Dana R. Epstein

Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors

AIM This paper is a report of a study to describe the efficacy of cognitive behavioural therapy for insomnia on fatigue, mood and quality of life in breast cancer survivors. BACKGROUND Women who receive primary treatment for breast cancer often complain of insomnia. Rarely evaluated in insomnia intervention studies is the effect of cognitive behavioural treatment on the psychosocial outcomes of fatigue, mood and quality of life. METHOD Data were collected between December 2002 and March 2004 with 72 women who were at least 3 months post-completion of primary treatment without current evidence of disease. Women were randomly assigned to either the cognitive behavioural therapy for insomnia group, which received stimulus control instructions, sleep restriction therapy and sleep education and hygiene, or the component control group which received sleep education and hygiene only. The 10-week study consisted of 2 weeks of pre-treatment, 6 weeks of treatment and 2 weeks of post-treatment. Fatigue, mood and quality of life were measured at pre- and post-treatment. FINDINGS Women receiving cognitive behavioural therapy for insomnia had significant improvements in fatigue, trait anxiety, depression and quality of life. The component control group also had statistically significant increases in quality of life, with a trend suggestive of lower depression at post-treatment. CONCLUSION Globally, as the number of survivors in this population continues to grow, it is imperative that nurses continue testing interventions that may positively affect quality of life and the commonly experienced symptoms of fatigue, anxiety and depression.

Randomized Trial of a Cognitive-Behavioral Intervention for Insomnia in Breast Cancer Survivors

PURPOSE/OBJECTIVES To determine the efficacy of a cognitive-behavioral intervention for treating insomnia in breast cancer survivors. DESIGN Randomized controlled trial. SETTING University and medical center settings. SAMPLE 72 women at least three months after primary treatment for breast cancer with sleep-onset or sleep maintenance insomnia at least three nights per week for at least three months as determined through daily sleep diaries. METHODS Random assignment to a multicomponent intervention (stimulus control instructions, sleep restriction, and sleep education and hygiene) or a single-component control group (sleep education and hygiene). MAIN RESEARCH VARIABLES Sleep-onset latency, wake after sleep onset, total sleep time, time in bed, sleep efficiency, and sleep quality. FINDINGS After the intervention, both groups improved on sleep-onset latency, wake after sleep onset, total sleep time, time in bed, sleep efficiency, and sleep quality based on daily sleep diaries. A between-group difference existed for time in bed. Wrist actigraph data showed significant pre- to postintervention changes for sleep-onset latency, wake after sleep onset, total sleep time, and time in bed. When compared to the control group, the multicomponent intervention group rated overall sleep as more improved. CONCLUSIONS A nonpharmacologic intervention is effective in the treatment of insomnia in breast cancer survivors. IMPLICATIONS FOR NURSING Breast cancer survivors can benefit from a cognitive-behavioral intervention for chronic insomnia. Sleep education and hygiene, a less complex treatment than a multicomponent intervention, also is effective in treating insomnia.

Dismantling Multicomponent Behavioral Treatment for Insomnia in Older Adults: A Randomized Controlled Trial

STUDY OBJECTIVE Recently, the use of multicomponent insomnia treatment has increased. This study compares the effect of single component and multicomponent behavioral treatments for insomnia in older adults after intervention and at 3 months and 1 yr posttreatment. DESIGN A randomized, controlled study. SETTING Veterans Affairs medical center. PARTICIPANTS 179 older adults (mean age, 68.9 yr ± 8.0; 115 women [64.2%]) with chronic primary insomnia. INTERVENTIONS Participants were randomly assigned to 6 wk of stimulus control therapy (SCT), sleep restriction therapy (SRT), the 2 therapies combined into a multicomponent intervention (MCI), or a wait-list control group. MEASUREMENTS AND RESULTS Primary outcomes were subjective (daily sleep diary) and objective (actigraphy) measures of sleep-onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), time in bed (TIB), and sleep efficiency (SE). Secondary outcomes were clinical measures including response and remission rates. There were no differences between the single and multicomponent interventions on primary sleep outcomes measured by diary and actigraphy. All treatments produced significant improvement in diary-reported sleep in comparison with the control group. Effect sizes for sleep diary outcomes were medium to large. Treatment gains were maintained at follow-up for diary and actigraph measured SOL, WASO, and SE. The MCI group had the largest proportion of treatment remitters. CONCLUSIONS For older adults with chronic primary insomnia, the findings provide initial evidence that SCT, SRT, and MCI are equally efficacious and produce sustainable treatment gains on diary, actigraphy, and clinical outcomes. From a clinical perspective, MCI may be a preferred treatment due to its higher remission rate. CLINICAL TRIAL INFORMATION Behavioral Intervention for Insomnia in Older Adults. NCT01154023. URL: http://clinicaltrials.gov/ct2/show/NCT01154023?term=Behavioral+Intervention+for+Insomnia+in+Older+Adults&rank=1.

