Behavioral Approaches May Help Insomnia

Sheila Garland, PhD

Cognitive behavioral therapy for insomnia (CBT-I) and mindfulness-based stress reduction (MBSR) can improve sleep for patients with cancer, but CBT-I continues to be the best nonpharmacologic option, according to findings of a study directly comparing the two (J Clin Oncol. 2014;32(5):449-457).

Although medications are available for the treatment of insomnia, many cancer patients do not want to add to the already long list of medications they must take and also worry over possible side effects, drug interactions, and developing dependence.

For the study, 111 adults who received treatment at a Canadian tertiary cancer center for nonmetastatic cancer were randomly assigned to receive either CBT-I (n = 47) or MBSR (n = 64). The CBT-I protocol involved stimulus control, sleep restriction, cognitive therapy, and relaxation training. The MBSR program offered a psychoeducational component explaining the link between stress and health, accompanied by the practice of meditation techniques and gentle yoga. Both cohorts received 90-minute interventions weekly for 8 weeks. The MBSR group also participated in a 6-hour weekend retreat.

The study’s primary outcome, insomnia severity, was measured by the Insomnia Severity Index (ISI), a sevenitem questionnaire which assesses difficulties with sleep onset and sleep maintenance, the extent to which sleep problems interfere with daily function, and distress levels elicited by insomnia. The researchers set a four-point noninferiority margin for comparing the two interventions.

Secondary outcomes of the study included sleep quality, sleep beliefs, mood, and stress. Patient sleep diaries and actigraphy monitoring were used to determine sleep efficiency, sleep onset latency, wake after sleep onset, and total sleep time.

Patients were assessed at baseline, at the end of the program, and at 5 months. After completing the 8-week programs, both CBT-I and MBSR resulted in reduced insomnia severity; the CBT-I cohort experienced more rapid results, whereas MBSR led to a more gradual improvement. At the 5-month follow-up, MBSR met the established noninferiority criterion.

Sleep onset latency was reduced by 22 minutes in the CBT-I cohort and by 14 minutes for those receiving the MBSR. Total sleep time increased by 0.60 hours with CBT-I and 0.75 hours with MBSR. Both groups experienced a reduction in the time it took to fall asleep and return to sleep during the night, as well as improvements in mood and stress-related symptoms.

“If not properly addressed, sleep disturbances can negatively influence therapeutic and supportive care measures for these patients, so it’s critical that clinicians can offer patients reliable, effective, and tailored interventions,” said lead study author Sheila Garland, PhD, a Clinical Psychology Post-Doctoral Fellow in Integrative Oncology and Behavioral Sleep Medicine at Penn’s Abramson Cancer Center. “This study suggests that we should not apply a ‘one-size-fits-all’ model to the treatment of insomnia and emphasizes the need to individualize treatment based on patient characteristics and preferences.”

Nurse Perspective

Kristin Barber, RN, MSN, APRN

Utah Cancer Specialists

Salt Lake City, UT

Assessment of insomnia is difficult because it usually is not the most important focus of my patient visit, but it no doubt impacts patient care. When I first reviewed the article above I was worried about my assessment skills for insomnia. After reviewing the Insomnia Severity Index (ISI), I feel a bit better about how I approach patients. Usually I try to focus on what part of their sleep they are having trouble with: falling asleep, staying asleep, or waking up early. The second half of the ISI focuses on how this impacts the patient. Here is where we as providers may not always get accurate or current information.

Finding out about patients’ sleep patterns is important, and we know this because half of all cancer patients suffer from this. I agree completely with the study that a majority of my patients do not want another “pill” to take for this diagnosis. Offering patients an intervention like cognitive behavioral therapy (CBT) or mindfulness-based stress reduction is a refreshing way to be able to offer a solution. One can see from the study above that both are effective interventions.

One limitation to this that we may run into in daily practice is that patients often do not want another appointment with another specialist. It is important to use these data to support our referrals to therapists for patients. Reminding them that help can benefit the quality of their sleep along with their sleep beliefs and sleep efficiency may help encourage them to seek assistance.

I see this intervention helping mainly in the population of patients who had trouble with insomnia prior to their cancer diagnosis. I am not sure they identified the duration of insomnia in patients’ in this trial. Patients with new-onset insomnia due to anxiety from their cancer, in my opinion, may just need short-term oral medication therapy. Another point mentioned in the article is that treatment of insomnia is individual, so being able to identify which patients would benefit from CBT and which from oral medication is what makes us great providers.