Cognitive Behavioral Therapy Aids in Easing Insomnia for Osteoarthritis Patients

Susan M. McCurry, PhD (University of Washington)

Cognitive behavioral therapy for insomnia (CBT-I) could be a viable option to treat older adults with osteoarthritis (OA) in rural and underserved communities who lack ready access to insomnia treatment.

A team, led by Susan M. McCurry, PhD, Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, evaluated the effectiveness if telephone CBT-I compared to education-only controls for older adults with moderate to severe osteoarthritis pain that is causing insomnia.

In the randomized clinical trial, the researchers examined 327 patients at least 60 years who were recruited statewide through Kaiser Permanente Washington between September 2016 and December 2018. The mean age was 70.2 years old and 74.6% (n = 244) were women.

Study Design

Each individual in the study was double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis pain symptoms, with blinded assessments conducted at baseline, 2 months following treatment, and at a 12-month follow-up.

The interventions included 6 20-30 minute telephone sessions over the course of 8 weeks, as well as daily diaries and group-specific educational materials. The CBT-I instruction including sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework.

For the education-only control group, the regimen included information about sleep and osteoarthritis.

Outcomes

The investigators sought primary outcomes of the score on the Insomnia Severity Index (ISI) at 2 months following treatment and at the 12-month follow-up. They also sought secondary outcomes of pain, characterized by the score on the Brief Pain Inventory short form, depression, identified by the score on the 8-item Patient Health Questionnaire, and fatigue, computed by the score on the Flinders Fatigue Scale.

Of the 282 individuals with follow-up ISI data, the total two-month posttreatment ISI scores decreased by 8.1 points in the CBT-I group, compared to just 4.8 points in the education-only control group.

The adjusted mean between-group difference was -3.5 points (95% CI, -4.4 to -2.6 points; P <0.001). The results also sustained at the 12-month follow-up (adjusted mean difference, −3.0 points; 95% CI, −4.1 to −2.0 points; P < .001).

At this point, 67 (56.3%) individuals in the treatment group remained in remission (ISI score, ≤7) compared to 33 (25.8%) participants receiving education-only control. For fatigue, the CBT-I group had significantly reduced the effects compared to the control groups at 2 months (mean between-group difference, −2.0 points; 95% CI, −3.1 to −0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, −1.8 points; 95% CI, −3.1 to −0.6 points; P = 0 .003).

While the posttreatment significant differences were observed for pain, the differences were not sustained at the 12-month follow-up.

“In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan,” the authors wrote. “Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.”

The study, “Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain,” was published online in
JAMA Internal Medicine.