Cognitive behavioral therapy for insomnia (CBT-I) and mindfulness-based stress reduction (MBSR) can improve sleep for patients with cancer, but CBT-I continues to be the best nonpharmacologic option
Sheila N. Garland, PhD
Clinical Psychology Postdoctoral Fellow
Integrative Oncology and Behavioral Sleep Medicine Abramson Cancer Center
Cognitive behavioral therapy for insomnia (CBT-I) and mindfulness-based stress reduction (MBSR) can improve sleep for patients with cancer, but CBT-I continues to be the best nonpharmacologic option, according to findings of a study directly comparing the two approaches.1
It is estimated that between 36% and 59% of patients with cancer suffer from sleep disorders during and following cancer treatment, and up to 28% of patients with cancer receive a formal diagnosis of insomnia. Although medications are available for the treatment of insomnia, many patients do not want to add to the already long list of medications they must take and also worry over possible side effects, drug interactions, and developing dependence.
For the study, 111 adults who received treatment at a Canadian tertiary cancer center for nonmetastatic cancer were randomly assigned to receive either CBT-I (n = 47) or MBSR (n = 64). The CBT-I protocol involved stimulus control, sleep restriction, cognitive therapy, and relaxation training. The MBSR program offered a psychoeducational component explaining the link between stress and health, accompanied by the practice of meditation techniques and gentle yoga. Both cohorts received 90-minute interventions weekly for 8 weeks. The MBSR group also participated in a 6-hour weekend retreat. To be eligible for the trial, participants needed to have completed their chemotherapy and radiotherapy treatments at least 1 month prior to enrollment; those taking psychotropic drugs could participate if their dosage had not changed over the previous 6 weeks.
The study’s primary outcome, insomnia severity, was measured by the Insomnia Severity Index (ISI), a seven-item questionnaire which assesses difficulties with sleep onset and sleep maintenance, the extent to which sleep problems interfere with daily function, and distress levels elicited by insomnia.
The researchers determined that a reduction of at least eight points on the ISI would be needed to demonstrate a reduction in insomnia severity, and they set a four-point noninferiority margin for comparing the two interventions.
Secondary outcomes of the study included sleep quality, sleep beliefs, mood, and stress. Patient sleep diaries and actigraphy monitoring were used to determine sleep efficiency, sleep onset latency, wake after sleep onset, and total sleep time.
Patients were assessed at baseline, at the end of the program, and at 5 months. After completing the 8-week programs, both CBT-I and MBSR resulted in reduced insomnia severity; the CBT-I cohort experienced more rapid results, whereas MBSR led to a more gradual improvement. At the 5-month follow-up, MBSR met the established noninferiority criterion.
Sleep onset latency was reduced by 22 minutes in the CBT-I cohort and by 14 minutes for those receiving the MSBR. Total sleep time increased by 0.60 hours with CBT-I and 0.75 hours with MBSR. Both groups experienced a reduction in the time it took to fall asleep and return to sleep during the night, as well as improvements in mood and stress-related symptoms.
“Insomnia and disturbed sleep are significant problems that can affect approximately half of all cancer patients,” said lead study author Sheila N. Garland, PhD, a clinical psychology postdoctoral fellow in Integrative Oncology and Behavioral Sleep Medicine at Penn’s Abramson Cancer Center, in a press release announcing the study findings.
“If not properly addressed, sleep disturbances can negatively influence therapeutic and supportive care measures for these patients, so it’s critical that clinicians can offer patients reliable, effective, and tailored interventions.”
Garland added that the study’s findings expand available treatment options for insomnia in cancer patients.
“This study suggests that we should not apply a ‘one-size-fits-all’ model to the treatment of insomnia and emphasizes the need to individualize treatment based on patient characteristics and preferences.”
Significant attrition occurred in the MBSR group, which, the researchers suggested, may be a result of patient preference and poses a possible limitation of the study, along with the fact that 27 potential participants were excluded because they had already engaged in an MBSR program. The researchers posited that when compared with the CBT-I intervention, the benefits of the MBSR approach may be less evident to those not already inclined toward a meditation/yoga approach.
1. Garland SN, Carlson LE, Stephens AJ, et al. Mindfulness- based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial [published online January 6, 2014]. J Clin Oncol. 2014;32(5):449-457.