1Q-587 Please download file ( Answer Question) and answer all  Questions. Use all those website and documents upload.   https://www.countyhealthran

1Q-587 Please download file ( Answer Question) and answer all  Questions.

Use all those website and documents upload. 

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please Read and answers all 276Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011

Study Objectives: 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.
Methods: Students in one residence hall (n = 48) participated
in Refresh and students in another residence hall (n = 53) par-
ticipated in a program of equal length (Breathe) designed to im-
prove 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 partici-
pants reported poor sleep quality at baseline (scores ≥ 5 on
the Pittsburgh Sleep Quality Index [PSQI]). Participants com-
pleted the PSQI and the Center for Epidemiological Studies-
Depression Scale (CES-D) at baseline and post-intervention.
Results: Among students with poor sleep (PSQI > 5) at base-
line, participation in Refresh was associated with greater im-

provements in sleep quality and greater reduction in depres-
sive 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 de-
pressive symptom severity (CES-D).
Conclusions: 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 ques-
tion is whether improving sleep will also reduce risk for future
depression.
Keywords: Insomnia, depression, prevention
Citation: Trockel M; Manber R; Chang V; Thurston A; Tailor
CB. An e-mail delivered CBT for sleep-health program for col-
lege students: effects on sleep quality and depression symp-
toms. J Clin Sleep Med 2011;7(3):276-281.

DOI: 10.5664/JCSM.1072

An E-mail Delivered CBT for Sleep-Health Program for College
Students: Effects on Sleep Quality and Depression Symptoms

Mickey Trockel, M.D., Ph.D.1; Rachel Manber, Ph.D.1; Vickie Chang, Ph.D.2; Alexandra Thurston, B.A.3; Craig Barr Tailor, M.D.1
1Stanford University, Stanford, CA; 2University of California San-Francisco, San-Francisco, CA;

3PGSP-Stanford PsyD Consortium, Palo Alto, CA

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College students often have erratic sleep schedules, poor sleep hygiene, and correspondingly poor sleep quality.1
One report suggests that as many as 89% of college students
report poor quality sleep.2 Inadequate or poor quality sleep may
put students at increased risk for developing unipolar depres-
sive disorders.3-6 In 1989, Ford and Kamerow published data
suggesting that poor sleep is a risk factor for subsequent clinical
depression and that further research is needed to determine if
early recognition and treatment of sleep disturbance can pre-
vent subsequent psychiatric problems.4 Since then, several au-
thors have published empirical evidence indicating disturbed
sleep, measured by self-report or with polysomnography6 is a
risk factor for subsequent depression.3,5-12

Poor sleep is a predictor of subsequent depression during
adolescence,5 and continues to constitute a risk in young3,7 and
older adults.11,12 There is a dose response relationship between
sleep disturbance in adolescence and subsequent symptoms of
depression, with severe sleep disturbance incurring greater risk
than moderate disturbance.13 It is therefore important to devel-
op and test the feasibility of potentially cost-effective interven-
tions to improve sleep among adolescents and young adults,
which might subsequently be used to determine whether early
intervention to improve sleep reverses the progression from
disturbed sleep to depressive disorder.

The present study is an important first step toward this
important goal. We developed and evaluated the feasibility
and short-term efficacy of an intervention to improve sleep

in college freshmen and its immediate effects on depressive
symptom severity. In addition to addressing disturbed sleep,
the intervention also addressed irregular sleep habits because
such habits constitute a risk for insomnia and, importantly,
there is evidence that day-to-day variations in bed-times and
wake-up times by 2 to 4 h is associated with greater severity
of symptoms of depression, even among students who regu-
larly obtain ≥ 8 h of sleep.14 Moreover, a recent analysis of
risk for depression and suicidal ideation among adolescents
suggests having parents who insist on earlier bedtimes is a
protective factor, which appears to be partially mediated by
sleep duration and perception of getting enough sleep.15 Past
research demonstrated that increasing the regularity of times

BRIEF SUMMARY
Current Knowledge/Study Rationale: College students often have
poor sleep and associated symptoms of depressed mood. The purpose
of this study is to test the efficacy of an e-mail delivered self-help pro-
gram, based on CBT strategies for insomnia, designed for students living
in on-campus residence halls.
Study Impact: Results of this quasi-experimental study indicate college
students with poor sleep can improve their sleep and reduce symptoms
of depression by self-administering a cognitive behavior strategy based
program delivered via low-cost electronic media. These findings suggest
further program development, implementation, and evaluation may help
students improve the quality and regularity of their sleep, and perhaps
even help halt or slow the progression from poor sleep to depressive
illness.

