHOSOMATIC RESEARCH Ong, J. C., Kuo, T. F., Manber, R. 2008; 64 (4): 419-425


    The aim of the present study was to identify characteristics of patients who are at risk for dropout from a seven-session group cognitive-behavior therapy for insomnia (CBT-I) in a clinical setting using the receiver operating characteristic curve (ROC) approach.Two separate ROC analyses were conducted using predictor variables taken from questionnaire packets and sleep diaries collected at baseline including age, gender, Beck Depression Inventory (BDI), Morningness-Eveningness Questionnaire, Beliefs and Attitudes about Sleep, use of sleep medication, sleep onset latency, wake time after sleep onset, and total sleep time (TST).The first ROC analysis was conducted on the entire sample of 528 patients with treatment completion vs. dropout (noncompletion) as the outcome variable. No significant predictor variables were found in this analysis. The second ROC analysis was conducted on the 211 patients who did not complete treatment with early termination (prior to fourth session) vs. late termination (at or after fourth session) as the outcome variable. The results revealed that patients who reported an average baseline TST <3.65 h were at greatest risk for early termination. Sixty percent of patients in this group terminated early compared to 9.3% of patients with TST > or =3.65 h. Among patients with TST > or =3.65 h, 22% of those with BDI scores > or =16 were early dropouts compared to 4.3% of those who reported BDI <16.These findings indicate that short sleep duration and elevated symptoms of depression at baseline are associated with increased risk of early termination from CBT-I.

    View details for DOI 10.1016/j.jpsychores.2007.10.009

    View details for Web of Science ID 000254812200011

    View details for PubMedID 18374742

  • Cognitive and behavioral mediators of combined pharmacotherapy and psychotherapy of chronic depression COGNITIVE THERAPY AND RESEARCH Blalock, J. A., Fouladi, R. T., Cinciripini, P. M., Markowitz, J. C., Klein, D. N., Rothbaum, B. O., Arnow, B. A., Manber, R., Riso, L. P., Sui, D., McCullough, J. P. 2008; 32 (2): 197-211
  • Use of and attitudes about sleep medications in a tertiary sleep clinic 22nd Annual Meeting of the Associated-Professional-Sleep-Societies Adler, S., CARDE, N., Kuo, T., Ong, J., Manber, R. AMER ACAD SLEEP MEDICINE. 2008: A326–A327
  • Therapists' responses to training in brief supportive psychotherapy. American journal of psychotherapy Markowitz, J. C., Manber, R., Rosen, P. 2008; 62 (1): 67-81


    There is little research addressing supportive psychotherapy training. This article describes training clinicians in a form of brief supportive psychotherapy (BSP) for a multisite depression study, and reports on a survey of therapist attitudes toward BSP. We hypothesized that while most therapists would report acclimating to BSP, cognitive-behavioral therapy (CBT)-trained therapists would report greater frustration with BSP. Sixteen (89%) of 18 therapists completed a brief questionnaire. Therapists reported gaining comfort with supportive concepts and interventions. Therapists with cognitive behavior therapy orientations did not report significantly greater frustration with intervention restrictions. All practitioners indicated they were already using or were planning to use BSP outside the study, and that BSP training had altered their appreciation of psychotherapy. Most study therapists lacked prior supportive therapy training but reported adapting to BSP and appreciating its strengths and limitations.

    View details for PubMedID 18461844

  • Cardiac vagal control in the severity and course of depression: The importance of symptomatic heterogeneity JOURNAL OF AFFECTIVE DISORDERS Rottenberg, J., Chambers, A. S., Allen, J. J., Manber, R. 2007; 103 (1-3): 173-179


    Impaired cardiac vagal control (CVC), as indexed by respiratory sinus arrhythmia, has been investigated as a risk factor for major depressive disorder (MDD), but prior findings are mixed with respect to whether impaired CVC predicts greater global depression severity and/or a more severe course of disorder. One possible explanation for mixed findings is that CVC abnormalities in MDD are related more closely to specific depression symptoms than to the syndrome as a whole.Depression severity (both global and symptom-specific indices) and electrocardiogram measures of resting CVC were obtained from 151 diagnosed MDD participants at intake, before randomization to a novel treatment for depression (acupuncture), and again after 8 and 16 weeks.Resting CVC did not predict global indices of depression in cross-sectional or longitudinal analyses. In symptom-specific analyses, resting CVC was positively related to sad mood and crying and inversely related to middle and late insomnia. Improvement in late insomnia was related to increases in CVC over time.Relationships between CVC and MDD were studied only within the clinical range of severity. Symptom analyses were exploratory and hence did not correct for Type I error.Resting CVC did not exhibit concurrent or prospective relations with overall depression severity but a few specific symptoms did. Symptomatic heterogeneity across samples may account for mixed findings within the CVC-depression literature.

    View details for DOI 10.1016/j.jad.2007.01.028

    View details for Web of Science ID 000250396800021

    View details for PubMedID 17320191

  • Acupuncture for postmenopausal hot flashes MATURITAS Nir, Y., Huang, M. I., Schnyer, R., Chen, B., Manber, R. 2007; 56 (4): 383-395


    To determine whether individually tailored acupuncture is an effective treatment option for reducing postmenopausal hot flashes and improving quality of life.In a randomized, placebo-controlled pilot study, 29 postmenopausal participants averaging at least seven moderate to severe hot flashes per 24h, with a baseline estradiol concentration of less than 50 pg/mL and a normal TSH level, were randomized to receive 7 weeks (nine treatment sessions) of either active acupuncture or placebo acupuncture (placebo needles that did not penetrate the skin at sham acupuncture points). Participants recorded hot flashes in logs that were reported daily. Global indices of the severity and frequency of hot flashes were derived from the participants' daily logs.Participants receiving the active treatment had a greater reduction in hot flash severity (24.5+/-30.7%) compared to those receiving placebo (4.4+/-17.1%, P=0.042). Within group repeated measures analyses of variance revealed a significant reduction in hot flash severity in the active (P=0.042), but not in the placebo treatment group (P=0.15). Although there was no significant group difference in the reduction of hot flash frequency between the active (42.4+/-32.2%) and placebo groups (32.0+/-26.5%; P>or=0.352), within group repeated measures analyses of variance revealed that the reduction was statistically significant in both groups (P

    View details for DOI 10.1016/j.maturitas.2006.11.001

    View details for Web of Science ID 000245757900006

    View details for PubMedID 17182200

  • Beliefs about sleep in disorders characterized by sleep and mood disturbance JOURNAL OF PSYCHOSOMATIC RESEARCH Carney, C. E., Edinger, J. D., Manber, R., Garson, C., Segal, Z. V. 2007; 62 (2): 179-188


    Maladaptive sleep beliefs play an important role in primary insomnia, but their role in other disorders with concomitant sleep disruption has rarely been explored. Thus, this study investigated the link between insomnia and sleep beliefs in five groups (N=422): primary insomnia (PI), good sleepers (GS), fibromyalgia (FM), major depressive disorder (MDD), and Community Sleep Clinic patients with comorbid insomnia and mood disturbance (CSC).Groups were compared on the Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16) scale.Unlike the GS group, the MDD, FM, and CSC groups had elevated DBAS-16 scores that were similar to, or more pathological than, those of primary insomnia sufferers. Only some of the differences were removed after controlling for depression.Like primary insomnia patients, other sleep-disturbed patient groups have problematic sleep beliefs. Depression was not sufficient to account for all elevations in beliefs. The presence of maladaptive sleep beliefs in these patients suggests that belief-targeted treatment might be helpful in alleviating sleep complaints.

