Veterans in the United States experience heightened suicide risk, compared to civilians, accounting for approximately 7,400 suicides annually. Among many potential risk factors, insomnia (i.e., difficulty falling asleep or staying asleep) is prevalent in veterans. Individuals with insomnia often encounter difficulties in daily functioning (e.g., fatigue, difficulty concentrating, decreased work performance) and, as a result, may experience perceived burdensomeness (i.e., perceptions of being restrictive or taxing to others), a known contributor to suicide risk. However, not all veterans who suffer from insomnia or perceive themselves as a burden engage in suicidal behaviors, perhaps due to individual-level protective factors. One such factor, self-compassion (i.e., the extension of kindness to oneself in adverse or difficult times), is comprised of self-kindness, common humanity, and mindfulness, and may reduce suicide risk by buffering against negative self-evaluations regarding sleeplessness and performance. However, this premise has not been previously investigated; therefore, in the current study, we examined the mediating role of perceived burdensomeness on the relation between insomnia and suicide risk and, further, the moderating role of self-compassion on these paths. At the bivariate level, we hypothesized that insomnia, perceived burdensomeness, and suicidal ideation would be positively related, and self-compassion would be inversely related to these factors. At the multivariate level, we hypothesized that the relation between insomnia and suicide risk would be mediated by perceived burdensomeness, and that this association would be moderated by self-compassion on all model paths; such that increased insomnia would be associated with higher levels of perceived burdensomeness and, in turn, suicide risk, and that self-compassion would weaken these deleterious linkages. Participants (N=551; Mean Age=50.4, SD=16.6) were community-dwelling veterans, most of whom were White (85.1%) males (69.3%) and were recruited via online invitations distributed to veteran-related social media groups and organizations. Participants completed an online survey, including: Insomnia Severity Index, Interpersonal Needs Questionnaire, Suicidal Behaviors Questionnaire – Revised, and SelfCompassion Scale Short-Form. All bivariate hypotheses were supported, with significance at the p

Problemas no momento de dormir e frequentes despertares noturnos são comuns em crianças, afetando 20% a 30% da população infantil. Tais dificuldades com o sono podem afetar aspectos comportamentais da criança, além de prejudicar o sono, o humor e a funcionalidade diurna de seus cuidadores. Apesar da importância do sono para a saúde infantil, há uma carência de estudos sobre o tema no cenário nacional. Esta pesquisa teve como objetivo avaliar a eficácia de uma intervenção comportamental para insônia infantil por meio de um programa dirigido aos pais. Participaram 62 pais de crianças de um a cinco anos de idade que apresentavam problemas de ordem comportamental relacionados ao sono. Os participantes foram randomizados em bloco de oito para os grupos de intervenção e controle. O programa de intervenção foi composto por cinco sessões nas quais os pais receberam educação sobre o sono da criança, orientações sobre o estabelecimento de horários e rotina para dormir e quanto ao uso de técnicas (extinção e reforço positivo) para a melhoria do momento de dormir e redução de despertares noturnos. Os participantes foram avaliados em quatro etapas pré-­intervenção, pós-­intervenção, seguimento de um e seis meses por meio dos instrumentos Escala UNESP de Hábitos e Higiene do Sono -­ Versão Crianças, Escala de Distúrbios do Sono para Crianças e Adolescentes, Inventário de Comportamentos para Crianças entre 1½ a 5 anos (CBCL), Inventário de Autoavaliação para adultos de 18 a 59 anos (ASR), Diário de Sono, Diário de Comportamento e Actigrafia. Os resultados deste estudo demonstraram que depois da intervenção houve melhora (p<0,05) nas variáveis do sono, tais como horário para dormir, latência para início do sono, despertares, duração total, bem como nos comportamentos das crianças no momento de dormir, avaliados por medidas subjetivas, como dormir com os pais e resistência a ir para a cama. Também houve melhora na latência para início do sono das crianças e na latência, eficiência e despertares de suas mães por actigrafia. Além da melhora na qualidade do sono, foi observada melhora detectável nos problemas de comportamento externalizante, internalizante e total de problemas de comportamento das crianças avaliados pelo CBCL, e um menor número de mães com pontuações clínicas no ASR. Conclui-­se que a intervenção comportamental para insônia infantil, por meio de orientação para pais, é eficaz na melhora da qualidade de sono e nos comportamentos diurnos das crianças, além de trazer benefícios no sono e nos comportamentos de suas