277 Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011

CBT for Sleep: Effects on Sleep and Mood
incorporated vignette examples specific to college students.
Students were encouraged to spend 30 min on each session.

The Refresh program has 2 tracks, one for students with
poor sleep quality at baseline and a second (attenuated) version
of the program for students with no or minimal sleep difficul-
ties. Students were assigned a track based on their score on the
Pittsburgh Sleep Quality index (PSQI), using a score > 5 to
identify those with poor sleep quality.24 The complete program
version for students with poor sleep at baseline, addressed:
(1) the physiology of sleep with particular emphasis on circa-
dian rhythms and recommendations for stabilizing circadian
rhythm through anchoring wake time; (2) instructions on a
time in bed-restriction protocol to consolidate sleep25; (3) re-
laxation training; (4) mindfulness training; (5) stimulus control
strategies26; and (6) cognitive strategies to reduce the impact
of maladaptive thoughts about sleep. The program encouraged
participants to keep daily sleep logs and implement strategies
for improved sleep health. The daily sleep log allowed students
to record daily bedtimes, time out of bed, minutes in bed be-
fore sleep onset, number of night time awakenings, total min-
utes spent lying in bed awake during the night, total amount of
sleep, number of alcoholic beverages before bedtime, satisfac-
tion with sleep, and degree to which the student felt refreshed
in the morning.

The time in bed restriction protocol was a significant por-
tion of the program version for students with poor sleep, begin-
ning with session three. The program first showed students how
to self-administer sleep restriction. Students were instructed
to compute their average total sleep time over the past week
and then instructed to be in bed only as long as their average
estimated actual sleep time, plus a margin ≤ 30 minutes. Sub-
sequent program sessions instructed students to add 30 min to
their scheduled time in bed if, on average: (a) they were able to
fall asleep within 30 min, (b) they spent < 45 min lying in bed at night, and (c) they felt sleepy during most daytime hours. If students were consistently unable to fall asleep in < 30 min after going to bed or were consistently spending > 45 min per
night lying in bed awake, they were asked to review a check-
list of strategies to improve sleep presented to them previously
in the Refresh program, and to consider adopting one of these
strategies. If they had already implemented these strategies,
they were encouraged to decrease total time in bed by 30 min
per night, to a minimum of 6 h per night if needed.

Students were instructed not to attempt the sleep restric-
tion protocol if they believed any of the following applied to
them at baseline: (1) “You have Bipolar Affective Disorder”;
(2) “You have a family member with Bipolar Affective Disor-
der”; (3) “You have had a period of time lasting one week or
longer during which you felt euphoric, felt like you had special
abilities other people don’t have, or felt persistently irritable”;
(4) “Within the last 2 months you started a medication to treat
depression or anxiety”; (5) “You frequently have trouble stay-
ing awake while driving or performing other activities in which
drowsiness may have fatal consequences”; (6) “You have a long
road trip coming up within the next 3 weeks and you have to
be the driver, or you have to perform other activities in which
drowsiness may have fatal consequences.”

The attenuated version of the Refresh program developed for
students with good sleep quality at baseline included the same

into and out of bed in college students improves sleep, sleepi-
ness, and mood.16

Cognitive behavioral therapy for insomnia (CBT-I) has been
established as an effective treatment for primary insomnia in
adults when delivered in person,17-19 as a self-help intervention
mailed to participants,20 or delivered via interactive Internet
programs.21,22 In addition, a pilot study found that addition of
CBT-I to pharmacologic treatment of depression led to im-
proved outcomes in patients with insomnia and Major Depres-
sive Disorder.23 We have therefore adapted CBT-I methods to
the special circumstances of college life and to be delivered as
a self-help intervention in 8 separate installments via e-mail.

In this report, we present data from a quasi-experimental
design study of the effects on sleep quality and symptoms of
depressed mood of an e-mail delivered cognitive and behavior
strategy based sleep health improvement program, which was
delivered to college students living in on-campus residence halls.