    View details for DOI 10.1016/j.jpsychores.2006.08.006

    View details for Web of Science ID 000244282900009

    View details for PubMedID 17270576

  • Dropouts versus completers among chronically depressed outpatients JOURNAL OF AFFECTIVE DISORDERS Arnow, B. A., Blasey, C., Manber, R., Constantino, M. J., Markowitz, J. C., Klein, D. N., Thase, M. E., Koesis, J. H., Rush, A. J. 2007; 97 (1-3): 197-202


    Premature termination is common among patients treated for depression with either pharmacotherapy or psychotherapy. Yet little is known about factors associated with premature treatment termination among depressed patients.This study examines predictors of, time to, and reasons for dropout from the 12-week acute phase treatment of nonpsychotic adult outpatients, age 18-75, with chronic major depression who were randomly assigned to nefazadone alone (MED), cognitive behavioral analysis system of psychotherapy alone (CBASP) or both treatments (COMB).Of 681 randomized study participants, 156 were defined as dropouts. Dropout rates were equivalent across the three treatments. Among dropouts, those in COMB remained in treatment (Mean=40 days) significantly longer than those in either MED (Mean=27 days) or CBASP (Mean=28 days). Dropouts attributed to medication side-effects were significantly lower in COMB than in MED, suggesting that the relationship with the psychotherapist may increase patient willingness to tolerate side-effects associated with antidepressant medications. Ethnic or racial minority status, younger age, lower income, and co-morbid anxiety disorders significantly predicted dropout in the full sample. Within treatments, differences between completers and dropouts in minority status and the prevalence of anxiety disorders were most pronounced in MED. Among those receiving CBASP, dropouts had significantly lower therapeutic alliance scores than completers.The sample included only individuals with chronic depression.Predictors of dropout included baseline patient characteristics, but not early response to treatment. Ethnic and racial minorities and those with comorbid anxiety are at higher risk of premature termination, particularly in pharmacotherapy, and may require modified treatment strategies.

    View details for DOI 10.1016/j.jad.2006.06.017

    View details for Web of Science ID 000243734600023

    View details for PubMedID 16857266

  • Characteristics of Insomniacs with Self-Reported Morning and Evening Chronotypes JOURNAL OF CLINICAL SLEEP MEDICINE Ong, J. C., Huang, J. S., Kuo, T. F., Manber, R. 2007; 3 (3): 289-294
  • Patient expectations and therapeutic alliance as predictors of outcome in group cognitive-behavioral therapy for insomnia. Behavioral sleep medicine Constantino, M. J., Manber, R., Ong, J., Kuo, T. F., Huang, J. S., Arnow, B. A. 2007; 5 (3): 210-228


    Despite growing evidence for the efficacy of cognitive-behavioral therapy for insomnia (CBT-I), few data exist on the relation between process and outcome for this treatment. Drawing on interpersonal theory and the broader psychotherapy literature, this study examined the contribution of patient expectations and the therapeutic alliance to outcomes in group CBT-I. For patients with low early treatment expectations for improvement, those perceiving the therapist as higher in affiliation had greater reduction in sleep problems. Perceiving the therapist as critically confrontive was generally associated with less treatment satisfaction, and particularly so for those individuals who came to treatment with high expectations for improvement. Critical confrontation also differentiated dropouts from continuers, with dropouts experiencing their therapist as more critically confrontive.

    View details for PubMedID 17680732

  • Acupuncture for depression: A randomized controlled trial JOURNAL OF CLINICAL PSYCHIATRY Allen, J. J., Schnyer, R. N., Chambers, A. S., Hitt, S. K., Moreno, F. A., Manber, R. 2006; 67 (11): 1665-1673


    To assess the efficacy of acupuncture as an intervention for major depressive disorder (MDD).Acupuncture was examined in 151 patients with MDD (DSM-IV) who were randomly assigned to 1 of 3 groups in a double-blind randomized controlled trial. The specific intervention involved Traditional Chinese Medicine (TCM)-style acupuncture with manual stimulation for depression; the control conditions consisted of (1) a nonspecific intervention using a comparable number of legitimate acupuncture points not specifically targeted to depressive symptoms and (2) a waitlist condition, which involved waiting without intervention for 8 weeks. After 8 weeks, all patients received the depression-specific acupuncture. Each 8-week intervention regimen consisted of 12 acupuncture sessions delivered in an acupuncturist's office in the community. The primary outcome measure was the 17-item Hamilton Rating Scale for Depression. The study was conducted from February 1998 to April 2002.Twenty patients terminated treatment before the completion of the 8-week intervention (13%) but not differentially by study group. Random regression models of the intent-to-treat sample revealed that although patients receiving acupuncture improved more than those awaiting intervention, no evidence of differential efficacy of the depression-specific over nonspecific intervention was found. Response rates in acupuncture-treated patients were relatively low after 8 weeks (22% and 39% for specific and nonspecific intervention groups, respectively), with the response rate after the entire 16-week trial reaching 50%.Although TCM manual acupuncture is a well-tolerated intervention, results fail to support its efficacy as a monotherapy for MDD. It can't be ruled out that factors unique to the implementation of acupuncture in this research study may have limited the efficacy of interventions compared to those provided in naturalistic identifier NCT00010517.

    View details for Web of Science ID 000242432300001

    View details for PubMedID 17196044

  • A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and sleep quality FERTILITY AND STERILITY Huang, M. I., Nir, Y., Chen, B., Schnyer, R., Manber, R. 2006; 86 (3): 700-710


    To assess the effectiveness of acupuncture on postmenopausal nocturnal hot flashes and sleep.Prospective randomized placebo-controlled study.Stanford University School of Medicine and private acupuncture offices.Active or placebo acupuncture was administered for nine sessions over seven weeks.Severity and frequency of nocturnal hot flashes from daily diaries and Pittsburgh Sleep Quality Index (PSQI).Twenty-nine postmenopausal women experiencing at least seven moderate to severe hot flashes daily, with E(2) <18 pg/mL and FSH 30.0-110.0 IU/L.Nocturnal hot-flash severity significantly decreased in the active acupuncture group (28%) compared with the placebo group (6%), P=.017. The frequency of nocturnal hot flashes also decreased in the active group (47%, P=.001), though it was not significantly different from the placebo group (24%, P=.170; effect size = 0.65). Treatment did not differentially influence sleep; however, correlations between improvements in PSQI and reductions in nocturnal hot flash severity and frequency were significant (P<.026).Acupuncture significantly reduced the severity of nocturnal hot flashes compared with placebo. Given the strength of correlations between improvements in sleep and reductions in nocturnal hot flashes, further exploration is merited.