mães. Tais resultados apontam para a necessidade de disseminação desse conhecimento no Brasil, a partir da possibilidade de aplicação desse protocolo em clínicas-­escolas de psicologia / Problems when they sleep and frequent awakenings are common in children. They affect approximately 20 % to 30 % of the child population. These problems, classified as behavioral childhood insomnia, can affect behavioral, emotional and educational aspects of the child, in addition to affecting sleep, mood and daytime functionality of their caregivers. Despite the importance of sleep for and on children\'s health, there is a lack of studies on this topic on the national scene. The present study aimed to evaluate the efficacy of a behavioral intervention for childhood insomnia through a program aimed at parents. Sixty-­two parents of children 1-­5 years of age who have behavioral problems related to sleep participated order. Participants were randomized into eight block for the intervention and control group. The intervention program consisted of five sessions in which parents received training on child sleep, guidelines on establishing schedules and bedtime routines and how the use of techniques (extinction and positive reinforcement) to improve the time to sleep and reduced nighttime awakenings. Participants were evaluated in four stages pre-­intervention, post-­intervention, follow-­ up at one and six month intervals through the instruments Escala UNESP de Hábitos e Higiene do Sono Versão Crianças, Escala de Distúrbios do Sono para Crianças e Adolescentes, Child Behavior Checklist 1½ to 5 years (CBCL), Adult Self Report (ASR), sleep and behavior diaries and actigraphy. The results of this study demonstrated that post intervention, there are improvement (p<0.05) of sleep variables, such as bedtime schedule, sleep latency, awakenings, time sleep total, and in behaviors at bedtime, like co-­sleeping and resistance to go to bed, in children, evaluated by subjective measures and improvement in latency to sleep in children and latency, efficiency and awakenings of their mothers for actigraphy. Besides the improvement in sleep quality, we also noted a detectable improvement at behavior problems externalizing, internalizing and total behavior problems of children evaluated by CBCL and smaller number of mothers with clinical scores by ASR. Behavioral interventions for insomnia to childhood, through parental guidance, is effective in improving the quality of sleep and daytime behavior in children and brings benefits to sleep and behavior in our female caregivers. These results indicate the need to dissemination this knowledge in Brazil from the opportunity to apply this protocol in schools of clinical psychology

Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro / A proposta primeira da dissertação Contra a Luz: insônia, prosa de ficção e Graciliano Ramos é a de investigar desdobramentos narrativos do tema da insônia na prosa de ficção da primeira metade do século XX. O primeiro capítulo, de um lado, traça um panorama histórico-literário da insônia da Idade Média ao século passado e, de outro lado, propõe algumas considerações de cunho psicanalítico sobre o tema. Pretende-se, assim, estabelecer alguns argumentos-chave que se desenvolverão ao longo dos capítulos subseqüentes, a saber: o de que a escuridão e o vazio noturno são altamente propícios à concentração na reflexão em detrimento da ação e que, portanto, possibilitam uma excepcional exploração da subjetividade dos personagens em questão. O segundo capítulo pensará tal situação no contexto da prosa de ficção moderna, a partir de breves estudos das obras Em busca do tempo perdido, de Marcel Proust; Livro do desassossego, de Fernando Pessoa (sob o heterônimo Bernardo Soares); Funes, o memorioso, de Jorge Luis Borges; e Buriti, de João Guimarães Rosa. Assim, serão expostas as maneiras pelas quais, nessas obras, as cenas de insônia mostram-se essenciais tanto à proposição de uma reflexão sobre a própria construção da narrativa, quanto permitem o aprofundamento psicológico dos personagens e o experimentalismo formal. Estes dois eixos permearão a Parte II da dissertação, que terá por foco a obra de Graciliano Ramos. O terceiro capítulo analisará a insônia do personagem Paulo Honório, no romance S.Bernardo, em relação à composição da narrativa feita por ele em suas noites em claro. O quarto capítulo, dedicado ao romance Angústia, investigará a instalação de um clima angustiado e de experimentações narrativas a partir das noites insones de Luís da Silva. Por fim, o quinto capítulo, abordando os contos Insônia e O relógio do hospital, traçará algumas conclusões sobre a função da insônia no estilo de Graciliano Ramos, e proporá também algumas considerações finais acerca de toda a dissertação / The main proposal of Against the Light: insomnia, prose fiction and Graciliano Ramos is to investigate narrative developments of insomnia in early 20th Century