A step in the right direction: making cognitive-behavioral therapy for insomnia more accessible to people diagnosed with cancer

Abstract

Insomnia is a prevalent and persistent condition that affects roughly half of all people diagnosed with cancer. As such, demand for insomnia treatment far exceeds available resources. A dearth of providers trained in sleep interventions and inadequate access to services continues to plague the field of behavioral sleep medicine [1], but for those whose insomnia began or was worsened by a cancer diagnosis, treatment is even more elusive [2]. Stepped care has been proposed as a possible service delivery model for increasing access to scarce Cognitive Behavioral Therapy for Insomnia (CBT-I) services [3]. In this issue, Savard et al. used a noninferiority design to test whether the short- and long-term effects of a stepped care approach to deliver CBT-I (StepCBT-I) was not significantly worse than professionally administered treatment (StanCBT-I) in a cancer setting [4]. Their CBT-I protocol was a 6-week intervention combining stimulus control, sleep restriction, cognitive restructuring, and sleep hygiene education. They found that StepCBT-I was not significantly inferior to StanCBT-I with overall reductions in Insomnia Severity Index (ISI) scores of −8.16 and −9.24, respectively, and that these improvements were durable up to 1 year. Improvements were also observed on measures of anxiety, depression, fatigue, and quality of life. These reductions are consistent with the overall data for the efficacy of CBT-I 5, further strengthening the evidence for the use of CBT-I with those impacted by cancer. Clinical guidelines recommend screening and treatment of insomnia in cancer settings [5–7], but individual providers and organizations often lack clear treatment pathways based on this information. An important feature of the model tested by Savard et al. was that initial treatment was tailored based on symptom severity (also known as a stratified stepped care model). In the Savard et al. trial, those who were randomized to the StanCBT-I group (n = 59) received 6 weekly 50-minute face-to-face sessions of CBT-I, whereas those who were randomized to the StepCBT-I (n = 118) group were further stratified by insomnia severity. In Step 1, those with less severe symptoms (as indicated by an ISI score of ≧8 but <15) were provided with a web-based CBT-I program called Insomnet, while those with more severe insomnia symptoms (as indicated by an ISI score of ≧15) were provided with face-to-face treatment. Compared with a pure stepped care model where everyone starts out with the least intensive intervention and then moves upwards, this stratification allows patients to receive more timely delivery of the appropriate intensity of intervention. Another unique feature of the Savard et al. trial was that the treatment algorithm was able to adapt to the needs of the patient in cases where there was an incomplete therapeutic response to the lower-level intervention. In Step 2, only those who were unremitted (defined as an ISI score of ≧8) were given up to three face-to-face booster sessions dedicated to individual problem solving and motivational interviewing to address difficulties with implementation of specific aspects of treatment. The availability and utilization of booster sessions in the StepCBT-I group has clinical applications to more efficiently utilize provider time. After Step 1, 72% of StanCBT-I and 58% of StepCBT-I patients were remitted. Of those individuals assigned to the StepCBT-I group, 66% of patients who began with face-to-face sessions experienced remission, compared with 51% of patients who received the web-based treatment. The acceptance of booster sessions also appeared to differ by group. Of those individuals who received web-based CBT-I as their first step, 27% accepted one or more booster sessions, compared with only 8% of those who received face-to-face CBT-I as their first step. This suggests that face-to-face therapy will remain necessary for a proportion of patients who need more individualized treatment because of challenges with motivation and/or more complex clinical presentations. Accordingly, the preponderance of evidence still suggests that face-to-face intervention produces outcomes that exceed those from web-based or digital treatment [8–10]. As such, entry-level interventions such as the program tested by Savard et al. should not be used to replace face-to-face service provision by skilled practitioners. Rather, less-intensive interventions, when applied appropriately, can make treatment more accessible and more efficiently utilize scarce resources. Only one other study has assessed the use of a stepped care model to treat insomnia in cancer survivors [11]. In Step 1 of this study, participants with an ISI score of ≧12 received a single sleep education session. If participants were still symptomatic 1 month later, they were offered a group treatment program consisting of three sessions. Participants were classified as “responders” if their ISI score improved by ≧6 points and as “remitted” if th