Telephone-Based CBT Improves Menopause-Related Insomnia

Tara Haelle

May 26, 2016

Cognitive behavioral therapy for insomnia (CBT-I) delivered by telephone improved insomnia symptoms in peri- and postmenopausal women, according to the results of a randomized trial published online May 24 in JAMA Internal Medicine.

"Our findings support the potential for training nonsleep specialists to deliver telephone-based CBT-I to women with insomnia and vasomotor symptoms in a variety of primary and women's health care settings," write Susan M. McCurry, PhD, from the University of Washington in Seattle, and colleagues.

"Cognitive behavioral therapy and pharmacotherapy are considered effective for treating chronic insomnia, with medications offering an advantage owing to immediate treatment effects, but CBT-I produces superior long-term outcomes," the authors write. "Reductions in Insomnia Severity Index [ISI] score with CBT-I in our trial approached those observed in previous studies examining the effect of eszopiclone on insomnia symptoms in menopausal women and were larger than have been reported in placebo-controlled trials of the effects of escitalopram, venlafaxine, or low-dose estradiol on sleep in this population," they continue.

The new findings are in line with a recently published clinical practice guideline from the American College of Physicians that recommends CBT as first-line treatment for chronic insomnia.

In the current trial, Dr McCurry and colleagues randomly assigned 106 women, with an average age of 54 years, to either a CBT-I group or a menopause education control (MEC) group. Both interventions included six telephone sessions delivered over the course of 8 weeks. Participants also kept weekly electronic sleep diaries. Information during MEC sessions focused on menopause and women's health, whereas CBT-I sessions focused on "sleep restriction, stimulus control, sleep hygiene education, cognitive restructuring, and behavioral homework."

Participants averaged 5.7 sessions, and sessions lasted an average 22.8 minutes, with no significant differences between the two groups in terms of participation or length of session. At the start of the study, 58% of women in the CBT-I group and 62% of those in the MEC group had moderate to severe insomnia based on ISI scores, and 92.5% of women in both groups had poor sleep quality based on Pittsburgh Sleep Quality Index scores of at least 5 on a scale of 0 to 21.

After treatment, women receiving CBT-I saw their ISI scores drop by 9.9 points compared with 4.7 among those receiving MEC, a mean difference of 5.2 points (95% confidence interval [CI], −6.1 to −3.3; P < .001). Moreover, in the CBT-I group, 70% of the women had no insomnia based on ISI scores at 8 weeks, and 84% of the women had no insomnia at 24 weeks. Meanwhile, 24% of the MEC group had no insomnia at 8 weeks, and 43% had none at 24 weeks.

Pittsburgh Sleep Quality Index scores dropped 4.0 points in the CBT-I group and 1.4 points in the MEC group, for a mean difference of 2.7 points (95% CI, −3.9 to −1.5; P < .001). A mean difference of 3 points is considered clinically significant.

Women in the CBT-I group had more than 5 times greater odds of good sleep quality after 8 weeks (odds ratio, 5.6; 95% CI, 2.3 - 14.8; P < .001), and more than 3 times greater odds at 24 weeks (odds ratio, 3.7; 95% CI, 1.4 - 9.5; P = .006). Self-reported wake time, sleep efficiency, and time to fall asleep also improved among women receiving CBT-I compared with among those receiving MEC.

Hot flash frequency, severity, or bother did not differ significantly between the groups at 8 or 24 weeks. Hot Flash Related Daily Interference Scale scores were significantly lower in the CBT-I group at 8 weeks, but scores were similar after exclusion of the sleep item. Women in both groups expressed high satisfaction with the interventions and similar assessments of acceptability, treatment adherence, and relationship quality with the menopause coach.

As reported previously by Medscape Medical News, Dr McCurry and colleagues presented the findings from this study at SLEEP 2015: Annual Meeting of the Associated Professional Sleep Societies.

The research was funded by the National Institute on Aging, the Eunice Kennedy Shriver National Institute of Child Health and Development, the National Center for Complementary and Alternative Medicine, and the Office of Research on Women's Health One coauthor received consulting fees from Merck and grants from Novartis. Another coauthor received grant funding from Merck and consulting fees from NeRRe Therapeutics, Merck, SAGE Therapeutics, and Mitsubishi Tanabe. Another coauthor received consulting fees from JDS Therapeutics LLC, Noven Pharmaceuticals, and PamLab LLC, and grant funding from AstraZeneca Pharmaceuticals, Alkermes, Bristol-Myers Squibb/Otsuka, Sunovion Pharmaceuticals Inc, Bayer HealthCare Pharmaceuticals, Ortho-McNeil Janssen Pharmaceuticals Inc, Pfizer Inc, Forest Laboratories Inc, Cephalon Inc, GlaxoSmithKline, and Takeda/Lundbeck.

JAMA Intern Med. Published online May 24, 2016. Abstract

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