fiction. The first chapter, on the one hand, traces a historical and literary panorama of insomnia from the Middle Ages to the past century and, on the other hand, proposes some reflections on the theme through a psychoanalytic bias. Thus, it establishes some key arguments that will be developed in the next chapters, namely: that darkness and nocturnal emptiness may be highly propitious to the concentration on thought rather than action and that, therefore, both enhance an exceptional exploration of the characters subjectivity. The second chapter thinks such situation within the context of modern fiction, through Marcel Prousts In Search of Lost Time, Fernando Pessoa (under the heteronym of Bernardo Soares)s Book of Disquiet, Jorge Luis Borges Funes the Memorious and João Guimarães Rosas Buriti. It is possible to envision, in these works, how insomnia episodes turn out to be essential to think the narrative composition itself, as well as to the characters psychological development and formal experiments. These two axes will pervade the second part of the thesis, which is focused on Graciliano Ramos works. The third chapter analyzes Paulo Honórios insomnia, in the novel S. Bernardo, in relation to the narrative composition itself made by him during his sleepless nights. The fourth chapter, concentrated on the novel Angústia, investigates the establishment of an anguished atmosphere and of some narrative experiments, based on Luís da Silvas insomnia. Finally, the fifth chapter, aproaching the short stories Insônia and O relógio do hospital, traces some conclusions on the function of insomnia in Graciliano Ramos style, and gives place to some final words concerning the whole thesis

Literature Review: The current review presents a recent review of the effectiveness of psychological therapies to treat sleep difficulties (such as insomnia and nightmares) in sufferers of posttraumatic stress disorder (PTSD). The review also aimed to investigate whether there are differences in the effectiveness of specific psychological therapies to treat sleep disturbances in PTSD, such as between the different types of psychological therapies such as cognitive behavioural therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT). Eleven studies were included in the review that met the inclusion and exclusion criteria. Results are presented in tables and a descriptive account is included. The review demonstrates that psychological therapies are effective for the treatment of insomnia and other sleep difficulties such as nightmares. However, firm conclusions cannot be drawn about the effectiveness of different types of psychological therapies as studies predominantly used CBT and only one non-CBT study was included in the review. Comparisons between the effectiveness of different CBT approaches is also not possible as there was a large range of diversity in the study characteristics and also there were only a small number of studies for each intervention, which therefore limits the generalisability of results in the current review. It may be that different CBT interventions such as CBT-I or EERT and IRT may be better suited to treat insomnia and nightmares respectively, but further research needs to be conducted into which of these approaches are beneficial for different PTSD specific sleep difficulties. Empirical Paper: Initial studies demonstrate that self-compassion reduces symptoms of PTSD in Armed Forces Veterans (AFV), however the use of self-compassion approaches in AFV is under-researched. The current study utilised self-report and psychophysiological measures to investigate whether a single self-compassion experimental induction reduced hyperarousal symptoms (PTSD Cluster E symptoms) and increased feelings of social connectedness in AFV. The study hypothesised that there would be a decrease in hyperarousal symptoms and an increase in social connectedness, which would be associated with PTSD severity. Fifty-three AFV who had been deployed to a combat zone took part in the study, of which n = 15 (28.3%) currently met criteria for PTSD and n = 4 (7.5%) met criteria for Subsyndromal PTSD on the PCL-5. Participants listened to a recording of a Loving Kindness Meditation for self-compassion (LKM-S) and psychophysiological recordings were taken throughout. Participants completed state measures of hyperarousal and social connectedness before and after the LKM-S. Findings partially demonstrated that self-compassion can be elicited in an AFV population. However, changes on the self-report measures were largely not supported by psychophysiological measures, apart from skin conductance levels (SCL). The longevity of the effects observed in the study were not measured and should be investigated in future studies. Although this study has demonstrated that self-compassion can be elicited within the AFV population, further research is needed including to test a longer self-compassion intervention.