The evidence base of sleep restriction therapy for treating insomnia disorder

Sleep restriction therapy is routinely used within cognitive behavioral therapy to treat chronic insomnia. However, the efficacy for sleep restriction therapy as a standalone intervention has yet to be comprehensively reviewed. This review evaluates the evidence for the use of sleep restriction therapy in the treatment of chronic insomnia. The literature was searched using web-based databases, finding 1344 studies. Twenty-one were accessed in full (1323 were deemed irrelevant to this review). Nine were considered relevant and evaluated in relation to study design using a standardized study checklist and levels of evidence. Four trials met adequate methodological strength to examine the efficacy of therapy for chronic insomnia. Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement. Standalone sleep restriction therapy is efficacious for the treatment of chronic insomnia for sleep diary continuity variables. Studies are insufficient to evaluate the full impact on objective sleep variables. Measures of daytime functioning in response to therapy are lacking. Variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy. A future research agenda is outlined.

Relationships between personal beliefs and treatment acceptability, and preferences for behavioral treatments

BACKGROUND The literature on preferences for behavioral interventions is limited in terms of understanding treatment-related factors that underlie treatment choice. The objectives of this study were to examine the direct relationships between personal beliefs about clinical condition, perception of treatment acceptability, and preferences for behavioral interventions for insomnia. METHODS The data set used in this study was obtained from 431 persons with insomnia who participated in a partially randomized clinical trial and expressed preferences for treatment options. The data were collected at baseline. Logistic regression was used to examine the relationships between personal beliefs and treatment acceptability, and preferences. The relationships between personal beliefs and perception of treatment acceptability were explored with correlational analysis. RESULTS Perception of treatment acceptability was associated with preferences. Persons viewing the option as convenient tended to choose that option for managing insomnia. Personal beliefs were not related to preferences. However, beliefs about sleep promoting behaviors were correlated with perceived treatment effectiveness. CONCLUSIONS Perception of treatment acceptability underlies expressed preferences for behavioral interventions. Personal beliefs about insomnia are not directly associated with preferences. Importance is highlighted for providing information about treatment options and exploring perception of each options acceptability during the process of treatment selection.

Insomnia treatment acceptability and preferences of male Iraq and Afghanistan combat Veterans and their healthcare providers

Sleep difficulty is a prevalent problem among returning Veterans. Although there is strong evidence for the efficacy and durability of cognitive-behavioral treatment for insomnia (CBT-I) in the general population, the interventions require motivation, attention, and adherence from patients to achieve successful outcomes. Given the unique characteristics of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans who have experienced blast-related injuries and other trauma, CBT-I for these patients may require modification, including alternative delivery methods, to ensure effective implementation and positive outcomes. We interviewed 18 OIF/OEF Veterans who screened positive for mild traumatic brain injury and 19 healthcare providers to determine the acceptability of insomnia treatments and preferences for the interventions and treatment delivery. Veterans and providers had distinct preferences for insomnia treatment and its delivery. The treatments the Veterans found most acceptable were also the ones they preferred: relaxation treatment and pharmacotherapy. The providers identified relaxation therapy as the most acceptable treatment. Veterans preferred the individual treatment format as well as electronic methods of treatment delivery. Despite some differences between patients and providers, a compromise through modification of empirically supported behavioral treatments is feasible, and implications for preference-based insomnia intervention development and testing are discussed.