METHODS

Participants
We invited all students 18 years of age or older in 2 first-

year student residence halls in a large private university to par-
ticipate in a health promotion program. We presented the study
at the first house meeting of the quarter and gave students an
opportunity to ask questions and sign informed consent forms
to participate in the study. Students were offered one unit of
course credit for their participation in the study. The institu-
tional review board approved the study protocol prior to com-
mencement of the study.

Students in one residence hall were invited to participate in
an 8-week CBT-I based sleep-health promotion program called
Refresh. More than two-thirds (70% [58 of 83]) of eligible stu-
dents elected to participate in the program. Students in the sec-
ond residence hall were invited to participate in another health
promotion program (called Breathe) designed to help students
cope with stress and to improve their emotional health by using
skills common to cognitive behavioral therapy (CBT) for de-
pression. Fewer than half (41% [67 of 162]) of eligible students
elected to participate in the program.

The baseline sample consisted of 61 women (32 in Re-
fresh and 29 in Breathe) and 64 men (26 in Refresh and 38
in Breathe). Sixty-three (50%) identified themselves as White/
Caucasian, 17 (14%) as Latino/Hispanic or Mexican American,
and 14 (11%) as Chinese/Chinese American. Fewer than 5 stu-
dents identified themselves as part of any other single racial or
ethnic group, and 9 elected not to answer the question on race/
ethnicity. Ninety-nine participating students were 18 years of
age at the time they enrolled in the study, and the other 26 were
between 19 and 22 years of age.

We sent students a link to online baseline and post-interven-
tion surveys by e-mail, using Survey Monkey. For both baseline
and post-intervention data collection, we sent as many as 3 re-
minder e-mails to students who had not yet responded.

Interventions
Both interventions were delivered in 8 weekly sessions, sent

via e-mail messages with attached PDF files. Both programs

278Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011

M Trockel, R Manber, V Chang et al

Statistical Analyses
The analyzable sample consisted of all individuals who

provided both pre and post measures. We computed change in
PSQI and CES-D scores by subtracting baseline scores from
post-intervention scores. We then used t-tests for independent
samples to test for between-groups differences in PSQI and
CES-D score changes from baseline to post-intervention. We
also calculated Cohen’s d effect sizes for within-group changes
from baseline to post intervention on both outcome measures.
Separate analyses were conducted for students with high (PSQI
> 5) and low (PSQI ≥ 5) baseline sleep quality. We completed
analyses using SPSS version 18.0.

RESULTS

Forty-eight of the 58 students (83%) participating in the
Refresh program and 53 of 67 students (79%) participat-
ing in the Breathe program completed baseline and post-test
PSQI and CES-D measures, and thus constitute the sample for
this study. The 24 students who began the study but failed to
complete one or both post-test measures did not differ signifi-
cantly in baseline PSQI (4.4 vs. 4.8; t = −0.93; df = 123; p =
0.36), baseline CES-D (11.4 vs. 13.8; t = −1.56; df = 123; p =
0.13), or gender (46% women vs. 50% women; χ2 = 0.11; p =
0.75). Nineteen Refresh program participants and 15 Breathe
program participants had poor sleep (PSQI > 5) at baseline.
Tables 1 and 2 provide baseline data for students with baseline
PSQI scores > 5 (Table 1) and those with lower PSQI scores
(Table 2). Among students with PSQI scores > 5 at baseline,
there were no statistically significant differences in gender,
proportion of white students vs. other racial or ethnic group, or
outcome measure (PSQI and CESD) scores at baseline. Among
students with lower PSQI scores at baseline, there were statis-
tically significant differences between the intervention groups
in the proportion of participants who were women and in aver-
age baseline CES-D scores.

More than half (54%) of the participants who received Re-
fresh reported completing the entire program; the majority
(94%) reported completing ≥ 4 of 8 sessions. For the Breathe
program, 28% reported completing the entire program and 81%
reported completing ≥ 4 of 8 sessions. Among Refresh students
with baseline PSQI scores > 5, all but 2 (89%) completed ≥ 7
sessions. The remaining 2 Refresh students with elevated PSQI

content as the full version, except that it did not include instruc-
tion on how to self-administer a time in bed restriction protocol
to consolidate sleep.

