Nurse-led cognitive behavioral therapy program reduces insomnia symptoms

Key takeaways:

• CBTi improved insomnia severity and multiple sleep outcomes, like sleep efficiency, in veterans.
• The findings suggest that health care providers could play a role in CBTi.

A nurse-supported cognitive behavioral therapy intervention for insomnia reduced symptoms and improved sleep outcomes in veterans, results from a randomized study published in JAMA Internal Medicine showed.

The program also significantly reduced fatigue and depression among those who underwent cognitive behavioral therapy for insomnia (CBTi), according to researchers.

“We were motivated to conduct this research to address poor access to the standard of care for treatment of insomnia disorder,” Christi S. Ulmer, PhD, DBSM, an assistant professor in the department of psychiatry at Duke University Medical Center, told Healio.

According to Ulmer, CBTi is the standard of care as recommended by leading health organizations like the ACP and American Academy of Sleep Medicine.

“However, the number of providers trained in this treatment modality is insufficient to match the prevalence of insomnia disorder, and this is even more true among veterans and military service members having greater prevalence of insomnia disorder than nonveterans,” she said.

In the study, researchers randomly assigned 178 veterans (mean age, 55 years; 71.9% men) with insomnia to either CBTi — supported by nurses instead of mental health clinicians — or to a health education control group.

Participants in the intervention group received six weekly phone calls from a nurse lasting around 20 minutes and were given weekly manual readings on CBTi treatment components, such as sleep hygiene and cognitive therapy.

Those in the control group also had six weekly phone calls with nurses but were given a health education manual that focused on health topics and not sleep.

Insomnia severity served as the study’s primary outcome measurement, which was measured at 8 weeks by the researchers using the Insomnia Severity Index.

The study also assessed several secondary outcomes, including depression, sleep efficacy, fatigue and wake after sleep onset.

Ulmer and colleagues found that insomnia severity decreased by an estimated mean of 5.7 points in the intervention group and 2 points in the control group at 8 weeks (mean improvement = 3.7 points; 95% CI,5 to2.4).

These differences persisted at the 6-month follow-up assessment (mean improvement = 2.8; 95% CI, 4.4 to 1.3)

The intervention group additionally showed greater improvement vs. the control group, in multiple sleep outcomes, including:

• sleep efficiency;
• actigraphy sleep efficiency;
• wake after sleep onset; and
• sleep onset latency.

These improvements continued at 6 months’ follow-up.

The researchers also observed greater fatigue and depression improvement in the intervention group compared with the control group at 8 weeks, but these differences did not persist at 6 months.

Ulmer noted that dissemination and implementation research is warranted to understand how to best implement the intervention into clinical practice.

“However, it seems quite feasible to train nurses and other health care providers to serve in the role of supporting patients; particularly when 1:1 treatment with a CBTi-trained provider is not available,” she said.

Self-directed CBTi, while not a substitute for the gold-standard CBTi provided by a trained health professional, “can increase patient access; a particularly important finding for settings with lesser access, such as rural clinics,” Ulmer explained.

“It’s important to understand, however, that not all patients in our trial benefited. Future research is needed to identify which patients are best suited for such interventions,” she said. “Once this is understood, patients could be matched with the intervention that best matches their clinical presentation and personal characteristics.”

She added that since veterans have greater comorbidity vs. the general population, she anticipates the intervention would have similar effectiveness in different patient populations.

“Additional research in civilian clinical settings is needed to answer this question,” she said.