Background: Although insomnia has been identified as a robust predictor of suicidal ideation and behaviors, little is known about the mechanisms by which sleep disturbances confer risk for suicide. We investigated thwarted belongingness as an explanatory link between insomnia symptoms and suicidal ideation across three military service member and veteran samples. Methods: Data were collected among United States military service members and veterans (N1=937, N2=3,386, N3=417) who completed self-report measures of insomnia symptoms, thwarted belongingness, suicidal ideation, and related psychiatric symptoms (e.g., anxiety, hopelessness). Bias-corrected bootstrap mediation analyses were utilized to examine the indirect effects of insomnia symptoms on suicidal ideation through thwarted belongingness, controlling for related psychiatric symptoms. Results: Consistent with study hypotheses, thwarted belongingness significantly accounted for the relationship between insomnia and suicidal ideation across all three samples; however, insomnia symptoms did not significantly account for the relationship between thwarted belongingness and suicidal ideation, highlighting the specificity of our findings. Limitations: This study utilized cross-sectional self-report data. Conclusions: Insomnia may confer suicide risk for military service members and veterans, in part, through the pathway of thwarted belongingness. Additional prospective studies are warranted to further delineate this model of risk. Our results offer a potential therapeutic target for the prevention of suicide, via the promotion of belongingness, among service members and veterans experiencing insomnia symptoms.

Background: Insomnia has been shown to have direct and indirect associations with suicidal ideation, attempts, and death in U.S. military and veteran populations. However, transdiagnostic models of insomnia and psychopathology have not been used to examine the contribution of psychopathology. Method: The present study is a secondary analysis examining the associations among insomnia symptoms, posttraumatic stress disorder (PTSD) and depressive symptoms, interpersonal theory of suicide variables, and risk for suicidal behavior in community veterans (n = 392). Serial mediation was used to test sequential associations, allowing for examination of direct and indirect associations. Results: The model with insomnia, PTSD, and depressive symptoms, and thwarted belongingness, accounted for 29% of the variance in risk. Insomnia symptoms had an indirect association through PTSD and depressive symptoms, and thwarted belongingness. The model with insomnia, PTSD, and depressive symptoms, and perceived burdensomeness accounted for 35% of the variance in risk. Insomnia symptoms had an indirect association through PTSD and depressive symptoms, and perceived burdensomeness. Limitations: Data are cross-sectional, precluding the testing of causal associations. Conclusions: In veterans, insomnia symptoms may be associated with increased PTSD and depressive symptoms, which may be associated with increased risk for suicidal behavior directly and indirectly through relationship disruptions.