    View details for DOI 10.1016/j.fertnstert.2006.02.100

    View details for Web of Science ID 000240998000036

    View details for PubMedID 16952511

  • The therapeutic alliance and CBASP-specific skill acquisition in the treatment of chronic depression COGNITIVE THERAPY AND RESEARCH Santiago, N. J., Klein, D. N., Vivian, D., Arnow, B. A., Blalock, J. A., Kocsis, J. H., Markowitz, J. C., Manber, R., Riso, L. P., Rothbaum, B. O., Rush, A. J., Thase, M. F., McCullough, J. P., Keller, M. B. 2005; 29 (6): 803-817
  • Historical perspective and future directions in Cognitive Behavioral Therapy for insomnia and behavioral sleep medicine CLINICAL PSYCHOLOGY REVIEW Manber, R., Harvey, A. 2005; 25 (5): 535-538

    View details for DOI 10.1016/J.CPR.2005.04.002

    View details for Web of Science ID 000230812200001

    View details for PubMedID 15950345

  • Chronic depression - Medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not ARCHIVES OF GENERAL PSYCHIATRY Schatzberg, A. F., Rush, A. J., Arnow, B. A., Banks, P. L., Blalock, J. A., Borian, F. E., Howland, R., Klein, D. N., Kocsis, J. H., Kornstein, S. G., Manber, R., Markowitz, J. C., Miller, I., Ninan, P. T., Rothbaum, B. O., Thase, M. E., Trivedi, M. H., Keller, M. B. 2005; 62 (5): 513-520


    Although various strategies are available to manage nonresponders to an initial treatment for depression, no controlled trials address the utility of switching from an antidepressant medication to psychotherapy or vice versa.To compare the responses of chronically depressed nonresponders to 12 weeks of treatment with either nefazodone or cognitive behavioral analysis system of psychotherapy (CBASP) who were crossed over to the alternate treatment (nefazodone, n = 79; CBASP, n = 61).Crossover trial.Twelve academic outpatient psychiatric centers.There were 140 outpatients with chronic major depressive disorder; 92 (65.7%) were female, 126 (90.0%) were white, and the mean age was 43.1 years. Thirty participants dropped out of the study prematurely, 22 in the nefazodone group and 8 in the CBASP group.Treatment lasted 12 weeks. The dosage of nefazodone was 100 to 600 mg/d; CBASP was provided twice weekly during weeks 1 through 4 and weekly thereafter.The 24-item Hamilton Rating Scale for Depression, administered by raters blinded to treatment, the Clinician Global Impressions-Severity scale, and the 30-item Inventory for Depressive Symptomatology-Self-Report.Analysis of the intent-to-treat sample revealed that both the switch from nefazodone to CBASP and the switch from from CBASP to nefazodone resulted in clinically and statistically significant improvements in symptoms. Neither the rates of response nor the rates of remission were significantly different when the groups of completers were compared. However, the switch to CBASP following nefazodone therapy was associated with significantly less attrition due to adverse events, which may explain the higher intent-to-treat response rate among those crossed over to CBASP (57% vs 42%).Among chronically depressed individuals, CBASP appears to be efficacious for nonresponders to nefazodone, and nefazodone appears to be effective for CBASP nonresponders. A switch from an antidepressant medication to psychotherapy or vice versa appears to be useful for nonresponders to the initial treatment.

    View details for Web of Science ID 000228905600007

    View details for PubMedID 15867104

  • Self-reported depressive symptom measures: Sensitivity to detecting change in a randomized, controlled trial of chronically depressed, nonpsychotic outpatients NEUROPSYCHOPHARMACOLOGY Rush, A. J., Trivedi, M. H., Carmody, T. J., Ibrahim, H. M., Markowitz, J. C., Keitner, G. I., Kornstein, S. G., Arnow, B., Klein, D. N., Manber, R., Dunner, D. L., Gelenberg, A. J., Kocsis, J. H., Nemeroff, C. B., Fawcett, J., Thase, M. E., Russell, J. M., Jody, D. N., Borian, F. E., Keller, M. B. 2005; 30 (2): 405-416


    This study evaluated and compared the performance of three self-report measures: (1) 30-item Inventory of Depressive Symptomatology-Self-Report (IDS-SR30); (2) 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16); and (3) Patient Global Impression-Improvement (PGI-I) in assessing clinical outcomes in depressed patients during a 12-week, acute phase, randomized, controlled trial comparing nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), and the combination in the treatment of chronic depression. The IDS-SR30, QIDS-SR16, PGI-I, and the 24-item Hamilton Depression Rating Scale (HDRS24) ratings were collected at baseline and at weeks 1-4, 6, 8, 10, and 12. Response was defined a priori as a > or =50% reduction in baseline total score for the IDS-SR30 or for the QIDS-SR16 or as a PGI-I score of 1 or 2 at exit. Overall response rates (LOCF) to nefazodone were 41% (IDS-SR30), 45% (QIDS-SR16), 53% (PCI-I), and 47% (HDRS17). For CBASP, response rates were 41% (IDS-SR30), 45% (QIDS-SR16), 48% (PGI-I), and 46% (HDRS17). For the combination, response rates were 68% (IDS-SR30 and QIDS-SR16), 73% (PGI-I), and 76% (HDRS17). Similarly, remission rates were comparable for nefazodone (IDS-SR30=32%, QIDS-SR16=28%, PGI-I=22%, HDRS17=30%), for CBASP (IDS-SR30=32%, QIDS-SR16=30%, PGI-I=21%, HDRS17=32%), and for the combination (IDS-SR30=52%, QIDS-SR16=50%, PGI-I=25%, HDRS17=49%). Both the IDS-SR30 and QIDS-SR16 closely mirrored and confirmed findings based on the HDRS24. These findings raise the possibility that these two self-reports could provide cost- and time-efficient substitutes for clinician ratings in treatment trials of outpatients with nonpsychotic MDD without cognitive impairment. Global patient ratings such as the PGI-I, as opposed to specific item-based ratings, provide less valid findings.