The equal length comparison program, Breathe, was devel-
oped to reduce depressive symptoms and improve coping skills
for stress. The program integrated concepts and skills from
Dialectical Behavior Therapy,27,28 Mindfulness-Based Stress
Reduction,29 and Aaron Beck’s Cognitive Therapy.30 Specific
topics include (1) recognizing and managing difficult emo-
tions, (2) coping with stress, (3) cognitive reframing of nega-
tive thoughts, and (4) improving relationships with friends and
family. Unlike Refresh, which used cognitive restructuring and
mindfulness meditation to address cognitions that interfere with
sleep and hyperarousal in bed, Breathe used these strategies to
address low mood and general stress.

The Breathe program introduces new treatment compo-
nents/modules each week, each focused on skill building.
These included (1) self-monitoring of stressful events, associ-
ated thoughts and emotions, and coping behaviors; (2) chal-
lenging automatic negative thoughts; (3) finding solutions to
interpersonal conflict; (4) engaging in enjoyable activities; (5)
mindfulness meditation; and (6) relaxation. The Breathe pro-
gram encouraged students to keep daily logs for a variety of
self-monitoring tasks relevant to each module and to complete
homework (assigned weekly) on topics such as motivation for
the behavior change, time management, relaxation, mindful-
ness meditation, and asking for help.

Measures
The baseline survey included demographic information, the

PSQI24 and the Center for Epidemiological Studies-Depression
Scale (CES-D).31 Post-treatment measures included the PSQI
and the CES-D.

The PSQI includes 19 questions and generates a sleep qual-
ity index ranging from 0 to 21. A PSQI score > 5 has good
sensitivity and specificity for identifying individuals who are
“poor sleepers.”24

The CES-D measures depressive symptoms in a general pop-
ulation with 20 items on a 0-3 point scale, for a total scale range
of 0 to 60. The CES-D has demonstrated good ROC curve per-
formance for detecting college students with clinically signifi-
cant depression; it has also demonstrated adequate sensitivity
and specificity using a cut off score > 15.32

Table 1—Baseline measures by intervention group, for the
subgroup of students with PSQI > 5 at baseline

Refresh,
n = 19
M (SD)

Breathe,
n = 15
M (SD)

Significance of
group difference

PSQI 7.7 (1.8) 7.5 (1.5) t = 0.38; p = 0.71
CESD 19.7 (10.4) 14.7 (8.1) t = 1.57; p = 0.13
Age 18.3 (0.4) 18.6 (1.0) t = −1.23; p = 0.24
Women* 0.63 (0.50) 0.73 (0.46) χ2 = 0.40; p = 0.53
White/Caucasian* 0.63 (0.50) 0.53 (0.52) χ2 = 0.33; p = 0.56

*Mean for categorical variables indicates the proportion of students who
identified themselves as part of the specified group.

Table 2—Baseline measures by intervention group, for the
subgroup of students with PSQI ≤ 5 at baseline

Refresh,
n = 29
M (SD)

Breathe,
n = 38
M (SD)

Significance of
group difference

PSQI 3.3 (1.5) 3.3 (1.2) t = −0.31; p = 0.76
CESD 9.7 (5.6) 13.7 (8.3) t = −2.23; p = 0.02
Age 18.1 (0.4) 18.2 (0.5) t = −0.40; p = 0.69
Women* 0.55 (0.51) 0.29 (0.46) χ2 = 4.70; p = 0.03
White/Caucasian* 0.48 (0.51) 0.42 (0.50) χ2 = 0.25; p = 0.62

*Mean for categorical variables indicates the proportion of students who
identified themselves as part of the specified group.

279 Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011

CBT for Sleep: Effects on Sleep and Mood

DISCUSSION

We focus our discussion primarily on findings among
students with disturbed sleep at baseline who received the
full version of the e-mail delivered self-help program us-
ing validated cognitive behavior therapy for insomnia strate-
gies.17-19 The main findings of this study are that, compared
to an equal length comparison program, participation in an
e-mail delivered self-help CBT-I based program was associ-
ated with greater improvements in sleep quality and greater
reductions in symptoms of depression among college stu-
dents with low sleep quality at baseline. This study extends
prior findings that self-help CBT-I is effective for adults with
insomnia.17-22 Previous adult self-help CBT-I studies have
used written materials20 or the Internet.21,22 Our study sug-
gests e-mail delivery of weekly CBT-I based content may be
an effective method of helping students with sleep problems
improve their sleep.

scores completed ≥ 5 of 8 sessions. Among Breathe students
with baseline PSQI scores > 5, a third (33%) completed ≥ 7 ses-
sions, and just over half (53%) completed ≥ 5 weekly sessions.
Table 3 provides completion rates—defined as self-report of
having completed ≥ 7 of 8 sessions—by baseline sleep category
(PSQI > 5 or PSQI ≤ 5), and by program assignment.