There is evidence of a relationship between sleep-wake disturbances and pain variables in cancer patients. It is hypothesized that pain affects all aspects of sleep patterns. Pain has been known to affect sleep disturbances; however there are different facets of sleep-disturbances and pain that can be evaluated. These variables include pain distress, pain intensity, pain at its worst, relief from pain, sleep distress, how well the patient sleeps, how tired one feels, and drowsiness distress. Several studies identify relationships between sleep-disturbances and pain. This study using secondary analysis was designed to correlate variables related to sleep-wake disturbance and pain in cancer patients admitted to hospice home care. The study sample included 209 cancer patients from a previously completed clinical trial with various cancer diagnoses. Results of sleep and pain variables were re-analyzed using Pearson correlations. The results showed significant positive relationships between pain distress and sleep distress (p = .000), difficulty sleeping and pain intensity (p = .008), and sleep distress and pain at its worst (p = .008). There were no significant relationships found between sleep distress and relief from pain, pain distress and how well the patient sleeps, pain distress and how tired one feels, and pain distress and drowsiness distress. Sleep-wake disturbances and pain have been studied in cancer patients, but there is little known concerning pain and its correlation to sleep disturbances of cancer patients admitted to hospice home care. This study provided important information on the relationship between sleep-wake disturbance and pain variables in this group of cancer patients. This study provides data to support the necessity to provide complete and accurate assessments of sleep and pain symptoms on admission to hospice home care and throughout the patient's care to aid in improved quality of life.

Hot flashes are one of the most bothersome symptoms experienced by women who have undergone breast cancer treatment-induced menopause. This vasomotor symptom has been hypothesized to be responsible for decreased sleep quality. This study further investigated the relationship between hot flashes and sleep quality in this population. The convenience sample consisted of 30 women being seen at an outpatient clinic in a comprehensive cancer center in southwest Florida. All participants were between the ages of 36-65, had a diagnosis of breast cancer and were currently taking a selective estrogen receptor modulator for at least six weeks. The participants completed the Hot Flash Diary, Hot Flash Questionnaire, Hot Flash Related Daily Interference Scale, Pittsburgh Sleep Quality Index and a demographic form. The mean sleep score of the sample was 9.33 (SD= 4.4). Global sleep scores above five are indicative of poor sleep quality, and global sleep scores of eight or more have been linked to cancer-related fatigue. Sleep was strongly correlated with hot flash distress (r = .754, p. = .000) and hot flash severity (r = .718, p. = .000) and moderately correlated with hot flash interference (r = .507, p. = .004) and hot flash frequency while asleep (r = .680, p. = .000). The small sample size was a study limitation. However, study results do support findings from previous studies. This study addresses a symptom management problem that may give nurses better understanding of the experiences of their patients. These findings also may assist patients in helping their providers to understand the frustration they are experiencing with regard to their decreased sleep quality.

Background Cardiovascular disease (CVD) remains the number one killer even after years of advances and preventative measures. Identifying and reducing modifiable risk factors is a health care priority. CVD Risk assessments are calculated using several traditional risk factors including age, gender, race, blood pressure, cholesterol, history of diabetes, and smoking to estimate a persons’ risk of developing CVD (heart disease or stroke) in the next 10-years. In addition to the traditional risk factors for CVD, there is increasing evidence of metabolic disorders, depressive symptoms, inflammation and sleep quality posing a greater risk for