    View details for DOI 10.1038/sj.npp.1300614

    View details for Web of Science ID 000226569900020

    View details for PubMedID 15578008

  • Sleep disturbance and depression symptom severity in postpartum women 19th Annual Meeting of the Associated-Professional-Sleep-Societies Packard, A. E., Martin-Okada, R., Huang, M. I., Manber, R. AMER ACAD SLEEP MEDICINE. 2005: A308–A309
  • Morningness/eveningness and CBT for insomnia 19th Annual Meeting of the Associated-Professional-Sleep-Societies Huang, J. S., Ong, J. C., Kuo, T. F., Manber, R. AMER ACAD SLEEP MEDICINE. 2005: A226–A227
  • Chronic insomnia and health care utilization 19th Annual Meeting of the Associated-Professional-Sleep-Societies Lee, C., Kuo, T. F., Manber, R. AMER ACAD SLEEP MEDICINE. 2005: A236–A236
  • Therapist variables that predict symptom change in psychotherapy with chronically depressed outpatients PSYCHOTHERAPY Vocisano, C., Klein, D. N., Arnow, B., RIVERA, C., Blalock, J. A., Rothbaum, B., Vivian, D., Markowitz, J. C., Kocsis, J. H., Manber, R., Castonguay, L., Rush, A. J., Borian, F. E., McCullough, J. P., Kornstein, S. G., Riso, L. P., Thase, M. E. 2004; 41 (3): 255-265
  • Cognitive-behavioral analysis system of psychotherapy as a maintenance treatment for chronic depression JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Klein, D. N., Santiago, N. J., Vivian, D., Arnow, B. A., Blalock, J. A., Dunner, D. L., Kocsis, J. H., Markowitz, J. C., Manber, R., McCullough, J. P., Rothbaum, B., Rush, A. J., Trivedi, M. H., Thase, M. E., Borian, F. E., Keitner, G. I., Miller, I. W., Keller, M. B. 2004; 72 (4): 681-688


    Although the efficacy of maintenance pharmacotherapy for the prevention of recurrence in major depressive disorder (MDD) is well documented, few studies have tested the efficacy of psychotherapy as a maintenance treatment. The authors examined the efficacy of the cognitive-behavioral analysis system of psychotherapy (CBASP) as a maintenance treatment for chronic forms of MDD. Eighty-two patients who had responded to acute and continuation phase CBASP were randomized to monthly CBASP or assessment only for 1 year. Significantly fewer patients in the CBASP than assessment only condition experienced a recurrence. The 2 conditions also differed significantly on change in depressive symptoms over time. These findings support the use of CBASP as a maintenance treatment for chronic forms of MDD.

    View details for DOI 10.1037/0022-006X.72.4.681

    View details for Web of Science ID 000222924600015

    View details for PubMedID 15301653

  • Management of bipolar disorder during pregnancy and the postpartum period AMERICAN JOURNAL OF PSYCHIATRY Yonkers, K. A., Wisner, K. L., Stowe, Z., Leibenluft, E., Cohen, L., Miller, L., Manber, R., Viguera, A., Suppes, T., Altshuler, L. 2004; 161 (4): 608-620


    Bipolar disorder affects 0.5%-1.5% of individuals in the United States. The typical age at onset is late adolescence or early adulthood, placing women at risk for episodes throughout their reproductive years. General guidelines for the treatment of bipolar disorder are available from the American Psychiatric Association, but additional issues arise when these guidelines are applied in the treatment of peripartum women. The authors summarize knowledge regarding the management of bipolar disorder during pregnancy and the postpartum period, with a focus on managing mania, hypomania, and the psychotic components of the illness.An expert panel reviewed articles that address the management of bipolar disorder and the consequences of the use of mood stabilizers during pregnancy, and a consensus document was generated.The treatment of bipolar disorder in pregnant women involves significant challenges. Some mood stabilizers, e.g., sodium valproate and carbamazepine, are human teratogens. On the other hand, the teratogenicity associated with lithium may have been overestimated in the past.Since treatment can be managed most effectively if pregnancy is planned, clinicians should discuss the issue of pregnancy and its management with every bipolar disorder patient who has childbearing potential, regardless of future reproductive plans. Additional research should address the risks of disturbed sleep to pregnant and postpartum women with bipolar disorder, as well as structural and behavioral consequences to offspring when mood stabilizers are used during pregnancy. Longitudinal and cohort studies can promote these efforts. Given the rate of bipolar disorder in the general population, research efforts will need to be broad based and include multiple collaborating centers.

    View details for Web of Science ID 000221276200003

    View details for PubMedID 15056503

  • Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D., Vocisano, C., Castonguay, L. G., Arnow, B., Blalock, J. A., Manber, R., Markowitz, J. C., Riso, L. P., Rothbaum, B., McCullough, J. P., Thase, M. E., Borian, F. E., Miller, I. W., Keller, M. B. 2003; 71 (6): 997-1006


    Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.

    View details for DOI 10.1037/0022-006X.71.6.997

    View details for Web of Science ID 000186693600005

    View details for PubMedID 14622075

  • Therapeutic reactance as a predictor of outcome in the treatment of chronic depression JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Arnow, B. A., Manber, R., Blasey, C., Klein, D. N., Blalock, J. A., Markowitz, J. C., Rothbaum, B. O., Rush, A. J., Thase, M. E., Riso, L. P., Vivian, D., McCullough, J. P., Keller, M. B. 2003; 71 (6): 1025-1035


    This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone, cognitive-behavioral analysis system of psychotherapy (CBASP), or combination therapy. Contrary to our hypotheses, reactance positively predicted treatment outcome in CBASP on 2 of 4 scales. These effects were independent of the therapeutic alliance, which also positively predicted outcome. Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP. The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship. Results support the importance of Aptitude * Treatment interactions in psychotherapy outcome. The direction and significance of such interactions may vary with different forms of psychopathology.

