Nurse-Supported Cognitive Behavioral Therapy for Insomnia Improved Sleep Outcomes

Nurse-supported, self-directed cognitive behavioral therapy (CBT) for insomnia reduced severity scores and improved sleep outcomes, a randomized trial of veterans showed.

Among 178 veterans, Insomnia Severity Index scores fell by an estimated mean of 5.7 points at 8 weeks in the group who participated in six weekly phone calls that specifically covered insomnia content compared with 2 points in a control group who also participated in weekly calls without sleep-focused content (P<0.001), reported Christi Ulmer, PhD, DBSM, of the Durham VA Healthcare System in North Carolina, and co-authors.

These differences persisted at 6 months (mean -2.8, 95% CI -4.4 to -1.3, P<0.001), they noted in JAMA Internal Medicine.

Improvements were also seen at 8 weeks in sleep diary metrics in the intervention group compared with the control group (all P<0.001):

• Sleep onset latency decreased by an estimated mean of 23 minutes versus 3.4 minutes
• Wake after sleep onset decreased by an estimated mean of 25.4 minutes versus 4.8 minutes
• Sleep efficiency increased by an estimated 13.7% versus 2.6%

These results also persisted at 6 months.

CBT is standard of care for treating insomnia disorder, but access is limited due to an inadequate number of clinicians and by limited awareness of CBT as the recommended first-line treatment, the authors explained.

“In an ideal world, everyone would obviously have access to the gold-standard treatment delivery … but we simply don’t have enough trained providers to address the prevalence,” Ulmer told MedPage Today. “I wouldn’t want to say that anybody could do this intervention,” she stressed, but “we need to offer alternatives.”

Notably, fatigue and depression ratings also improved in the intervention arm at 8 weeks. The estimated mean Multi-Dimensional Fatigue Inventory score fell 4.6 points in the CBT for insomnia group compared with 0.9 points among controls (P=0.03), and Patient Health Questionnaire-8 scores for depression dropped 2.5 points versus 0.4 points, respectively (P=0.001). However, differences between the groups were not sustained at 6 months.

In addition, estimated mean Insomnia Treatment Knowledge Questionnaire scores jumped 4.5 points in the intervention group compared with a drop of 0.3 points in the control group at 8 weeks (P<0.001).

Given that the veteran population has many comorbidities, both physical and mental, “it’s encouraging to see that a fairly light-touch intervention could help in this way,” Ulmer said.

For this study, participants were recruited from a VA hospital from September 2019 to April 2022. Mean age was 55.1 years, 71.9% were men, 42.7% were Black, and 48.9% were white. Overall, 82.6% had a mental health diagnosis, and 67.4% were currently using sleep medications.

The intervention consisted of a combination of six weekly nurse phone contacts lasting approximately 20 minutes plus weekly readings from a treatment manual, including typical CBT for insomnia content: sleep restriction, stimulus control, cognitive therapy, relaxation, and sleep hygiene. Participants randomized to the control group also received the combination of six weekly nurse phone contacts lasting approximately 20 minutes plus a treatment manual focused on a range of health topics. Sleep-focused content was prohibited during their calls.

A limitation of the study was the higher drop-out rate in the intervention group. In addition, although the number of calls did not differ, Ulmer and team noted that they did not achieve equal contact time across groups, with nurse contacts in the intervention group lasting about 10 minutes longer.

However, greater uptake of CBT for insomnia concepts in the intervention arm suggested that the superior outcomes were more likely related to treatment effects rather than longer nurse contacts, they said.

The future goal would be to stratify patients with certain phenotypes of insomnia to certain interventions, ranging from more “light-touch” interventions to one-on-one treatment with a CBT for insomnia-trained clinician, but “we don’t have the data to do that just yet,” Ulmer said.

Please enable JavaScript to view the comments powered by Disqus.