CVD. However, these factors are not included in the current risk prediction models including the Framingham Risk Score, Reynolds Risk Score, and Pooled Cohort Risk Equations. Therefore, this study examined the effect of depressive symptoms, inflammation, and sleep quality on the independent risk for CVD. Objective The primary objective of this study was to evaluate the independent relationships between traditional cardiac risk factors, depressive symptoms, inflammation, and sleep quality, on long-term risk of major adverse cardiovascular events (MACE). The secondary objective was to evaluate whether gender modifies the relationships between depressive symptoms, inflammation, and sleep quality on long-term risk of MACE. Design A secondary analysis was conducted on data obtained from the Longitudinal prospective cohort study Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) conducted by the University of Pittsburgh. The ongoing Heart SCORE study has been prospectively examining cardiovascular disease (CVD) risk factors and CVD events on an initial cohort of 2,000 enrolled adults ages 45 to 75 at study entry. A Cox proportional-hazard model was used to evaluate the relationship between traditional risk factors as well as independently and collectively for depressive symptoms, inflammation and sleep quality and risk of MACE. Models were reanalyzed adding gender as an interaction term and in stratified analyses to evaluate whether gender modifies the relationships between sleep quality, depressive symptoms, and inflammation and long-term risk of MACE. Results The participants (N= 1,895) included in this study were, 1256 females (66%), 639 males (34%), ranging from 45 to 75 years of age with a median age of 60 years, 42% Blacks, 55% Whites and 3% other race. Six percent, (n =113) of the participants experienced a major cardiac event during a mean of nearly 10 year follow up. Results indicated that men as compared with women with high levels of interleukin-6 had particularly high risk for CVD, as defined by two separate definitions of MACE, MACE1: Hazard Ratio (HR) 3.44 vs. 1.72 for males and females, respectively, MACE6: HR 2.51 vs. 1.69 for males and females, respectively. These results suggest the high inflammation in men is strongly associated with future risk of CVD. The addition of depressive symptoms to the initial traditional risk factor model was associated with a modest increase in the risk of both definitions of MACE (HR range from 1.20 to 1.68) with similar results observed by gender. Sleep quality/Insomnia was not associated with long-term risk of MACE overall or when evaluated separately by gender. Conclusion Primary prevention with early identification of potential modifiable risk factors is a key strategy in planning interventions to reduce the risk of CVD. Results from this study suggest that depression and inflammation (e.g. IL-6) should be studied in other populations to estimate their independent predictive value in risk stratification. Whereas sleep quality was not associated with long-term risk of CVD in this analysis, future studies should consider the use of objective measures of sleep quality, such as actigraphy in addition to standard use of self-report measures and sleep diaries.

緒論 失眠困擾對身心健康有重大的影響，除了藥物取向的治療外，失眠認知行為治療（CBT-I）有足夠的實證研究證據肯定其療效，由於在認知行為治療（CBT）的研究中有證據支持參與者在家中，對治療技術練習與執行的程度與療效有關，因此CBT-I的療效可能也與患者對治療技術的執行程度有關，過去雖然也有少數研究探討CBT-I執行程度與療效的關係，但這些研究缺乏針對CBT-I各個治療技術的執行程度評估，因此本研究欲探討CBT-I中，各項治療技術（睡眠衛生教育、放鬆訓練、刺激控制法、睡眠限制法，及認知重建）的執行程度及執行規律程度，與特定療效指標改善程度的關係。 方法 研究參與者含原發性失眠患者22位，共病其它疾患的失眠患者16位，經篩選階段確認符合收案條件後，在接受為期七週的CBT-I團體治療期間，於第二週起需每日填寫執行程度問卷，同時帶領團體的治療師也於治療第三週起，以治療師執行程度評估量表來評估參與者的執行程度。參與者在治療前後另需分別填寫一週睡眠日誌以及睡眠困擾問卷（Insomnia Severity Inventory；ISI），以睡眠日誌中的SOL、WASO、TST、SE，及ISI得分的前後測改變分數，作為代表療效指標之依變項，預測變項則為參與者自評及治療師所評估的各項治療技術之執行程度分數，治療技術包括：睡眠衛生、放鬆訓練、刺激控制法、睡眠限制法，以及認知重建；並分別以平均數代表執行程度，而以變異數代表執行期間的規律程度。 結果 資料分析以皮爾森相關分析檢驗執行程度與療效間的關聯性，在全部樣本中的結果發現，參與者自評對認知重建的平均數與WASO的改善程度有正相關，以及治療師評估CBT-I的平均數與SOL的改善程度有正相關；而參與者自評放鬆訓練的平均數越低、刺激控制法變異數越高，則ISI的改善程度越好，為不符合預期的結果。在原發性失眠組中發現治療師評估睡眠衛生的平均數與WASO的改善有正相關，治療師評估睡眠限制法的平均數與SOL、TST，以及SE的改善有正相關，而變異數與SOL的改善有負相關，以及治療師評估CBT-I的平均數與SOL的改善有正相關；而不符合預期的結果為，參與者自評執行刺激控制法的變異數與ISI的改善有正相關。最後，在共病組中並沒有發現執行程度與療效之間有顯著相關的結果，而放鬆訓練以及刺激控制法兩項治療技術，也沒有與療效指標有符合預期的顯著相關結果。 