Can Cognitive Behavioral Therapy Help with Insomnia?
By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
SUMMARY POINTS
- In a randomized clinical trial comparing the efficacy of telephone cognitive behavioral therapy for insomnia (CBT-i) against education alone in patients with comorbid osteoarthritis, researchers evaluated Kaiser Permanente Washington patients aged 60 years and older with osteoarthritis for comorbid insomnia.
- In all, 327 eligible patients were identified and randomized into treatment arms; over an eight-week period, both intervention groups received six telephone sessions, each lasting between 20 and 30 minutes.
- At the two-month completion of study and at 12-month follow-up, the average insomnia scale score in the CBT-i group was significantly improved compared to the control group (P < 0.001). At the 12-month mark, 56.3 % of the CBT-i arm achieved remission compared to just 25.8% of the education-only control group.
SYNOPSIS: In this randomized clinical trial, telephone-administered cognitive behavioral therapy for insomnia significantly outperformed education alone in alleviating insomnia and reducing daytime fatigue in older adults with osteoarthritis pain.
SOURCE: McCurry SM, Zhu W, Von Korff M, et al. Effect of telephone cognitive behavioral therapy for insomnia in older adults with osteoarthritis pain: A randomized clinical trial. JAMA Intern Med 2021;181:530-538.
Osteoarthritis, accompanied by pain, stiffness, and swelling is a leading cause of disability among adults worldwide. Affecting 32.7 million U.S. adults, the risk of developing this disorder increases with age.1
Many researchers have identified osteoarthritis-related insomnia as affecting up to half of patients with osteoarthritis, and more recent longitudinal investigations point to insomnia as an independent risk factor for osteoarthritis. There is building evidence suggesting that addressing insomnia can protect against or mitigate the effect of osteoarthritis.1-4
Cognitive behavioral therapy for insomnia (CBT-i) is a structured form of talk therapy considered a first-line treatment for insomnia. This treatment involves restructuring the beliefs and behaviors that surround a sleep problem and introducing substitute behaviors and relaxation techniques. For example, patients are instructed in mindfulness techniques to reduce hyperarousal at night and taught to limit time in bed to promote greater sleep efficacy. A lack of clinicians trained to deliver CBT-i, especially in rural and other underserved areas, is a major barrier to widespread availability of CBT-i.5,6
McCurry et al reported results from the Osteoarthritis and Therapy for Sleep (OATS) trial, one of the only studies to test telephone-delivered CBT-i for patients with osteoarthritis living primarily in rural or medically underserved areas.
Patients aged 60 years and older with known diagnoses of osteoarthritis were recruited from Kaiser Permanente Washington electronic health records. Eligibility criteria included a high score on both an insomnia and chronic pain screens, which were delivered via telephone.
Exclusion criteria included patients with known sleep disorders and/or cognitive impairments.
The 327 participants were randomized to receive either CBT-i or education only. Both treatments were delivered via six 30-minute telephone sessions over eight weeks. All participants were asked to keep track of sleep via a sleep diary.
Telephone assessments involved administering several evaluation tools, including the Insomnia Severity Index (ISI) and scales measuring other outcomes, such as depression, intensity of pain, and the effect of pain on activity and fatigue levels.7 These assessments took place at three specific time points: at baseline, at the end of the two-month treatment period, and at 12-month follow-up.
RESULTS
A total of 282 participants (136 from the intervention group and 146 from the control group) completed at least the two-month post-treatment assessment and were included in the primary analysis.
The ISI consists of a seven-question survey measuring insomnia severity on a scale of 0-4. A cumulative score of 15 or greater indicates moderate to severe insomnia, while a score below 7 indicates “no significant” insomnia symptoms.7
Table 1 displays the results of the ISI at baseline, end of study, and 12-month follow-up. The decrease in the ISI score for the CBT-i group appears sustained during the follow-up period, and the difference between the mean scores in each group reached statistical significance.
