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04-03-2021 | Rheumatology | News | Article

Telephone CBT for insomnia possible option for patients with osteoarthritis

Hannah Kitt

medwireNews: Cognitive behavioral therapy for insomnia (CBT-I) could be delivered via the telephone to patients with osteoarthritis (OA), proving useful for those unable to access in-person options, OATS trial findings suggest.

“The ongoing coronavirus disease 2019 pandemic highlights the importance of being able to deliver effective health care remotely through a modality as widely available as the telephone,” highlight Susan McCurry (University of Washington, Seattle, USA) and colleagues.

They add that the “[r]esults support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment,” which may be particularly effective for older patients and those living in rural or medically underserved areas.

In all, 327 patients with OA and insomnia (mean age 70.2 years, 74.6% female), from the Kaiser Permanente Washington healthcare system, were randomly assigned to receive CBT-I or an education-only control (EOC). Both interventions lasted 8 weeks and involved six 20- to 30-minute telephone sessions with a trained psychologist, in the majority of cases, nurse, or social worker. All the participants were asked to maintain a daily sleep diary.

The patients in the CBT-I arm were assigned to follow an in-bed restriction plan that matched their average baseline sleep time but was required to be no less than 6 hours, with stimulus control instructions to reduce time spent in bed not asleep, and information about sleep hygiene to improve bedtime routines. They were also taught cognitive techniques, such as mindfulness, to reduce hyperarousal at night.

By contrast, the EOC provided support and education on living with chronic OA but no instruction on CBT-I principles; the only specific instruction given to the patients was to read the educational booklet.

As reported in JAMA Internal Medicine, 80.0% and 89.6% of patients completed the full CBT-I and EOC courses, respectively.

Patients in the CBT-I cohort were a significant 4.9 times more likely than those in the EOC cohort to meet the predetermined threshold for a clinically meaningful reduction in insomnia severity of 30% after the 2 months of treatment, a difference that was maintained at 12 months.

Indeed, patients in the CBT-I arm had a mean 8.1-point reduction on the Insomnia Severity Index (ISI) after 2 months, which was significantly greater than the 4.3-point decrease among patients in the EOC arm. The mean adjusted between-group difference was 3.5 points.

At 12 months, the patients receiving CBT-I still had a significant 3-point greater reduction in ISI score, on average, than those receiving the EOC, and over half (56.3%) were in remission from insomnia versus 25.8% of patients given the EOC.

The researchers also measured fatigue (Flinders Fatigue Scale), pain (Brief Pain Inventory-short form), and depression (8-item Patient Health Questionnaire). They found superior reductions in fatigue with CBT-I versus the EOC at both 2 and 12 months, whereas superior improvements in pain with CBT-I were only seen at 2 months.

The effects on depression were generally comparable, which the researchers speculate may be due to the fact that “relatively few patients had elevated baseline depression scores.”

McCurry and team conclude: “The current study shows that CBT-I was associated with short-term reductions in pain and suggests the possibility of a small and transient reciprocal sleep-pain relationship.

“However, improvements were not sustained long-term, and further research is needed.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2021 Springer Healthcare Ltd, part of the Springer Nature Group

JAMA Intern Med 2021; doi:10.1001/jamainternmed.2020.9049

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