    View details for DOI 10.1037/0022-006X.71.6.1025

    View details for Web of Science ID 000186693600008

    View details for PubMedID 14622078

  • Randomized, placebo-controlled trial of nefazodone maintenance treatment in preventing recurrence in chronic depression BIOLOGICAL PSYCHIATRY Gelenberg, A. J., Trivedi, M. H., Rush, A. J., Thase, M. E., Howland, R., Klein, D. N., Kornstein, S. G., Dunner, D. L., Markowitz, J. C., Hirschfeld, R. M., Keitner, G. I., Zajecka, J., Kocsis, J. H., Russell, J. M., Miller, I., Manber, R., Arnow, B., Rothbaum, B., Munsaka, M., Banks, P., Borian, F. E., Keller, M. B. 2003; 54 (8): 806-817


    Maintenance treatment to prevent recurrences is recommended for chronic forms of major depressive disorder (MDD), but few studies have examined maintenance efficacy of antidepressants with chronic MDD. This randomized, placebo-controlled study of the efficacy and safety of nefazodone in preventing recurrence was conducted for patients with chronic MDD.A total of 165 outpatients with chronic, nonpsychotic MDD, MDD plus dysthymic disorder ("double-depression"), or recurrent MDD with incomplete inter-episode recovery, who achieved and maintained a clinical response during acute and continuation treatment with either nefazodone alone or nefazodone combined with psychotherapy, were randomized to 52 weeks of double-blind nefazodone (maximum dose 600 mg/day) or placebo. The occurrence of major depressive episodes during maintenance treatment was assessed with the 24-item Hamilton Rating Scale for Depression, a DSM-IV MDD checklist, and a blinded review of symptom exacerbations by a consensus committee of research clinicians.Application of a competing-risk model that estimated the conditional probability of recurrence among those patients remaining on active therapy revealed a significant (p =.043) difference between nefazodone (n = 76) and placebo (n = 74) when the latter part of the 1-year maintenance period was emphasized. At the end of 1 year, the conditional probability of recurrence was 30.3% for nefazodone-treated patients, compared with 47.5% for placebo-treated patients. Prior concomitant psychotherapy during acute/continuation treatment, although enhancing the initial response, was not associated with lower recurrence rates. Discontinuations due to adverse events were relatively low for both nefazodone (5.3%) and placebo (4.8%). Somnolence was significantly greater among the patients taking active medication (15.4%), compared with placebo (4.6%).Nefazodone is well-tolerated and is an effective maintenance therapy for chronic forms of MDD.

    View details for DOI 10.1016/S0006-3223(02)01971-6

    View details for Web of Science ID 000185750100005

    View details for PubMedID 14550680

  • The 16-item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in patients with chronic major depression BIOLOGICAL PSYCHIATRY Rush, A. J., Trivedi, M. H., Ibrahim, H. M., Carmody, T. J., Arnow, B., Klein, D. N., Markowitz, J. C., Ninan, P. T., Kornstein, S., Manber, R., Thase, M. E., Kocsis, J. H., Keller, M. B. 2003; 54 (5): 573-583


    The 16-item Quick Inventory of Depressive Symptomatology (QIDS), a new measure of depressive symptom severity derived from the 30-item Inventory of Depressive Symptomatology (IDS), is available in both self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) formats. This report evaluates and compares the psychometric properties of the QIDS-SR(16) in relation to the IDS-SR(30) and the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) in 596 adult outpatients treated for chronic nonpsychotic, major depressive disorder. Internal consistency was high for the QIDS-SR(16) (Cronbach's alpha =.86), the IDS-SR(30) (Cronbach's alpha =.92), and the HAM-D(24) (Cronbach's alpha =.88). QIDS-SR(16) total scores were highly correlated with IDS-SR(30) (.96) and HAM-D(24) (.86) total scores. Item-total correlations revealed that several similar items were highly correlated with both QIDS-SR(16) and IDS-SR(30) total scores. Roughly 1.3 times the QIDS-SR(16) total score is predictive of the HAM-D(17) (17-item version of the HAM-D) total score. The QIDS-SR(16) was as sensitive to symptom change as the IDS-SR(30) and HAM-D(24), indicating high concurrent validity for all three scales. The QIDS-SR(16) has highly acceptable psychometric properties, which supports the usefulness of this brief rating of depressive symptom severity in both clinical and research settings.

    View details for DOI 10.1016/S0006-3223(03)01866-8

    View details for Web of Science ID 000184906100009

    View details for PubMedID 12946886

  • Insomnia and heart rate variability in depression 17th Annual Meeting of the Associated-Professional-Sleep-Societies Manber, R., Chambers, A. S., Allen, J. J. AMER ACAD SLEEP MEDICINE. 2003: A375–A375
  • The effects of psychotherapy, nefazodone, and their combination on subjective assessment of disturbed sleep in chronic depression SLEEP Manber, R., Rush, A. J., Thase, M. E., Arnow, B., Klein, D., Trivedi, M. H., Korenstein, S. G., Markowitz, J. C., Dunner, D. L., Munsaka, M., Borian, F. E., Keller, M. B. 2003; 26 (2): 130-136


    The purpose of the study was to compare the effects of psychotherapy, nefazodone, and their combination on subjective measures of sleep in patients with chronic forms of major depression.Participants were randomized to receive 12 weeks of treatment with one of the three interventions.The study was conducted in parallel at 12 academic institutions and was approved by the Human Subjects Committee at each site.484 adult outpatients (65.29% female) who met DSM-IV criteria for one of three chronic forms of major depression.Psychotherapy (16-20 sessions) was provided by certified therapists following a standardized treatment manual for Cognitive Behavioral Analysis System of Psychotherapy (CBASP), a variant of cognitive psychotherapy developed for chronic depression. Pharmacotherapy consisted of open-label nefazodone, 300-600 mg per day in two divided doses prescribed by psychiatrists. The clinical management visits were limited to 15-20 minutes and followed a standardized protocol. Combination treatment consisted of both therapies.Depression outcome was determined by the 24-item Hamilton Rating Scale for Depression and the 30-item Inventory of Depressive Symptomatology-Self Rating. Sleep outcome was measured prospectively with daily sleep diaries that were completed a week prior to HRSD assessments at baseline and after 1, 2, 3, 4, 8, and 12 weeks of treatment. Although nefazodone alone and CBASP alone had comparable impact on global measures of depression outcome, only monotherapy with nefazodone improved early morning awakening and total sleep time. Significant improvements in sleep quality, time awake after sleep onset, latency to sleep onset, and sleep efficiency were present in each of the three treatment groups. These improvements, however, occurred earlier in the course of treatment for participants receiving nefazodone, alone or in combination with CBASP.Nefazodone therapy may have a direct impact on disturbed sleep associated with depression beyond what would be expected if the improvements were all a consequence of improved depression.

