Combined Treatment With Cognitive Behavioral Therapy for Insomnia and Acceptance and Commitment Therapy Enhances Objective and Subjective Reports of Sleep in Patients With Advanced Cancer

Abstract

Background: Sleep difficulties are common for people with advanced cancer and are associated with poorer mood, lower quality of life, and reduced survival. For these patients, insomnia severity ratings are tied to nighttime awakenings, but little is known about the reasons for awakenings.

Aims: This study reports actigraphy sleep outcomes, longitudinal self-reported insomnia severity, and circadian rhythm disruptions from a randomized pilot study comparing a multi-symptom intervention with a wait-list control group for people with advanced cancer.

Methods: Twenty-eight people with advanced cancer completed a brief intervention, Finding Our Center Under Stress (FOCUS), designed to enhance sleep and alleviate worry, depression, and fatigue. Participants completed questionnaires and wore an Actiwatch for 7 consecutive 24-h periods pre- and post-intervention.

Results: There were no significant group × time actigraphy effects. However, sensitivity analyses with the full intervention sample including the wait-list control arm demonstrated significant effects on actigraphy sleep efficiency, minutes awake after sleep onset (WASO), number of awakenings, naps, and activity at rest. Insomnia severity ratings on the Insomnia Severity Index were maintained longitudinally with 61% meeting the cut-off for insomnia at baseline compared to 18% at 1 year. Participants demonstrated reductions in key reasons for awakenings.

Conclusions: Multi-symptom interventions may be necessary for sustained insomnia improvements for people with advanced cancer. The FOCUS intervention is one of the first to demonstrate improvements on self-reported and actigraphic measures of sleep in addition to other symptoms (i.e., worry, uncertainty, depression, fatigue interference, distress) for this population. Future effectiveness studies are warranted given results of this pilot trial.

Trial registration: Cognitive-behavioral intervention for worry, uncertainty, and insomnia for cancer survivors (NCT01929720).

Keywords: acceptance and commitment therapy; cancer; cognitive behavioral therapy; depression; fatigue; oncology; sleep; uncertainty; worry.

FIGURE 1

Study flowchart.

FIGURE 2

Longitudinal insomnia severity outcomes at pre‐intervention, post‐intervention and 4, 8, and 12 months. Wait‐list control received intervention between 6 and 12 weeks. The red line represents the cut‐off score for the Insomnia Severity Index defining the boundary between sub‐threshold symptoms and moderate insomnia.

FIGURE 3

Reasons for awakenings from pre‐ to post‐intervention. Numbers represent the number of times each reason for awakening was listed. Numbers at end of bars represent the percent reduction in each reason for awakening from pre to post‐intervention.