A randomized controlled trial of telemedicine CBTI and PUMAS for prenatal insomnia: Reducing nocturnal cognitive arousal is a treatment mechanism for alleviating insomnia and depression during pregnancy

Abstract

Objective: Insomnia is common in pregnancy and fuels perinatal depression (PND). Cognitive-behavioral therapy for insomnia (CBTI) is effective during pregnancy, but unresolved cognitive arousal limits treatment outcomes. Enhancing reduction of cognitive arousal may improve patient outcomes. This randomized controlled trial (RCT) evaluated the effectiveness of CBTI and Perinatal Understanding of Mindful Awareness for Sleep (PUMAS, which combines mindfulness with behavioral sleep strategies) on insomnia, depression, and nocturnal cognitive arousal relative to sleep hygiene education (SHE).

Methods: A single-site, three-arm RCT of N = 64 pregnant women with clinically significant insomnia symptoms who received CBTI, PUMAS, or SHE. Active treatment was delivered via six weekly telemedicine video sessions. Outcomes included the insomnia severity index (ISI), Edinburgh postnatal depression scale (EPDS), and the pre-sleep arousal scale's cognitive factor (PSASC; nocturnal cognitive arousal).

Results: Over 95 % of active therapy patients completed ≥4 sessions, indicating high engagement. CBTI (ΔISI = -11.20 ± 6.93; 65.0 % insomnia remission) and PUMAS (ΔISI = -11.05 ± 3.84; 81.8 % insomnia remission) significantly alleviated insomnia relative to SHE (ΔISI = -4.50 ± 1.71; 13.6 % remission), which was replicated in women with comorbid OSA. PUMAS produced large reductions in PND and nocturnal cognitive arousal relative to SHE, whereas CBTI did not. Mediation analyses supported reducing cognitive arousal as a key mechanism by which PUMAS alleviated insomnia and PND.

Conclusions: CBTI and PUMAS are effective for prenatal insomnia, even in women with comorbid OSA. PUMAS may be especially beneficial for pregnant women presenting with PND and/or high cognitive arousal (including perinatal rumination and worry), whereas CBTI may yield more modest benefits for these non-sleep outcomes.

Keywords: COMISA; Cognitive behavioral therapy; Meditation; Prenatal; Rumination; Sleep; Worry.