Stepped care model can be effective for improving insomnia in cancer survivors

Reviewed by James Ives, M.Psych. (Editor)Sep 24 2019

Affecting as many as 30% of cancer survivors, chronic insomnia can be effectively treated with intensive cognitive-behavioral techniques, but such methods are time-consuming, costly, and limited by the availability of trained specialists. In a study published online today by the journal Cancer, investigators at Dana-Farber Cancer Institute report that a single-session sleep education program for survivors can cure insomnia in many participants, and that those who don't benefit from this approach are often helped by a more extensive, but still modest, three-session program.

The findings are based on a trial of this 'stepped care' approach involving 51 cancer survivors with moderate to severe insomnia. After participating in the one-time sleep-education program, 41% of participants saw their insomnia successfully treated. Fourteen of those whose insomnia remained took part in the second step, a three-part program using a cognitive-behavioral approach to insomnia treatment that investigators had previously shown to be effective. Of that group, 71% had their insomnia resolved after completing the program.

Our results demonstrate that a stepped care model – in which the first treatment is low-intensity and easily accessible to patients – can be effective for improving insomnia in cancer survivors. This represents a tremendous opportunity to treat a problem that can significantly diminish cancer survivors' health and quality of life when not addressed."

Dana-Farber's Eric Zhou, PhD, first author of the study

The difficulty sleeping that many survivors experience often originates during treatment for their cancer, as a result of a combination of factors including their anxiety, fatigue, or pain. While these problems may diminish or disappear after treatment, insomnia often lingers, Zhou stated.

The two-step model used in this trial grew out of a recognition that while cognitive-behavioral therapy (CBT) works well in alleviating chronic insomnia in cancer survivors, it can be difficult to access or utilize. Developed about 20 years ago, CBT for insomnia is a form of talk therapy that helps patients understand the maladaptive sleep behaviors and thought patterns that cause their insomnia to persist – and teaches them to adopt healthier behaviors and change their thoughts at night. A shortage of providers trained in CBT for insomnia has limited the number of cancer survivors who can take advantage of this approach. Even when these specialists are available, survivors may balk at the cost or duration of standard treatment, which usually involves six to eight sessions.

The first step in this trial – the one-session sleep-education class – was designed so that it could be easily implemented by a small cancer center, with limited resources or staff. "The content is straightforward, the skills needed to teach it are basic," said Zhou, who developed the class with senior author Christopher Recklitis, PhD, MPH, of Dana-Farber. "It could be led by someone with an interest in mental health and sleep, without extensive training in behavioral sleep medicine. In a few hours, they could acquire enough knowledge about sleep and sleep habits to be able to offer this kind of program."

Much of the material covered in the session is not especially advanced and can be found on "tips for sleeping" handouts commonly available at primary care clinics and cancer centers, but investigators have found that, in the absence of instructions on how to implement these new sleep behaviors or setting appropriate expectations for the timeline and magnitude of sleep improvements, a printed sheet often is inadequate. "There's little guidance on how to make the text a reality," Zhou remarked. "The gap between what's already available to patients on handouts and what we offered is small, but the added guidance we offered resulted in sizable gains to the participants' sleep."

While the second step of the model needs to be led by a clinician trained in CBT for insomnia – and therefore might not be feasible for all cancer centers – the fact that it is offered in a group setting, rather than a one-on-one consultation, would expand its availability.

Upon enrolling the study, participants provided information on their medical history, the severity and duration of their insomnia, and their mood during and after treatment. Investigators found that survivors who had experienced sleep problems for a shorter period of time and felt less of a burden from those problems and less pain, were most likely to benefit from the single, sleep education session. Among patients not helped by that session, those with the greatest desire to improve their sleep were most likely to sign up for the second step of the program. These findings may help clinicians identify patients likely to be helped by a single session and those apt to participate the second step of the program.

"Universal implementation of the first step in our program is a very reasonable goal as a part of a commitment to quality survivorship care at all cancer centers," Recklitis said.