For participants with baseline PSQI scores > 5 (Figure 1), the
Refresh intervention was associated with significantly greater
reductions (t = −2.25; df = 32; p = 0.034) in PSQI scores (7.68
to 5.26 = −2.42 points; Cohen’s d = 1.33) than the Breathe
program (7.47 to 6.80 = −0.67 points; Cohen’s d = 0.47). The
between-group difference in PSQI change = −1.75 points, CI
[−3.36 to −0.15]. For participants with baseline PSQI scores >
5, the Refresh program was also associated with significantly
greater reductions (t = –2.19; df = 32; p = 0.036) in CES-D
scores (19.69 to 13.75 = −5.94 points; Cohen’s d = 0.57) than
the Breathe program (14.73 to 16.00 = 1.27 points; Cohen’s
d = 0.16) (Figure 2). The between-group difference in CES-D
change was −7.20 points, CI [−14.00 to −0.39]. For participants
with baseline PSQI scores ≤ 5, there were no significant dif-
ferences in pre to post changes in sleep quality or depressive
symptom severity between Refresh and Breathe (p = 0.23 for
PSQI and p = 0.80 for CES-D).

The average reductions in PSQI scores and CESD scores re-
ported by the 2 participants with baseline PSQI scores > 5 who
did not complete ≥ 7 units of the program were 0.00 and 1.00
respectively. The small sample number of participants this group
(n = 2) is not sufficient to test the statistical significance of these
score reductions compared with average score reductions among
participants who completed ≥ 7 of 8 units (n = 17), which were
2.71 and 6.51 for PSQI and CESD scores, respectively.

9

8

7

6

5

4

3

2

1

0
Baseline PSQI Post-test PSQI

Refresh, good sleepers (n = 29) Breathe, good sleepers (n = 38)
Refresh, poor sleepers* (n = 19) Breathe, poor sleepers (n = 15)

7.7 (SD = 1.8)

5.3 (SD = 2.4)

Figure 1—Baseline and post-test PSQI scores

*Change is significantly greater than observed in alternative treatment
control group

21

18

15

12

9

6

3

0
Baseline CESD Post-test CESD

19.7 (SD = 10.4)

13.8 (SD = 7.7)

Refresh, good sleepers (n = 29) Breathe, good sleepers (n = 38)
Refresh, poor sleepers* (n = 19) Breathe, poor sleepers (n = 15)

Figure 2—Baseline and post-test CESD scores

*Change is significantly greater than observed in alternative treatment
control group

Table 3—Completion rates—defined as self-report of having
completed ≥ 7 of 8 sessions—by baseline sleep quality
category, and program assignment

Refresh Breathe
Total in

category
Completers

(%)
Total in

category
Completers

(%)
Baseline
PSQI ≤ 5

29 14 (48%) 38 14 (37%)

Baseline
PSQI > 5

19 17 (89%) 15 5 (33%)

280Journal of Clinical Sleep Medicine, Vol. 7, No. 3, 2011

M Trockel, R Manber, V Chang et al
that the observed intervention group differences could be at least
partially explained by regression to the mean among Refresh
participants. Quasi-experimental design does not have the same
fidelity in internal validity inherent in a randomized clinical tri-
al. Further research using a true experimental design is needed
to establish an evidence base for the effectiveness of electroni-
cally delivered CBT-I for improving sleep and symptoms of de-
pression among college students with sleep difficulties. Future
experimental design research with adequate follow-up time is
also needed to determine whether improving sleep will reduce
risk of future depression.

Selection of students residing at a highly selective private
university may limit the generalizability of our results. Com-
pared to other groups of college students, the students who par-
ticipated in this study may be more motivated and better able to
follow a self-directed program to improve sleep through cogni-
tive and behavioral strategies.

Another limitation of our study is that both sleep quality
and depression were each assessed with only one self-report
measure. Self-report measures are subject to demand charac-
teristics, which could bias our results. The assessment of par-
ticipant adherence was limited to self-report of the number of
units they had completed. Although limited, these data revealed
that a higher proportion of students with poor sleep at baseline
completed at least 7 of 8 units, suggesting Refresh is acceptable
to a large majority of freshmen with sleep problems.

