The ASCO Post’s Integrative Oncology series is intended to facilitate the availability of evidence-based information on integrative and complementary therapies commonly used by patients with cancer. In this installment, Sheila N. Garland, PhD, R Psych, and Jun J. Mao, MD, MSCE, present information on the brief intervention known as cognitive behavior therapy for insomnia, which contains three primary components: sleep restriction, stimulus control, and cognitive restructuring.
INSOMNIA OCCURS in up to 60% of cancer patients, but it is underrecognized, inadequately managed, and does not typically remit without intervention.1 Unlike the occasional sleepless night, insomnia is a disorder characterized by difficulty falling asleep, staying asleep, or waking up too early at least three times per week for the past 3 months.2 Insomnia in cancer patients can have significant consequences, including an increased risk of infections,3 decreased overall quality of life,4 higher risk of (and poorer recovery from) depression and anxiety,5 and greater severity of other cancer-related symptoms.6
THE 3P MODEL of insomnia aims to explain interactions among Predisposing, Precipitating, and Perpetuating factors in the development and maintenance of insomnia. Predisposing factors represent the underlying vulnerability to develop insomnia and comprise biologic features such as a genetic predisposition, age, and sex, and psychological traits such as the tendency to worry and/ or ruminate.7 Diseases that disrupt homeostasis, including cancer, can be broadly thought of as both physical and psychological stressors that may precipitate insomnia.8
Perpetuating factors refer to the behaviors that an individual engages in that actually make it more likely the insomnia will persist. These behaviors include going to bed earlier, “trying” harder to sleep, napping during the day, and engaging in activities other than sleep while in bed. Eventually, insomnia becomes a classically conditioned response because sleep-related stimuli are repeatedly paired with wakefulness, anxiety, and arousal. Thus, the 3P model of insomnia provides a solid explanation for how acute insomnia can develop into chronic insomnia.9
Cognitive Behavior Therapy for Insomnia
COGNITIVE BEHAVIOR therapy for insomnia is a brief intervention that has three primary components: sleep restriction, stimulus control, and cognitive restructuring.10 Sleep restriction addresses the primary perpetuating factor for chronic insomnia, which is the attempt to try to force sleep and the tendency to spend more time in bed trying to sleep. Stimulus control targets the conditioned arousal associated with insomnia caused by repeatedly engaging in activities other than sleep while in bed. Cognitive restructuring is used to identify and address thoughts and beliefs that may contribute to the development of, or reinforce, behaviors that produce pre-sleep arousal and/or performance anxiety.
A systematic review and meta-analysis of 8 randomized controlled trials comprising 752 cancer patients concluded that cognitive behavior therapy for insomnia is a highly effective treatment and produces significant improvements in a variety of subjective sleep components.11 Compared with controls, patients who received cognitive behavior therapy for insomnia fell asleep 22 minutes faster, spent 30 fewer minutes awake during the night, and reported improvement in self-reported insomnia severity.
Published evidence also suggests that cognitive behavior therapy for insomnia is effective for reducing fatigue, anxiety, and depression related to cancer treatment.12 Compared with medication, cognitive behavior therapy for insomnia has similar short-term effect sizes13 and is more durable, often extending beyond acute treatment up to 24 months.14 Furthermore, more than 55% of patients treated with cognitive behavior therapy for insomnia reach remission within 6 months of the discontinuation of acute therapy.15 Given these findings, it is not surprising that in 2016, the American College of Physicians released a position statement recommending that all adult patients receive cognitive behavior therapy for insomnia as the initial treatment for chronic insomnia disorder and that pharmaceuticals should only be added in patients for whom this intervention alone was unsuccessful.16
THE NATIONAL CANCER INSTITUTE, National Comprehensive Cancer Network®, and the Oncology Nursing Society have released guidelines recommending routine screening and treatment of sleep wake disturbances comorbid with cancer.17 Within these recommendations, cognitive behavior therapy for insomnia is considered to have strong and consistent evidence as a first-line intervention, whereas medication is considered to be only a useful short-term strategy. Oncologists and health-care providers should refer patients who experience insomnia to credentialed providers (psychologists, social workers, or nurses) with cognitive behavior therapy for insomnia training. Treatment typically consists of four to eight individual or group sessions over the course of 2 to 3 months, with an option for an additional booster session if necessary. ■
DISCLOSURE: Drs. Garland and Mao reported no conflicts of interest.
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