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Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: A pilot randomised controlled trial

https://doi.org/10.1016/j.brat.2012.08.006Get rights and content

Abstract

Objective

Insomnia is a debilitating comorbidity of chronic pain. This pilot trial tested the utility of a hybrid treatment that simultaneously targets insomnia and pain-related interference.

Methods

Chronic pain patients with clinical insomnia were randomly allocated to receive 4 weekly 2-h sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). Participants were assessed at the beginning and end of this 4-week period. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were fatigue, anxiety, depression and pain intensity. Ancillary information about the hybrid treatment's effect on psychological processes and sleep (as measured with sleep diary and actigraphy) are also presented, alongside data demonstrating the treatment's clinical significance, acceptability and durability after one and six months. Data from all participants (n = 20) were combined for this purpose.

Results

Compared to symptom monitoring, the hybrid intervention was associated with greater improvement in sleep (as measured with the Insomnia Severity Index and sleep diary) at post-treatment. Although pain intensity did not change, the Hybrid Group reported greater reductions in pain interference, fatigue and depression than the Monitoring Group. Overall, changes associated with the hybrid intervention were clinically significant and durable at 1- and 6-month follow-ups. Participants also rated highly on treatment acceptability.

Conclusion

The hybrid intervention appeared to be an effective treatment for chronic pain patients with insomnia. It may be a treatment approach more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.

Highlights

► We tested a new treatment that targets both insomnia and pain-related interference. ► The hybrid treatment involved 4 weekly cognitive-behaviour therapy sessions. ► Compared to symptom monitoring, the hybrid treatment was linked to greater improvements in sleep. ► The treatment was also linked to greater reductions in pain interference, fatigue and depression. ► All treatment-associated gains were maintained at 1- and 6-month post-treatment.

Introduction

Chronic pain affects tens of millions of people worldwide (Gureje et al., 1998). Aside from the unpleasant sensation and potential restrictions on functioning, people with chronic pain are at higher risk of developing anxiety, mood, substance misuse and/or physical health problems (Von Korff et al., 2005). One debilitating comorbidity of chronic pain is insomnia. More than half of patients seeking treatment from pain clinics have insomnia that warrants clinical attention (Tang, Wright, et al., 2007). Compared with pain patients without problems sleeping, those with insomnia report greater pain, fatigue and disability (Nicassio et al., 2002).

Several findings on the interaction of sleep and pain are of clinical relevance. First, many cases of insomnia persist despite continuous use of hypnotics (e.g., King & Strain, 1990) and ongoing treatment for pain (e.g., Gustavsson & von Koch, 2006). Second, sleep fragmentation/deprivation can not only aggravate pain and inflammation, but also dampen mood and pain inhibitory responses (e.g., Smith et al., 2007). Third, insomnia is linked to an increased incidence of widespread pain in the general population (Mork & Nilsen, 2012). Together, these findings make a strong case for treating insomnia co-occurring with chronic pain.

Recently, cognitive behaviour therapy originally developed for primary insomnia (CBT-I) has been used to address pain-related insomnia. This advance was motivated by the shift in thinking that comorbid insomnia should be treated as a problem in its own right (National Institute for Health, 2005). Moreover, evidence has accrued to suggest that primary and pain-related insomnia are similar in presentation (Okura et al., 2008) and that the cognitive-behavioural processes perpetuating primary insomnia also operate in pain-related insomnia (Tang et al., 2012a, 2012b). At least four randomised controlled trials (RCT) have been conducted to evaluate the utility of CBT-I in adults with chronic musculoskeletal pain (Currie et al., 2000; Jungquist et al., 2010), fibromyalgia (Edinger et al., 2005), and older adults with osteoarthritis (Vitello et al., 2009). Although significant improvements were achieved in a range of sleep outcome measures, improved sleep in these RCTs was not consistently followed by a reduction in pain and its associated distress and interference, contradicting the common assumption that pain and sleep are reciprocally linked. Simultaneous input to both problem areas may be required to effectively restore sleep and functioning in these individuals, justifying the development of a hybrid treatment approach.

The current study evaluated the utility of a brief intervention designed to simultaneously improve sleep and reduce distress and interference associated with chronic pain. The hybrid intervention concept pushes conventional boundaries that confine the development and application of treatments to well-defined diagnoses, particularly in psychology where the flexible combination of therapies designed for different disorders remains a novel practice. Consistent with the transdiagnostic perspective of research and treatment development (Harvey et al., 2004), the hybrid approach may provide a treatment option more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.

Section snippets

Overview

Chronic pain patients with concomitant insomnia were randomly assigned to one of two conditions; to receive 4 weekly sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). All participants were assessed before and after this 4-week period, enabling us to evaluate the efficacy of the hybrid treatment compared with symptom monitoring. Ancillary information about the hybrid treatment's

Participant characteristics

Table 2 presents the participants' characteristics by group. The sample represented a variety of pain conditions, including musculoskeletal pain (85%), osteoarthritis (35%), rheumatoid arthritis (10%), complex regional pain syndrome (10%), headache (10%), and fibromyalgia (5%), with more than half of the sample (55%) meeting criteria for ≥1 concurrent DSM-IV diagnoses (depression = 6, specific phobia = 5, substance dependence = 3, posttraumatic stress disorder = 2, generalised anxiety

Discussion

As a proof of concept, the findings above demonstrated the superiority of the hybrid CBT over symptom monitoring in treating chronic pain patients with clinical insomnia. The hybrid CBT was associated with greater improvements in participants' sleep quality. Although pain intensity – as expected – remained unchanged, the hybrid treatment was associated with greater reductions in pain interference, fatigue and depression than did symptom monitoring. The magnitude of these improvements was large,

Acknowledgements

This research was funded by a personal award to Nicole Tang from the National Institute for Health Research (Department of Health). The authors would like to thank Dr. Melanie Edwards, Jennifer Barley, Anthony Gabay, Rhian Tait and staff at the Pain Relief Unit, King's College Hospital for their assistance in patient recruitment.

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    Present address: Department of Psychology, University of Warwick, Coventry CV4 7AL, UK.

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