Table 1. ISI Mean Score (Standard Deviation) in Intervention vs. Control Group |
|||
| Baseline | Post Treatment (Month 2) | Follow-up (Month 12) | |
CBT-i (n = 136) |
15.3 (3.2) |
7.2 (4.0) |
7.7 (4.5) |
Education control (n = 146) |
15.5 (3.2) |
10.7 (4.3) |
10.8 (4.5) |
P value (difference between the means) |
N/A |
P < 0.001* |
P < 0.001* |
*Statistically significant value ISI: Insomnia Severity Index; CBT-i: cognitive behavioral therapy for insomnia |
|||
Other findings included:
- Pain: There was no statistical significance noted in the difference between the mean pain intensity scores or in the mean interference with activity scores between the two study arms.
- Depression: While there appeared to be a statistical difference in level of depression at the two-month mark (with improvement in depression scores in the CBT-i group compared to the education control group), this finding was not sustained at the 12-month follow-up mark.
- Fatigue: Improvement in fatigue scales in the CBT-i group was significantly better than in the education-only control group at two months and at 12- months (P < 0.001 and P < 0.003, respectively.)
Meanwhile, results for the remission of insomnia (scores below 7 on ISI) included:
- Baseline: 1 participant in the CBT-i arm vs. 0 in the education control;
- Month 2: 79 participants (58.1%) in the CBT-i arm vs. 37 (25.5%) in the education control;
- Month 12: 67 participants (56.3%) in the CBT-i arm vs. 33 (25.8%) in the education control.
There were no serious adverse effects linked to treatment during this study.
COMMENTARY
This comprehensive, randomized, controlled study illustrates the potential of a cost-effective, low-tech approach to delivering successful insomnia treatment for older adults with osteoarthritis.
By utilizing telephone communication instead of relying on in-person meetings or internet-based delivery methods, the accessibility of this intervention is expanded, making it available to a wider spectrum of patients.
Although this study revealed significant benefits in alleviating insomnia and improving daytime fatigue through CBT-i, it did not yield the same positive results for pain or depression symptoms. This discrepancy may underscore the targeted nature of CBT-i specifically toward insomnia. It also raises the question of whether extended sleep alone can alleviate the pain and functional limitations associated with osteoarthritis.
Other researchers may want to explore and define the nuanced relationship between pain and sleep in osteoarthritis.
This study does have some limitations. One notable constraint is that all participants were drawn from a single healthcare system, limiting the generalizability of the findings. Future studies with a more diverse participant pool can help in this regard. Additionally, the reliance on self-report for outcomes introduces a degree of subjectivity, but advances in monitoring techniques could allow for more objective data collection in upcoming research.
Despite the study limitations, this study provides a clear clinical message for the integrative provider. For now, integrative providers should consider assisting osteoarthritis patients experiencing insomnia in finding accessible CBT-i delivery methods.
Future research is necessary to further understand the relationship between sleep and pain in osteoarthritis and to generalize the findings to a broader population.
REFERENCES
- Centers for Disease Control and Prevention. Osteoarthritis (OA). July 27, 2020. Published July 27, 2020. https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
- Rothrauff B, Tang Q, Wang J, He J. Osteoarthritis is positively associated with self-reported sleep trouble in older adults. Aging Clin Exp Res 2022;34:2835-2843.
- Jacob L, Smith L, Konrad, M, Kostev, K. Association between sleep disorders and osteoarthritis: A case–control study of 351,932 adults in the U.K. J Sleep Res 2021;30:e13367.
- Ni J, Zhou W, Cen H, et al. Evidence for causal effects of sleep disturbances on risk for osteoarthritis: a univariable and multivariable Mendelian randomization study. Osteoarthritis Cartilage 2022;30:443-450.
- van der Zweerde T, Bisdounis L, Kyle SD, et al. Cognitive behavioral therapy for insomnia: A meta-analysis of long-term effects in controlled studies. Sleep Med Rev 2019;48:101208.
- Rossman J. Cognitive-behavioral therapy for insomnia: An effective and underutilized treatment for insomnia. Am J Lifestyle Med 2019;13:544-547.
- Shahid A, Wilkinson K, Marcu S, Shapiro CM, eds. STOP, THAT and One Hundred Other Sleep Scales. Springer; 2012.
In this randomized clinical trial, telephone-administered cognitive behavioral therapy for insomnia significantly outperformed education alone in alleviating insomnia and reducing daytime fatigue in older adults with osteoarthritis pain.
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