The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain

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Sleep Medicine 11 (2010) 302–309

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Original Article

The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain
Carla R. Jungquist a,b,c,*, Chris O’Brien a,c, Sara Matteson-Rusby c, Michael T. Smith d, Wilfred R. Pigeon c, Yinglin Xia e, Naiji Lu e,Michael L. Perlis f,*

University of Rochester, School of Nursing, NY, USA University of Rochester, Department of Anesthesiology, NY, USA University of Rochester, Sleep and Neurophysiology Research Laboratory, NY, USA d John Hopkins University, Department of Psychiatry and Behavioral Sciences, MD, USA e University of Rochester, Department of Biostatistics, NY, USA f University of Pennsylvania,Department of Psychiatry, PA, USA
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Study objectives: To assess the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) in patients with non-malignant chronic pain. Methods: Twenty-eight subjects with chronic neck and back pain were stratified according to gender, age, and ethnicity, then assigned to one of the two treatment groups: CBT-I ora contact control condition. Intervention: Eight weeks of CBT-I including sleep restriction, stimulus control, sleep hygiene, and one session of cognitive therapy devoted to catastrophic thoughts about the consequences of insomnia. Measurements and results: Outcomes included sleep diary assessments of sleep continuity, pre–post measures of insomnia severity (ISI), pain (Multidimensional PainInventory), and mood (BDI and POMS). Subjects receiving CBT-I (n = 19), as compared to control subjects (n = 9), exhibited significant decreases in sleep latency, wake after sleep onset, number of awakenings, and significant increase in sleep efficiency. The diary findings were paralleled by significant changes in the ISI (p = 0.05). Significant improvement (p = 0.03) was found on the Interference Scale ofthe Multidimensional Pain Inventory. The groups did not significantly differ on mood measures or measures of pain severity. Conclusions: CBT-I was successfully applied to patients experiencing chronic pain. Significant improvements were found in sleep as well as in the extent to which pain interfered with daily functioning. The observed effect sizes for the sleep outcomes appear comparable to orbetter than meta-analytic norms for subjects with Primary Insomnia. Ó 2010 Elsevier B.V. All rights reserved.

Article history: Received 16 March 2009 Received in revised form 11 May 2009 Accepted 30 May 2009 Available online 4 February 2010 Keywords: Insomnia Pain Cognitive-behavioral therapy Sleep Nurse therapist Randomized controlled trial Chronic pain

1. Introduction In recent years therehas been a growing interest in the veracity of the concept of ‘‘Secondary Insomnia” and the assumption that such forms of sleep continuity disturbance are likely to be more resistant to treatment than Primary Insomnia. This challenge has largely occurred at a theoretical level. Lichstein and co-worker [1,2], have argued that it is nearly impossible to substantiate that
* Corresponding authors.Addresses: University of Rochester, Department of Anesthesiology, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA. Tel.: +1 585 275 3524; fax: +1 585 473 5007 (C.R. Jungquist), University of Pennsylvania, Department of Psychiatry, Blockley Hall, Philadelphia, PA 19104-6021, USA. Tel.: +1 215 746 3577; fax: +1 270 512 9828 (M.L. Perlis). E-mail addresses: (C.R.Jungquist), (M.L. Perlis). 1389-9457/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.sleep.2009.05.018

insomnia is truly secondary and thus the distinction has little nosological value and should not be used to dictate when targeted treatment is warranted. This point of view is further buttressed by the Spielman Model [3,4] which clearly...