Who benefits from CBT for insomnia in primary care? Important patient selection and trial design lessons from longitudinal results of the Lifestyles trial.
OBJECTIVE
Evaluate long-term effects of group interventions on sleep and pain outcomes in a primary care population of older adults with osteoarthritis pain and sleep disturbance.


METHODS
Double-blind, cluster-randomized controlled trial with 18-mo follow-up.


METHODS
Group Health and University of Washington, Seattle, WA, from 2009 to 2011.


METHODS
Three hundred sixty-seven adults age 60 y and older, with osteoarthritis pain and insomnia symptoms.


METHODS
Six weekly sessions of group cognitive behavioral therapy for insomnia and pain (CBT-PI), pain alone (CBT-P), and education-only control (EOC) delivered in patients' primary care clinics.


RESULTS
There were no significant differences between treatment groups in sleep outcomes at 18 mo. This is a change from published significant 9-mo follow-up results for insomnia severity (Insomnia Severity Index) and sleep efficiency. There were no significant treatment differences in pain at either follow-up. Post hoc analyses of participants with greater insomnia and pain severity at baseline (n = 98) showed significant (P = 0.01) 18-mo reductions in pain comparing CBT-PI versus CBT-P (adjusted mean difference [AMD] = -1.29 [95% confidence interval (CI): -2.24,-0.33]). Moderate, albeit nonsignificant, CBT-PI versus EOC treatment effects for insomnia severity (AMD = -1.43 [95% CI: -4.71, 1.86]) and sleep efficiency (AMD = 2.50 [95% CI: -5.04, 10.05]) were also observed. Possible trial design and methodological considerations that may have affected results are discussed.


CONCLUSIONS
Results suggest patients with higher levels of comorbid pain and insomnia may be most likely to experience sustained benefit from cognitive behavioral therapy interventions over time, and inclusion of insomnia treatment may yield more clinically meaningful improvements than cognitive behavioral therapy for pain alone.


BACKGROUND
clinicaltrials.gov identifier: NCT01142349.
Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, WA.
Susan M
SM
McCurry
Group Health Research Institute, Seattle, WA.
Susan M
SM
Shortreed
Group Health Research Institute, Seattle, WA.
Michael
M
Von Korff
Group Health Research Institute, Seattle, WA.
Benjamin H
BH
Balderson
Department of Internal Medicine and Epidemiology, Wake Forest University School of Medicine, Winston-Salem, NC.
Laura D
LD
Baker
Department of Psychology, Virginia Commonwealth University, Richmond, VA.
Bruce D
BD
Rybarczyk
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA.
Michael V
MV
Vitiello
D000368:Aged; D000369:Aged, 80 and over; D015928:Cognitive Behavioral Therapy; D005260:Female; D006801:Humans; D008019:Life Style; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010003:Osteoarthritis / Q000150:complications* / Q000523:psychology / Q000628:therapy; D010146:Pain / Q000150:complications; D059408:Pain Management; D018579:Patient Selection; D011320:Primary Health Care; D012107:Research Design; D012890:Sleep; D007319:Sleep Initiation and Maintenance Disorders / Q000150:complications* / Q000523:psychology / Q000628:therapy*; D016896:Treatment Outcome
Aging; cognitive behavioral therapy; insomnia; osteoarthritis; pain