Stepped-Care Approach to CBT for Insomnia in Cancer Patients Works

Reuters Staff

August 02, 2021

NEW YORK (Reuters Health) — For cancer-related insomnia, a stepped-care approach to delivering cognitive-behavioral therapy for insomnia (CBT-I) may work as well as standard CBT-I, according to a study from Canada.

This finding has "significant clinical implications as it offers an alternative model of care to treat cancer-related insomnia that is less costly, while being not less efficacious, and which can therefore be more easily implemented in routine cancer care than standard CBT-I," write Dr. Josee Savard with Laval University Research Center, Quebec, Canada, and colleagues in Sleep.

Use of stepped care CBT-I "could contribute considerably to improving patients' access to CBT-I and thus reduce the psychological, physical and financial burden of cancer-related insomnia," they add.

Between 30% and 60% of cancer patients suffer from insomnia during their cancer treatment. CBT-I has been shown to improve sleep in cancer patients but accessibility is limited.

Stepped-care models — starting with a self-administered intervention followed by a more intensive treatment if needed — have been proposed to help make CBT-I more widely available. Until now, however, only small uncontrolled studies have been published.

In a noninferiority randomized controlled trial, Dr. Savard's team compared the efficacy of stepped-care CBT-I with that of standard CBT-I in 177 adults (mean age, 55 years) with cancer-related insomnia. Most participants were women with breast cancer.

The 59 individuals in the StanCBT-I group received 6 weekly face-to-face sessions.

In the StepCBT-I group, individuals with less severe insomnia — defined as an insomnia severity index (ISI) score between 8 and 15 — first received web-based CBT-I (65 patients), while those with a more severe insomnia (ISI of 15+) received six face-to-face CBT-I sessions (53 patients).

Patients in both StepCBT-I groups could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step.

The content of CBT-I was the same whether it was delivered in face-to-face sessions or self-administered online.

Patients were assessed before treatment (T1), immediately after the first treatment step (T2; 6 weeks) and the second treatment step (T3; 3 months), and 6 (T4) and 12 months (T5) later.

StepCBT-I produced sleep improvements that were not significantly inferior to those of StanCBT-I at all post-treatment time points. After initial treatment (T2), 72.0% of StanCBT-I patients and 57.8% of StepCBT-I were remitted (ISI score < 8), a difference that was not significant (P < .09).

StepCBT-I patients who started with face-to-face sessions were more likely to be in remission at T2 compared to those started with the web-based program, but this difference was also not significant.

Remission rates in the StepCBT-I group at T3, T4 and T5 were 59.3%, 64.6% and 56.3%, respectively. These rates were not significantly different from rates achieved in the StanCBT-I group (74.8%, 63.2%, and 54.7%, respectively).

Analyses of secondary outcomes showed no significant between-group differences on other sleep diary variables, sleep medication usage, symptoms (depression, anxiety and fatigue) and quality of life.

"This shows that treating insomnia efficaciously with CBT-I is associated with parallel changes in psychological distress and fatigue," the study team reports.

It's also noteworthy, they say, that StepCBT-I patients with unremitted insomnia at T2 who completed at least one booster session saw a significant decrease in anxiety and fatigue, supporting the value of booster sessions.

The researchers caution that study participants were all white, highly educated, and predominantly composed of women with breast cancer (76.7%). "It will be important to replicate these findings in more diverse populations," they say.

The study supported by the Canadian Institutes of Health Research. The authors have indicated no relevant conflicts of interest.

SOURCE: Sleep, online July 6, 2021.