    View details for Web of Science ID 000181541300003

    View details for PubMedID 12683470

  • The effects of hormone replacement therapy on sleep-disordered breathing in postmenopausal women: A pilot study SLEEP Manber, R., Kuo, T. F., Cataldo, N., Colrain, I. M. 2003; 26 (2): 163-168


    To evaluate the impact of estrogen and estrogen plus progesterone hormone-replacement therapy (HRT) on mild-to-moderate sleep-disordered breathing (SDB) in postmenopausal women.Within-subjects, progesterone placebo-controlled prospective HRT trial in a clinical laboratory.Six postmenopausal women, diagnosed with mild-moderate SDB.Transdermal estradiol and oral micronized progesterone.Subjects underwent polysomnography (PSG) on four occasions: a screening/adaptation night; a baseline night on no HRT; and two nights on HRT: one night after 7 to 12 days on estrogen plus placebo followed by a second night after 7-13 days on estrogen plus progesterone. The PSG was performed with a Sandman computerized PSG system using a standard clinical montage. Modified sleep diaries were used in the baseline week and throughout the study period. Mood was measured with the 20-item version of the Positive and Negalive Affect Schedule (PANAS). Estrogen monotherapy was associated with a significant reduction in the overall apnea-hypopnea index (AHI) (from a mean of 22.7 events per hour at baseline to a mean of 12.2 events per hour), but the AHI reduction on estradiol plus progesterone relative to baseline was not statistically significant (AHI=16.2 events per hour). Similar results were found for the percentages of total sleep time and of total non-rapid eye movement sleep time with oxygen saturation less than 90%. Estrogen, neither alone nor in combination with progesterone, significantly altered PSG- or diary-based measures of total sleep time, time to sleep onset, or time awake after sleep onset.While the data are preliminary and based on a small number of subjects, estrogen appeared to have a substantial beneficial effect on measures of SDB in postmenopausal women. Overall, no additional benefit was seen with the addition of progesterone. In fact, progesterone attenuated the beneficial effects of estrogen in 4 out of the 6 participants.

    View details for Web of Science ID 000181541300008

    View details for PubMedID 12683475

  • Acupuncture for depression during pregnancy: Conceptual Framework and Two Case Reports Complementary Health Practice Review Schnyer, R. N., Manber, R., Fitzcharles, A. J. 2003; 8 (1): 40-53
  • Sexual function and satisfaction in the treatment of chronic major depression with nefazodone, psychotherapy, and their combination JOURNAL OF CLINICAL PSYCHIATRY Zajecka, J., Dunner, D. L., Gelenberg, A. J., Hirschfeld, R. M., Kornstein, S. G., Ninan, P. T., Rush, A. J., Thase, M. E., Trivedi, M. H., Arnow, B. A., Borian, F. E., Manber, R., Keller, M. B. 2002; 63 (8): 709-716


    Changes in sexual interest/satisfaction and function are frequently associated with major depression and the use of some antidepressant treatments. This study compares the effects of antidepressant medication, psychotherapy, and combined treatment on sexual interest/satisfaction and function in patients with chronic major depression.Outpatients with chronic forms of DSM-IV major depressive disorder (N = 681) were randomly assigned to 12 weeks of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combined nefazodone/CBASP. The Modified Rush Sexual Inventory was used to assess sexual functioning, and the 24-item Hamilton Rating Scale for Depression was used to assess depressive symptoms.At baseline, 65% of men and 48% of women reported some sexual dysfunction. Statistically significant linear improvement in sexual interest/satisfaction was noted across all 3 treatment groups (p < .001). Additionally, significant improvement in sexual function was observed across all 3 treatment groups on a composite measure of female sexual function (p < .001). Controlling for depressive symptoms and gender, combined treatment produced greater improvement in total sexual interest/satisfaction than CBASP alone (p = .007), but was not significantly different from nefazodone alone. Improvement in depressive symptoms was associated with improved sexual interest/satisfaction for men and women and, for men, improved sexual functioning.Chronic depression is associated with high rates of sexual dysfunction. Treatment with nefazodone, CBASP, and combined treatment improved sexual interest/satisfaction, with greatest improvement observed with combined treatment.

    View details for Web of Science ID 000177510300009

    View details for PubMedID 12197452

  • Alternative treatments for depression: Empirical support and relevance to women Seminar on Women and Depression Manber, R., Allen, J. J., Morris, M. M. PHYSICIANS POSTGRADUATE PRESS. 2002: 628-?


    This article is a critical review of the efficacy of selected alternative treatments for unipolar depression including exercise, stress management techniques, acupuncture, St. John's wort, bright light, and sleep deprivation. Issues related to women across the life span, including pregnancy and lactation, are highlighted.Evidence of efficacy is based on randomized controlled trials. A distinction is made between studies that address depressive symptoms and studies that address depressive disorders. The review emphasizes issues related to effectiveness, such as treatment availability, acceptability, safety, and cost and issues relevant to women.Exercise, stress reduction methods, bright light exposure, and sleep deprivation hold greater promise as adjuncts to conventional treatment than as monotherapies for major depression. The evidence to date is not sufficiently compelling to suggest the use of St. John's wort in favor of or as an alternative to existing U.S. Food and Drug Administration-regulated compounds. Initial evidence suggests that acupuncture might be an effective alternative monotherapy for major depression, single episode.This review indicates that some unconventional treatments hold promise as alternative or complementary treatments for unipolar depression in women and have the potential to contribute to its long-term management. Additional research is needed before further recommendations can be made, and there is an urgent need to carefully document and report the frequency of minor and major side effects.

    View details for Web of Science ID 000176954500019

    View details for PubMedID 12143922

  • Differential effects of nefazodone and cognitive behavioral analysis system of psychotherapy on insomnia associated with chronic forms of major depression JOURNAL OF CLINICAL PSYCHIATRY Thase, M. E., Rush, A. J., Manber, R., Kornstein, S. G., Klein, D. N., Markowitz, J. C., Ninan, P. T., Friedman, E. S., Dunner, D. L., Schatzberg, A. F., Borian, F. E., Trivedi, M. H., Keller, M. B. 2002; 63 (6): 493-500


    The antidepressant nefazodone and the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) were recently found to have significant, additive effects in a large multicenter study of chronic forms of major depression. As nefazodone-mediated blockade of serotonin-2 receptors may directly relieve insomnia associated with depression, we examined the more specific effects of CBASP and nefazodone, singly and in combination, on sleep disturbances.A total of 597 chronically depressed outpatients (DSM-III-R criteria) with at least 1 insomnia symptom were randomly assigned to 12 weeks of treatment with nefazodone (mean final dose = 466 mg/day), CBASP (mean = 16.0 sessions), or the combination (mean dose = 460 mg/day plus a mean of 16.2 CBASP sessions). Continuous and categorical insomnia outcomes, derived from standard clinician- and self-rated assessments, were compared.Patients receiving nefazodone (either alone or in combination with CBASP) obtained significantly more rapid and greater ultimate improvement in insomnia ratings when compared with those treated with CBASP alone. This difference was maximal by the fourth week of therapy and sustained thereafter. Combined treatment did not result in markedly better insomnia scores than treatment with nefazodone alone on most measures, although patients receiving both CBASP and nefazodone were significantly more likely (p < .001) to achieve > or = 50% decrease in insomnia severity.Despite comparable antidepressant efficacy, monotherapy with nefazodone or CBASP resulted in markedly different effects on the magnitude and temporal course of insomnia symptoms associated with chronic forms of major depression. Patients receiving the combination of psychotherapy and pharmacotherapy benefited from both the larger and more rapid improvements in insomnia associated with nefazodone therapy and the later-emerging effects of CBASP on the overall depressive syndrome.