We cannot determine from our data what, if any, informa-
tion or intervention may be beneficial for students with no sleep
problems. We are also unable to determine from our data wheth-
er one or a few components, rather than the whole collection of
cognitive and behavior strategies, is associated with observed
improvements among students with poor sleep at baseline.

Future research might experiment with intervention tailoring,
delivering intervention components that fit students’ needs de-
termined by baseline assessment. For example, students with a
delayed chronotype may benefit from a module that specifically
addresses circadian entrainment, and others may not need it. Most
students with insomnia will benefit from combined stimulus con-
trol and time-in-bed restriction modules. Although the self-report-
ed number of units completed was very high, we believe future
research will also need to evaluate reasons for dropout and con-
sider methods to enhance retention. Perhaps tailored interventions
with fewer modules may offer higher adherence without reducing
effectiveness, as will adding a motivation enhancement compo-
nent, though these possibilities await empirical support.

Future research may also determine whether intervention to
improve sleep will also improve students’ academic performance.
Chronic sleep disturbance is strongly associated with short-term
cognitive impairments,35 and in adolescents has been linked with
subsequent impairment in academic performance.36 College stu-
dents who report better sleep quality perform better on academic
measures than those reporting a poorer quality of sleep,37 and vari-
able sleep schedules, specifically later weekend wake-up times,
accounts for significant variance in end-of-term grades.38 Students
who obtain less REM sleep than needed may also be less able to
integrate and store newly learned information.39,40 Even moder-
ate sleep disturbance has serious implications for neurobehavioral
functions, as sleep duration of six hours or less per night for 14
consecutive nights has been shown to produce cognitive perfor-

Most encouraging was our finding that among individuals
with poor sleep quality, a sleep enhancement intervention was
associated with greater improvement in depressive symptoms
than an intervention to improve mood and reduce stress. Our re-
sults are consistent with a large body of literature indicating that
disturbed sleep constitutes a risk factor for depression3-12 and are
consistent with a previous finding that CBT-I improves outcomes
among depressed patients receiving antidepressant medication
therapy.23 A previous study found that irregular sleep patterns can
lead to desensitization of serotonergic receptor systems,33 which
suggests a possible biologic mechanism for the relationship be-
tween impaired sleep and depressed mood. As our study was
conducted with college students, many of whom have irregular
sleep schedules, it is possible that the observed improvement in
mood is mediated by regularizing the students’ sleep schedules.
However, we do not have sufficient data to test this hypothesis.

The full version of the program for students with sleep dif-
ficulties demonstrated effectiveness. However, we did not find
benefit of the sleep-health promotion program in a group of
college students with little or no sleep disturbance at baseline.
Brown and colleagues found improved sleep quality (PSQI
scores) with a single group 30-minute sleep-health education
program in a general population college sample.34 It may be that
the group of students studied by Brown and colleagues34 had
sleep distress at baseline (mean PSQI = 7.3 among intervention
group participants and 6.6 among controls) comparable to our
sample of students with sleep problems (mean PSQI = 7.7 for
Refresh participants and 7.5 for Breathe participants) and dif-
ferent from our group of participants without significant base-
line sleep problems (mean PSQI = 3.3 for Refresh participants
and 3.5 for Breathe participants). It seems reasonable to expect
that students with disturbed sleep at baseline may benefit most
from a program designed to help them improve their sleep.

Importantly, among students with baseline sleep difficulties, tar-
geting sleep-health appeared more successful at reducing depres-
sive symptoms than an intervention targeting negative self-talk
and coping strategies that are common targets of CBT for depres-
sion. Given that poor sleep is a modifiable risk factor for depressed
mood,3-12 it is encouraging that targeting sleep-health was also as-
sociated with reduction in depressive symptoms. Although we do
not have long-term data to directly test the assertion that improving
sleep will reduce the risk for a future depressive episode, improv-
ing sleep might be an important element in depression prevention
interventions for students with sleep problems.

There are limitations of our study that warrant mention. Per-
haps the most important limitation is that students were assigned
to intervention groups by residence hall, rather than by random
assignment. Although this feature in the design reduced the dan-
ger of cross-contamination of treatment, it …

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