Megan Brooks

June 09, 2015

SEATTLE ― Cognitive-behavioral therapy for insomnia (CBT-I) delivered by telephone proved feasible, acceptable, and highly effective for easing insomnia symptoms in menopausal women with vasomotor symptoms in a randomized, controlled study.

It also "significantly improved hot flash interference, depression symptoms, stress, and improved quality of life" compared with menopause education (control), reported Susan M. McCurry, PhD, Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, here at SLEEP 2015: the Annual Meeting of the Associated Professional Sleep Societies.

Most women experience insomnia symptoms when they go through menopause, which may lead to lost work productivity, mood disturbances, and reduced quality of life. However, there are no evidence-based nonpharmacologic strategies to ease insomnia symptoms in menopausal women, Dr McCurry noted.

Her study suggests that brief telephone-delivered CBT-I intervention can improve sleep in midlife women with vasomotor symptoms.

The study included 106 women (mean age, 54.8 years) with insomnia symptoms of moderate severity, defined as an Insomnia Severity Index (ISI) score of at least 12 and at least two hot flashes per day. None of the women had a prior diagnosis of a sleep disorder. The women were predominantly white (91.5%), college educated (77.4%), and married (78.3%); they were experiencing 7.5 hot flashes per day, on average.

Half were randomly allocated to the CBT-I intervention and half to menopause education (MEC) as a control group. Telephone CBT-I consisted of education on menopausal and age-related changes in sleep, sleep hygiene, sleep restriction and stimulus control procedures, and cognitive strategies to disrupt sleep-related dysfunctional beliefs and attitudes. MEC included basic health information for the menopausal woman.

Both CBT-I and MEC were delivered by a trained master's-level "coach" via weekly telephone calls lasting 20 to 30 minutes during an 8-week period. Women had the option of having the first session in person so that they could meet the therapist face to face. The women also kept daily sleep logs.

The women completed assessments at baseline and post treatment. Intent-to-treat analyses included all randomized participants who provided follow-up data, regardless of intervention adherence. A total of 101 patients completed the intervention; to date, 79% of CBT-I women and 60% of MEC women have returned mailed posttreatment assessment materials.

Telephone CBT-I was "very feasible and quite acceptable to women," Dr McCurry reported. "We had low dropout rates; most women in both conditions completed all sessions."

In addition, compared with women who received MEC, women who received CBT-I had significantly (P < .001) greater decreases in ISI scores (the primary outcome) and PSQI scores from baseline to week 8, and the benefits were sustained in sensitivity analysis, "which further supports the validity of the findings," Dr McCurry said.

Table: Mean (95% Confidence Interval) Baseline to Week 8 Change Scores

Outcome CBT-I MEC Difference
ISI -9.9 (-11.2 to -8.7) -4.6 (-6.0 to -3.2) -5.3 (-7.2 to -3.5)
PSQI -4.0 (-5.0 to -3.1) -1.4 (-2.1 to -0.7) -2.6 (-3.9 to -1.4)

ISI, Insomnia Severity Index; PSQI, Pittsburgh Sleep Quality Index.


Telephone CBT-I was also associated with significantly greater improvements in diary ratings of sleep efficiency (P < .001), depression (P = .006), and perceived stress (P = .04).

There were no changes between groups in reported frequency of hot flashes, but daily hot flash "interference" was significantly reduced in the CBT-I group, Dr McCurry said. The CBT-I group also reported improvement in menopause quality of life, self-reported depression symptoms, and perceived stress, relative to the MEC control group.

"It doesn't surprise me at all that telephone delivery of CBT-I would work. There have been other studies of telephone-based CBT-I working," Philip Gehrman, PhD, CBSM, of the Department of Psychiatry, University of Pennsylvania, in Philadelphia, and member of the Penn Sleep Center, noted in an interview with Medscape Medical News.

"What's interesting," he said, "is that in psychological treatment, there are the components of treatment and then the whole relationship with the patient, and some people think you lose that relationship with a telephone-based approach, and you do to some extent, but it seems to be that with CBT-I, it doesn't always matter."

"What you often see," Dr Gehrman added, "is that face-to-face, individual, one-on-one CBT-I has the largest effects. If you do it in group or over the telephone, you lose some efficacy, but not that much."

The study had no commercial funding. The authors and Dr Gehrman have disclosed no relevant financial relationships.

SLEEP 2015: Annual Meeting of the Associated Professional Sleep Societies: Abstract 1152. Presented June 8, 2015.


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