    View details for Web of Science ID 000176419700005

    View details for PubMedID 12088160

  • Emotional blunting associated with SSRI-induced sexual dysfunction. Do SSRIs inhibit emotional responses? INTERNATIONAL JOURNAL OF NEUROPSYCHOPHARMACOLOGY Opbroek, A., Delgado, P. L., Laukes, C., McGahuey, C., Katsanis, J., Moreno, F. A., Manber, R. 2002; 5 (2): 147-151


    Anecdotal and published case reports suggest that some patients taking selective serotonin reuptake inhibitors (SSRI) experience diminution in emotional responsiveness. This study aims to define the individual components of emotion disturbed in these patients. Fifteen patients reporting SSRI-induced sexual dysfunction completed the Laukes Emotional Intensity Scale (LEIS), a questionnaire about various emotions. Compared to controls, patients reported significantly (p<0.05) less ability to cry, irritation, care about others' feelings, sadness, erotic dreaming, creativity, surprise, anger, expression of their feelings, worry over things or situations, sexual pleasure, and interest in sex. Total score on the LEIS did not correlate with total score on the Hamilton Depression Rating Scale. In our sample, 80% of patients with SSRI-induced sexual dysfunction also describe clinically significant blunting of several emotions. Emotional blunting may be an under-appreciated side-effect of SSRIs that may contribute to treatment non-compliance and/or reduced quality of life.

    View details for DOI 10.1017/S1461145702002870

    View details for Web of Science ID 000176657300006

    View details for PubMedID 12135539

  • Symptomatic and syndromal anxiety in chronic forms of major depression: Effect of nefazodone, cognitive behavioral analysis system of psychotherapy, and their combination 153rd Annual Meeting of the American-Psychiatric-Association Ninan, P. T., Rush, J., Crits-Christoph, P., Kornstein, S. G., Manber, R., Thase, M. E., Trivedi, M. H., Rothbaum, B. O., Zajecka, J., Borian, F. E., Keller, M. B. PHYSICIANS POSTGRADUATE PRESS. 2002: 434–41


    Limited information is available on treatment response of anxiety symptoms in chronic forms of major depression. Concurrent anxiety disorders are prevalent in chronic depression, but the responsiveness of patients with such comorbidity to different treatments is largely unknown. This study investigated the comparative efficacy of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), and their combination in improving anxiety symptoms in patients with chronic forms of major depression, including those with a concurrent anxiety disorder.681 patients with chronic major depressive disorder (DSM-IV criteria) participated in a multicenter study of 12 weeks of acute treatment with nefazodone (N = 226), CBASP (N = 228), or the combination (N = 227). The Hamilton Rating Scale for Anxiety (HAM-A), the HAM-A psychic anxiety factor, and the anxiety/arousal subscale of the 30-item Inventory for Depressive Symptomatology-Self Report (IDS-SR-30) were used to assess anxiety symptoms.In the full sample. without controlling for change in depressive symptoms, combination therapy was superior to both monotherapies on all 3 anxiety measures both in the rate of change and at endpoint. When change in depressive symptoms was controlled for, there were no treatment differences in rate of change from baseline to week 12 on any of the 3 anxiety measures. In those patients with a concurrent anxiety disorder, however, the combination was superior to CBASP on the HAM-A and the IDS-SR-30. Nefazodone alone and combination therapy were both superior to CBASP on the HAM-A psychic anxiety factor.For patients with chronic depression, combination therapy is superior to CBASP or nefazodone alone. Among patients with a concurrent anxiety disorder, nefazodone. either alone or in combination with CBASP, improves anxiety symptoms faster than CBASP alone, independent of depressive symptom reduction.

    View details for Web of Science ID 000175596300010

    View details for PubMedID 12025827

  • Pretreatment Correlates of the Therapeutic Alliance in the Chronically Depressed J Contemporary Psychotherapy Santiago, N. H., Klein, D. N., Vivian, D., Vocisano, C., Dowling, F. B., Arnow, B. A., Manber, R., Markowitz, J. C., McCullough, J. P., Riso, L. P., Rothbaum, B. O., Ruch, A. J., Thase, M. E., Keller, M. B. 2002; 32 (4): 281-290
  • Six-month depression relapse rates among women treated with acupuncture COMPLEMENTARY THERAPIES IN MEDICINE Gallagher, S. M., Allen, J. J., Hitt, S. K., Schnyer, R. N., Manber, R. 2001; 9 (4): 216-218


    Conventional treatments for Major Depression, although reasonably effective, leave many without lasting relief. Alternative approaches would therefore be welcome for both short- and long-term treatment of depression. Thirty-eight women were randomized to one of three treatment conditions in a double-blind randomized controlled trial of acupuncture in depression. All participants eventually received eight weeks of acupuncture treatment specifically for depression. From among the 33 women who completed treatment, 26 (79%) were intertiewed at six-month follow-up. Relapse rates were comparable to those of established treatments, with four of the 17 women (24%) who achieved full remission at the conclusion of treatment experiencing a relapse six months later. Compared to other empirically validated treatments, acupuncture designed specifically to treat major depression produces results that are comparable in terms of rates of response and of relapse or recurrence. These results suggest a larger trial of acupuncture in the acute- and maintenance-phase treatment of depression is warranted.

    View details for DOI 10.1054/ctim.2001.0470

    View details for Web of Science ID 000175132000003

    View details for PubMedID 12184348

  • Valence-dependent modulation of psychophysiological measures: Is there consistency across repeated testing? 36th Annual Meeting of the Society-for-Psychophysiological-Research Manber, R., Allen, J. J., Burton, K., KASZNIAK, A. W. BLACKWELL PUBLISHING. 2000: 683–92


    The present study used the picture perception paradigm to examine the extent to which three well-documented psychophysiological measures demonstrate consistency across time in response to emotional stimuli. The three measures were the eye-blink startle response and the activation in two facial muscle regions (zygomatic and corrugator). Twenty-seven young women were assessed on two occasions, 2 weeks apart. Whereas activation in the corrugator and zygomatic muscle regions demonstrated the predicted patterns at both assessments (with some attenuation in the zygomatic muscle regions), the startle response had limited consistency across the two assessments. The startle response revealed the predicted linear pattern of valence modulation during the first assessment. During the second assessment, startle magnitude response was a quadratic function of valence ratings and a linear function of arousal ratings. The unexpected pattern of startle response during the second session appeared to be related to the content of the pleasant slides, with action slides generating quadratic valence modulation and erotic slides continuing to exhibit the expected linear valence modulation.

