Imagery Rehearsal Therapy (IRT) is associated with reduced nightmare severity and depressive, anxiety and suicidal symptoms in adults with Major Depressive Episode.

Abstract

Nightmare Disorder characterized by recurrent dysphoric dreams is strongly associated with major depressive episodes (MDE) and suicidal risk. Imagery rehearsal therapy (IRT) is the standard treatment for nightmares, but its effectiveness in individuals with MDE remain understudied. This study evaluated whether IRT is associated with greater improvement in nightmare symptoms compared to sleep education therapy (SET) in patients with MDE. In this non-randomized controlled study, 53 adults diagnosed with both MDE and Nightmare Disorder (DSM-5-TR criteria) received either four weekly group-based IRT sessions (n = 28) or a single SET session during the baseline interview, followed by a four-week waitlist before IRT (n = 25). Outcomes included the Nightmare Severity Index (NSI), depressive symptoms (QIDS-SR16 and HAD-D), anxiety symptoms (HAD-A and GAD-7) and suicidal ideation (item 12 of the QIDS-SR16). Treatment effects were assessed through change scores and pre- and post-intervention comparisons. IRT was significantly associated with greater reductions in nightmare severity (p < 0.001) with improvements observed across NSI subscales: frequency (p = 0.010), emotional (p = 0.003), diurnal (p = 0.017), and nocturnal impacts (p = 0.002). Associations were also found between IRT and reductions in depressive (ΔHAD-D p < 0.001, ΔQIDS-SR16 p = 0.028), anxiety (ΔHAD-A and ΔGAD-7 p < 0.001) and suicidal symptoms (p = 0.002). Treatment-resistant depression predicted greater improvements in the emotional impact of nightmares (p = 0.007), while nightmare frequency was associated with reduced benefit (p = 0.008). IRT is associated with meaningful reductions in nightmare severity, depressive symptoms, anxiety, and suicidal ideation in individuals with MDE. These findings support the integration of IRT in treatment plans for this high-risk population.