Fatigue-based subgroups of breast cancer survivors with insomnia

The purpose of this study was to determine if breast cancer survivors (BCS) with insomnia can be grouped according to their level of fatigue. A secondary data analysis was conducted on baseline data obtained from a randomized clinical trial that focused on a cognitive-behavioral intervention for insomnia in BCS. Participants were BCS (n = 86) with insomnia who were at least 3 months after completion of primary treatment without current evidence of disease. Three subgroups of women were identified with significant differences in fatigue, including exhausted (35%), tired (41%), and restored (24%). Results suggest that most women have moderate to severe fatigue many years after completion of treatment. Severe fatigue was associated with higher levels of other symptoms and poorer quality of life (exhausted subgroup). Significant differences in insomnia severity, anxiety, depression, and quality of life were noted among the exhausted, tired, and restored subgroups. The existence of fatigue-based subgroups offers important information when providing care to BCS. By determining symptoms associated with fatigue, patient care will benefit through a shift in focus from treatment of a single symptom such as fatigue to the delivery of a tailored intervention that targets multiple symptoms.

Insomnia, depression, and distress among outpatients with prostate cancer

Limited information is known about insomnia, depression, and distress in men with prostate cancer. This study explored insomnia and its relationship to depression and distress in this population. Participants (N = 51) were recruited from a Veterans Affairs Medical Center outpatient clinic. Questionnaires included the Insomnia Severity Index, Center for Epidemiologic Studies-Depression Scale, and Impact of Event Scale. Findings indicated that many men had insomnia and depression with a moderate level of distress. Half the men with clinically significant insomnia also had clinically significant depression. Significant relationships were found among insomnia, depression, and distress. Implications for research and practice are offered.

Exercise Preferences Among Men With Prostate Cancer Receiving Androgen-Deprivation Therapy

PURPOSE/OBJECTIVES To investigate acceptability of and preferences for physical activity participation in men receiving androgen-deprivation therapy (ADT) for prostate cancer, to identify influencing clinical and demographic factors, and to determine the percentage meeting national exercise guidelines. DESIGN Cross-sectional, descriptive. SETTING Ambulatory care clinic of a large medical center. SAMPLE 135 men receiving ADT. METHODS A structured interview with a systematic procedure was used to elicit preferences for physical activity. MAIN RESEARCH VARIABLES Exercise preferences and acceptability; evidence-based exercise intervention. FINDINGS Participants expressed high levels of acceptability of and willingness to participate in aerobic (64% and 79%) and muscle-strengthening (79% and 81%) programs. Preferences were expressed for muscle-strengthening activities performed at home, either alone or in the company of a family member. Flexible, spontaneous, and self-paced programs were preferred. Significant associations were identified for distance, age, obesity, duration of ADT, and meeting American College of Sports Medicine (ACSM) and American Heart Association (AHA) guidelines. Nineteen percent of the study population met the guidelines for weekly physical activity. CONCLUSIONS High levels of expressed acceptance of and willingness to participate in physical activity programs as well as the small number of participants meeting ACSM and AHA guidelines suggest feasibility of and support the need for the development of exercise programs in this population. IMPLICATIONS FOR NURSING Incorporating patient preferences and evidence-based practice is integral to providing high-quality patient-centered care and is the foundation for appropriate intervention programs. Insight from this study will facilitate the design of programs that better reflect actual preferences of prostate cancer survivors. KNOWLEDGE TRANSLATION ADT-induced changes in body composition are believed to contribute to a reduction in insulin sensitivity and dyslipidemia that contribute to increased cardiovascular risk profile. Exercise has the potential to mitigate the harmful effects of ADT.

Feasibility Test of Preference-Based Insomnia Treatment for Iraq and Afghanistan War Veterans

Purpose The study determined the feasibility of implementing a brief, preference‐based non‐medication insomnia treatment for Iraq/Afghanistan war Veterans who experienced blast and/or other injuries resulting in an altered level of consciousness. Methods The study used a one‐group pre‐post design with a 3‐month follow‐up assessment. Forty‐one veterans (two females, mean age 30.32 ± 7.73 years) with a mean insomnia duration of 3.90 years (±2.03) received treatment that included one in‐person and three telephone sessions of behavioral intervention and incorporated electronic delivery components. Feasibility indicators and preliminary treatment effectiveness were assessed. Findings Results indicate the preference‐based treatment was acceptable to veterans and feasible to implement. Treatment components delivered in‐person were used more than electronic methods. Insomnia decreased from moderate severity to the sub‐threshold range. Pre‐ to post‐treatment effect sizes were large for most sleep outcomes. Sleep improvement maintained at the 3‐month follow‐up assessment. Conclusion Further testing of a brief insomnia treatment model is needed. Clinical Relevance Successful insomnia treatment has the potential to maximize rehabilitation outcomes in Operations Enduring Freedom and Iraqi Freedom veterans and may provide a non‐stigmatizing entry to mental health services.