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Introduction Digital CBTI (dCBTI) may serve as a good initial intervention in a stepped-care approach to treat insomnia. Understanding who is likely to respond to dCBTI can guide triaging of care, thus shortening wait times for those who most need to meet with an insomnia therapist. The purpose of this study was to examine baseline predictors of response to a dCBTI program after two months of access. Methods Participants were 173 middle aged and older adults with insomnia (M age=63.56 [SD=8.43], 76% female) who received the dCBTI SleepioTM for two months in the RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice (RESTING) study. Baseline predictors included the Epworth Sleepiness Scale (ESS), Dysfunctional Beliefs and Attitudes about Sleep (DBAS), preference for treatment (digital vs. therapist-delivered), and comfort with technology. At baseline and two-month follow-up, participants completed outcome measures, including the Insomnia Severity Index (ISI) and the PROMIS-Sleep Related Impairment (PROMIS-SRI). Multilevel modeling was used. Results In the full sample, no predictors were associated with change on the ISI. Among our predictors, only higher DBAS scores were associated with a smaller reduction in PROMIS-SRI scores from baseline to two-month follow-up (Beta=-0.88, SE=0.35, p=0.01 , 95% CI=-1.57, -0.19). Among those who preferred digital CBTI (n=52), none of the predictors were associated with the ISI or PROMIS-SRI. Among those who preferred therapist-led CBTI (n=66), greater comfort with technology was associated with greater reduction on the ISI (Beta=-1.77, S =0.78, p=0.02 , 95% CI=-3.30, -0.24) and higher DBAS scores were associated with a smaller reduction on the PROMIS-SRI (Beta=-1.63, S =0.56, p<0.01 , 95% CI=-2.73, -0.53). Conclusion The results highlight the importance of targeting dysfunctional beliefs and attitudes, which is consistent with research examining the DBAS in CBTI. Results also indicate that patient preference is an important factor to consider when triaging patients to insomnia care. While additional predictors should be examined, these preliminary findings indicate that dCBTI may be a good initial treatment option for those with high level of comfort using technology and lacking a preference for therapist-led CBTI. Support (If Any) R01AG057500 and T32MH019938

Introduction Comorbid depression often exacerbates dysfunctional beliefs about sleep in those with insomnia disorder. Anhedonia, a core symptom of depression, may be mechanistic in this association. Previous research suggests that, when appraising potential decisions, individuals with anhedonia regularly overestimate the probability of negatively valenced outcomes and underestimate the likelihood of positive outcomes. This study explores the relationship between anhedonia and sleep-related cognitions in patients with insomnia disorder. Methods Adults 50 years and older (N = 241) who met DSM-5 criteria for insomnia disorder were enrolled in a randomized controlled trial assessing the effectiveness of a stepped care approach to delivering Cognitive Behavioral Therapy for Insomnia. At baseline, participants completed the Dysfunctional Beliefs and Attitudes about Sleep Scale, Pre-Sleep Arousal Scale (cognitive subscale), Beliefs about Medications Questionnaire (Subscales assess the belief that hypnotics are necessary and concern regarding consequences of use), and PROMIS sleep-related impairment short form. A t-test was used to compare participants who did and did not endorse anhedonia on the Geriatric Depression Scale (GDS). We also correlated the Patient Health Questionnaire-4 (PHQ-4) anhedonia item with sleep-related cognition measures. Results Participants reporting anhedonia (GDS) endorsed greater dysfunctional beliefs about sleep (p < .001, d = 0.44) and sleep-related impairment (p < .01, d = 0.39). Groups did not differ significantly regarding belief in the necessity of sleep medications and concern with hypnotic use, nor in pre-sleep arousal. Higher anhedonia (PHQ-4) was correlated with more severe dysfunctional beliefs about sleep (r = .20, p < .01), belief in the necessity of hypnotics to manage sleep disturbance (r = .22, p < .001), and greater pre-sleep arousal (r = .18, p < .01). Conclusion Endorsement of anhedonia was associated with stronger dysfunctional beliefs about sleep in this sample of middle age and older adults with insomnia disorder. Participants reporting anhedonia also reported greater sleep-related impairment. Exploring anhedonia as a transdiagnostic symptom that influences interpretation of sleep-related difficulties may elucidate underlying mechanisms that sustain maladaptive cognitions. Prospective, multi-method studies will be essential to clarify predictive interactions between reward system dysfunction and sleep-related beliefs in those with insomnia disorder. Support (If Any) 1R01AG057500

Introduction Digital CBTI programs are effective at treating symptoms of insomnia. They also have the potential to increase treatment reach, convenience, and affordability for patients, and to reduce long wait times for behavioral sleep medicine providers. The COVID-19 pandemic has instigated an increased reliance on the use of technology for many. Thus, this study evaluates middle aged and older adults before and during the COVID-19 pandemic to assess: (1) differences in treatment modality preference (digital vs. therapist-led CBTI) and (2) sleep-related predictors of treatment modality preference. Methods Participants were older adults (N=229, 74% female, mean age=63.14) who were enrolled in the RCT of the Effectiveness of Stepped-Care Sleep Therapy in General Practice (RESTING) study. At baseline, participants rated if they would prefer to access CBTI digitally or with a CBTI therapist, either in person or via telemedicine. After March 2020, in person was no longer listed as an option. Participants completed the Insomnia Severity Index (ISI) and a two-week sleep diary that allowed for an assessment of total sleep time (TST), sleep onset latency (SOL), and wake after sleep onset (WASO). Analyses compared responses to these items from participants completing assessments before March 2020 (Pre-Covid; n=74, 65% female, mean age=62.52) and after March 2020 (During-Covid; n=155, 78% female, mean age=63.44). Results Pre-Covid, 26% of participants preferred digital treatment, 47% of participants preferred a therapist-led intervention, and 27% did not express a preference. During-Covid, 35% of participants preferred digital treatment, 32% of participants preferred a therapist-led intervention, and 32% did not express a preference. This difference was statistically significant (c2=4.24, p=0.04). Responses were not significantly different between the first six months and the most recent six months of the pandemic (p=0.60). None of the sleep measures (ISI, TST, SOL, WASO) were associated with treatment modality preference in the full sample, Pre-Covid, or During-Covid. Conclusion The COVID-19 pandemic was associated with increased preference for digital CBTI among patients who are 50 and older, regardless of insomnia severity. Findings suggest that digital CBTI may be an acceptable treatment to many individuals with insomnia, thus increasing its dissemination potential. Support (If Any) R01AG057500 and T32MH019938