Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent treatment package that usually includes stimulus control, sleep restriction, and cognitive therapy and has emerged as the most prominent nonpharmacologic treatment for chronic insomnia. Previous meta-analyses have found that CBT-I improves sleep parameters and sleep quality at post treatment and follow-up for adults and older adults. Most of these studies selected individuals with primary insomnia, excluding patients with co-morbid psychiatric and medical conditions. However, patients with insomnia who present to internists and primary care physicians are likely to report comorbid conditions associated with the sleep disturbance. Furthermore, insomnia was previously conceptualized as a symptom arising from the comorbid disorder and treatment was targeted at the underlying disorder. However, accumulating evidence indicates that insomnia can have a distinct and independent trajectory from the comorbid disorder, thus indicating a need for separate treatment from the comorbid condition.
So begins this week’s Reading, which considers CBT-I for people with insomnia. Here’s a quick summary: big study, big journal – and big relevance to your patients.
This week’s Reading: “Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis” by Jade Q. Wu et al. was just published in JAMA Internal Medicine. Find the paper here.
Wu et al. consider a very common problem: insomnia. Many patients – whether they have mental health issues or physical health issues – struggle with insomnia. Boston University health economist Austin Frakt has written about his insomnia for The New York Times. He notes that he decided to receive treatment when:
One weekend afternoon a couple of years ago, while turning a page of the book I was reading to my daughters, I fell asleep.
Jade Q. Wu
The temptation is to see such patients struggling with sleep and suggest a prescription. Needless to say, in recent years, CBT-I (a short, focused therapy) has gained popularity. Just a few weeks ago, the Annals of Internal Medicine ran a thoughtful meta-analysis by Trauer et al. considering CBT-I for chronic insomnia – finding good effect size.
But many of our patients are complicated. Does CBT-I work in the real world? Certainly others have looked at CBT-I for pain, cancer, and depression. Here’s what’s cool about the Wu et al. paper – they look at a variety of papers considering a variety of conditions. As the University of Pennsylvania’s Michael A. Grandner and Michael Perlis note in the accompanying Invited Commentary: “the time seems ripe to take stock of such findings within the framework of a proper meta-analysis… [Wu’s] investigation… does precisely this.”
Here’s what they did:
· The authors did a systemic search in PubMed, PsycInfo and the Cochrane Library, searching broadly, using various search terms like CBT-I, CBT, behavioural sleep medicine, relaxation therapy and other sister terms; they also searched on the terms insomnia and sleep disturbance. They also looked through meta-analyses and reference lists.
· The authors then narrowed down the number of studies with inclusion criteria: CBT-I was part of the treatment; the sample consisted of people 18 or over; the trial included a randomized control trial design, with a control group; there was sufficient data for performing an effect size calculation.
· Three co-authors were involved in the selection process and an effort was made to have interrater agreement (initially 94%).
· The papers were considered for outcomes. Specifically, the authors looked at: remission from insomnia, sleep outcome measures, and comorbid outcome measures.
· The authors did data extraction, with care to focus on the most active nonpharmacological conditions; a random-effects model was used to address variance; the authors used strategies to deal with publication bias.
Here’s what they found:
· Of the 1,683 hits in the initial search, 158 potential papers were further examined. This was distilled down to 37 published studies, covering 2,189 participants. Most studies included men and women (the breast cancer work didn’t). Study quality was judged as “moderate to high.”
· CBT-I was found to have a “positive effect” on reducing insomnia symptoms and sleep disturbances in comorbid insomnia; their findings are well summarized in this graph:
· A numerical summary: 36.0% of patients who received CBT-I were in remission from insomnia compared to 16.9% of controls. In most sleep parameters, the effect sizes were medium to large (sleep efficiency, for example, was Hedges g = 0.91).
· Treatment effects were maintained for measures like sleep efficiency and sleep quality at follow up (meaning that benefits were maintained at 3 and 6 months post-treatment).
· There were improvements in co-morbid conditions (small to medium effect size), though, they were greater in people with psychiatric conditions, as opposed to medical conditions.
They conclude:
Our findings indicate that CBT-I can improve insomnia symptoms and sleep parameters when insomnia is comorbid with medical and psychiatric conditions. Furthermore, CBT-I can affect symptoms associated with the comorbid condition, with stronger effects observed in psychiatric conditions compared with medical conditions. These findings provide empirical support for the recommendation of using CBT-I as the treatment of choice for comorbid insomnia disorders.
The authors push further, suggesting that CBT-I be adopted in primary care settings.
For example, a brief behavioral therapy for insomnia delivered by a trained nurse has demonstrated efficacy in primary care and can serve as a model for implementing CBT-I in this setting.
A few thoughts:
1. This study isn’t perfect, but it’s very good. The approach is thorough and they cover the literature well.
2. I agree with the conclusion in that CBT-I should be more fully incorporated into care – not just to patients with mental illnesses, but also physical illnesses. CBT-I has utility for people with depression, yes; this study shows that people with breast cancer, COPD, and other physical illnesses benefit, too.
3. The authors suggest incorporating a nurse teaching CBT-I in primary care settings. Could we be more creative?
Let me pick up on that last point. Prof. Frakt chose CBT-I for his insomnia problems over prescription medications – but he didn’t work with a nurse. At the recommendation of his family doctor, he did an online course, which cost him about $40 USD. You can find “CBT for Insomnia” here:
I recommend “CBT-i Coach” to my patients. This app is free. Find it here:
http://www.ptsd.va.gov/professional/materials/apps/cbticoach_app_pro.asp
Further Reading
For more on Prof. Frakt and his struggle with insomnia, see:
The Trauer et al. paper can be found here:
http://annals.org/article.aspx?articleid=2301405
Please note that there will be no Readings for the next two weeks. Enjoy the long weekend. And, in the meantime, comments and questions are always welcome, as are suggested Readings.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.
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