    View details for Web of Science ID 000089677900011

    View details for PubMedID 11037044

  • A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England journal of medicine Keller, M. B., McCullough, J. P., Klein, D. N., Arnow, B., Dunner, D. L., Gelenberg, A. J., Markowitz, J. C., Nemeroff, C. B., Russell, J. M., Thase, M. E., Trivedi, M. H., Zajecka, J. 2000; 342 (20): 1462-1470


    Patients with chronic forms of major depression are difficult to treat, and the relative efficacy of medications and psychotherapy is uncertain.We randomly assigned 681 adults with a chronic nonpsychotic major depressive disorder to 12 weeks of outpatient treatment with nefazodone (maximal dose, 600 mg per day), the cognitive behavioral-analysis system of psychotherapy (16 to 20 sessions), or both. At base line, all patients had scores of at least 20 on the 24-item Hamilton Rating Scale for Depression (indicating clinically significant depression). Remission was defined as a score of 8 or less at weeks 10 and 12. For patients who did not have remission, a satisfactory response was defined as a reduction in the score by at least 50 percent from base line and a score of 15 or less. Raters were unaware of the patients' treatment assignments.Of the 681 patients, 662 attended at least one treatment session and were included in the analysis of response. The overall rate of response (both remission and satisfactory response) was 48 percent in both the nefazodone group and in the psychotherapy group, as compared with 73 percent in the combined-treatment group. (P<0.001 for both comparisons). Among the 519 subjects who completed the study, the rates of response were 55 percent in the nefazodone group and 52 percent in the psychotherapy group, as compared with 85 percent in the combined-treatment group (P<0.001 for both comparisons). The rates of withdrawal were similar in the three groups. Adverse events in the nefazodone group were consistent with the known side effects of the drug (e.g., headache, somnolence, dry mouth, nausea, and dizziness).Although about half of patients with chronic forms of major depression have a response to short-term treatment with either nefazodone or a cognitive behavioral-analysis system of psychotherapy, the combination of the two is significantly more efficacious than either treatment alone.

    View details for PubMedID 10816183

  • A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression NEW ENGLAND JOURNAL OF MEDICINE Keller, M. B., McCullough, J. P., Klein, D. N., Arnow, B., Dunner, D. L., Gelenberg, A. J., Markowitz, J. C., Nemeroff, C. B., Russell, J. M., Thase, M. E., Trivedi, M. H., Zajecka, J., Blalock, J. A., Borian, F. E., Jody, D. N., Debattista, C., Koran, L. M., Schatzberg, A. F., Fawcett, J., Hirschfeld, R. M., Keitner, G., Miller, I., Kocsis, J. H., Kornstein, S. G., Manber, R., Ninan, P. T., Rothbaum, B., Rush, A. J., Vivian, D., Rothbaum, B. 2000; 342 (20): 1462-1470
  • The Arizona Sexual Experience Scale (ASEX): Reliability and validity JOURNAL OF SEX & MARITAL THERAPY McGahuey, C. A., Gelenberg, A. J., Laukes, C. A., Moreno, F. A., Delgado, P. L., McKnight, K. M., Manber, R. 2000; 26 (1): 25-40


    Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.

    View details for Web of Science ID 000084786600002

    View details for PubMedID 10693114

  • Sex, steroids, and sleep: A review SLEEP Manber, R., Armitage, R. 1999; 22 (5): 540-555


    The present article reviews direct and indirect evidence of the effects of sex steroids on different aspects of sleep. It begins with a review of what is known about the effects of steroid hormones on sleep and on central nervous system processes related to sleep, such as the GABA-ergic system, in animals. It continues with a review of the effects of exogenous hormones on human sleep and a review of studies comparing sleep during hypogonadal states secondary to surgical or natural menopause. The article proceeds to review the data on the effects of the menstrual cycle on both subjective and objective aspects of sleep and circadian temperature and melatonin rhythms in samples of healthy women, women with premenstrual dysphoric disorder, and women with primary insomnia. Then, the article reviews gender differences in sleep during depression and raises the possibility that sex steroids moderate these differences. Finally, the article concludes with a discussion of the implications of the data reviewed for basic clinical, and methodological aspects of sleep research.

    View details for Web of Science ID 000081894700001

    View details for PubMedID 10450590

  • Sleep Disorders. In: Comprehensive Clinical Psychology A. Bellack & M. Hersen (Eds.) Oxford, England: Elsevier Science LTD. Manber, R., Bootzin, R.R., & Lowey, D. 1998: 505-527.
  • Sleep and the menstrual cycle HEALTH PSYCHOLOGY Manber, R., Bootzin, R. R. 1997; 16 (3): 209-214


    To evaluate changes in sleep across the phases of the menstrual cycle, sleep-wake diaries were completed by 32 healthy women twice daily for 2 menstrual cycles. There was a significant increase in sleep onset latency and a significant decrease in sleep efficiency and sleep quality during the luteal phase. This increase in sleep disturbance was observed in the entire sample and was not related to the severity of other premenstrual symptoms. However, women having increased severity of other premenstrual symptoms reported greater luteal increase in daytime sleepiness. Thus, although menstruating women are likely to show increased sleep disturbance during the luteal phase, those with other, more severe premenstrual symptoms are more likely to experience a luteal increase in daytime sleepiness.

    View details for Web of Science ID A1997WY52800002

    View details for PubMedID 9152698

  • The effects of regularizing sleep-wake schedules on daytime sleepiness SLEEP Manber, R., Bootzin, R. R., Acebo, C., Carskadon, M. A. 1996; 19 (5): 432-441


    The present study evaluated the differential effects of two manipulations of sleep-wake schedules on daily subjective ratings of daytime sleepiness of college undergraduate students. Two experimental conditions were compared: a sleep only group and a regularity group. Subjects in both conditions were given a lower limit for total sleep time (7.5 hours). Subjects in the regularity group received an additional instruction to keep a regular sleep schedule. The study was longitudinal and prospective. Following a baseline period (12 days), the experimental conditions were introduced. The experimental phase lasted 4 weeks and overall compliance was good. A follow-up phase (1 week) began 5 weeks past termination of the experimental phase. The findings indicated that when nocturnal sleep is not deprived, regularization of sleep-wake schedules is associated with reduced reported sleepiness. Subjects in the regular schedule condition reported greater and longer lasting improvements in alertness compared with subjects in the sleep only condition and reported improved sleep efficiency.

    View details for Web of Science ID A1996UZ88100011

    View details for PubMedID 8843535

  • Sleep disorders. In: P.B. Sutker & H.E. Adams (Eds), Comprehensive Handbook of Psychopathology, 2nd Edition. New York: Plenum Press. Bootzin, R.R., Manber, R., Perlis, , Salvio, M., & Wyatt, J.K. 1993: 531-561
  • Social science research and child-custody decision making Applied and Preventive Psychology Sales, B., Manber, R., Rohman, L. 1992; 1 (1): 23-40