結論 對於共病失眠患者而言，治療技術的執行評估與療效間未反映出顯著相關，可能因受限於睡眠生理疾患的干擾，使得療效未如原發性失眠組明顯；而就原發性失眠組而言，睡眠限制法的執行程度是與較多療效指標達到顯著相關的治療技術，顯示睡眠限制法的執行對於改善睡眠症狀有所幫助。本研究較為重大的限制在於，治療技術執行程度評估的評分者間一致性有限，後續研究可進一步發展評估執行程度更適當的方法。 / Introduction Insomnia is a common problem that has a significant impact on patients' physical and mental health. In addition to pharmacological therapy, there are sufficient empirical data to support treatment efficacy of cognitive behavioral therapy for insomnia (CBT-I). A major part of cognitive behavioral therapy is to teach the patients to learn specific cognitive and behavioral techniques that requires to be practiced at home by the patients. Previous studies have reported an association between the degree of adherence to treatment techniques and treatment effects in cognitive behavioral therapy for disorders other than insomnia. Some studies further explored the relationship between treatment adherence and treatment outcome in CBT-I. However, none of the study looked into the adherence to different treatment components on different aspects of treatment outcome. The aim of this study therefore is to explore the relationship between the adherence to different treatment components in CBT-I and the improvement in different sleep parameters. Method Twenty-two patients with primary insomnia and sixteen patients with comorbid insomnia were recruited for this study. During the 6-week period of treatment with CBT-I, they completed a treatment adherence questionnaire daily. The therapists also evaluated the patients’ adherence weekly after treatment sessions. They were required to keep sleep diaries from one week before to one week after the end of the 6-week CBT-I program. They also completed the ISI and sleep diary for one week before and after the treatment. The treatment outcome variables included the ISI score, and sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST) and the sleep efficiency (SE) from sleep diaries. The treatment components evaluated included sleep hygiene, relaxation, stimulus control, sleep restriction and cognitive reconstruction. The predictive variables included the mean for the adherence degrees and the variance for the adherence regularity of the adherence score evaluated by the participants and therapists. Results Pearson correlation was used to examine the associations between the adherence to respective treatment components in CBT-I and the variables of treatment outcome. In the whole sample, the decrease of the WASO correlated significantly with adherence to cognitive reconstruction evaluated by the patients, and the decrease of the SOL correlated significantly with adherence to CBT-I evaluated by the therapists. Nonetheless, the lower adherence to relaxation and the higher variance of adherence to stimulus control, the more improvement of the ISI. In patients with primary insomnia, the decrease of WASO correlated significantly with adherence to sleep hygiene evaluated by the therapists; the decrease of SOL and the increase of TST and SE showed significant correlation with adherence to sleep restriction evaluated by the therapists; the decrease of SOL showed significant negative correlation with the variance of adherence to sleep restriction evaluated by the therapists; the decrease of SOL showed significant positive correlation with the adherence to CBT-I evaluated by the therapists. Opposite to expectation, the decrease of the ISI score correlated significantly with variability of adherence to stimulus control evaluated by the patients. Finally, in patients with comorbid insomnia, the treatment component adherence did not correlate significantly with any outcome variables. The adherence of relaxation and stimulus control did not show significant correlation with outcome variables. Conclusion In patients with comorbid insomnia, treatment effects were not associated with adherence. This may due to the multifactorial nature of comorbid insomnia. Among the treatment components, adherence to sleep restriction seems to be the most predictive factor for good treatment outcome in primary insomnia. One limitation of the present study is its low inter-rater reliability of treatment components adherence evaluation. Therefore, more appropriate methods need to be developed to evaluate the adherence of treatment techniques.