Sheila N. Garland, PhD, R Psych
Jun J. Mao, MD, MSCE
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.
1. Savard J, Ivers H, Villa J, et al: Natural course of insomnia comorbid with cancer: An 18-month longitudinal study. J Clin Oncol 29:3580-3586, 2011.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Washington, DC, American Psychiatric Association Publishing, 2013.
3. Ruel S, Savard J, Ivers H: Insomnia and self-reported infections in cancer patients: An 18-month longitudinal study. Health Psychol 34:983-991, 2015.
4. Lis CG, Gupta D, Grutsch JF: The relationship between insomnia and patient satisfaction with quality of life in cancer. Support Care Cancer 16:261-266, 2008.
5. Irwin MR: Depression and insomnia in cancer: Prevalence, risk factors, and effects on cancer outcomes. Curr Psychiatry Rep 15:404, 2013.
6. Stepanski EJ, Walker MS, Schwartzberg LS, et al: The relation of trouble sleeping, depressed mood, pain, and fatigue in patients with cancer. J Clin Sleep Med 5:132-136, 2009.
7. Spielman AJ, Caruso LS, Glovinsky PB: A behavioral perspective on insomnia treatment. Psychiatr Clin North Am 10:541-553, 1987.
8. Drake CL, Roth T: Predisposition in the evolution of insomnia: Evidence, potential mechanisms, and future directions. Sleep Medicine Clinics 1:333-349, 2006.
9. Perlis M, Shaw PJ, Cano G, et al: Models of insomnia, in Kryger MH, Roth T, Dement WC (eds): Principles and Practice of Sleep Medicine, 5th ed, pp 850-865. St. Louis, MO, Elsevier, 2011.
10. Morin CM, Benca R: Chronic insomnia. Lancet 379:1129-1141, 2012.
11. Johnson JA, Rash JA, Campbell TS, et al: A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 27:20-28, 2016.
12. Fleming L, Randell K, Harvey CJ, et al: Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients? Psychooncology 23:679-684, 2014.
13. Smith MT, Perlis ML, Park A, et al: Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 159:5-11, 2002.
14. Beaulieu-Bonneau S, Ivers H, Guay B, et al: Long-term maintenance of therapeutic gains associated with cognitive-behavioral therapy for insomnia delivered alone or combined with zolpidem. Sleep 40(3), 2017.
15. Morin CM, Vallières A, Guay B, et al: Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial. JAMA 301:2005-2015, 2009.
16. Qaseem A, Kansagara D, Forciea MA, et al; Clinical Guidelines Committee of the American College of Physicians: Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 165:125-133, 2016.
17. Berger AM, Matthews EE, Kenkel AM: Management of sleep-wake disturbances comorbid with cancer. Oncology (Williston Park) 31:610-617, 2017.