Cognitive Improvements After Undergoing CBT-I for Sleep Issues

Sleep Issues: Sleep IssuesWhen it comes to health and well-being, many of the factors that determine how we feel day in and day out are interconnected. Sleep is one of those factors that affects several others. “Sleep is a foundational health behavior,” stated Sheila Garland, PhD, RPsych, a clinical psychologist and Associate Professor of Psychology and Oncology at Memorial University in Newfoundland, Canada. “People focus a lot on diet and physical activity; but without proper sleep, you are less likely to make good food choices and get enough exercise.” Sleep is a foundational health behavior for people with and recovering from cancer, too, said Garland, who is also Lab Director at the Sleep, Health, and Wellness Lab at Memorial University. “Sleep also plays a direct role in immunity, cognition, and emotional regulation, all of which are important for cancer recovery during and after treatment is completed.” That's why Garland and colleagues recently conducted a study to determine if undergoing cognitive behavioral therapy for insomnia (CBT-I), the gold standard treatment for everyone with insomnia, lessened insomnia symptoms and improved cancer-related cognitive impairment in a group of people with cancer. The answers to those questions are yes and yes (J Clin Oncol 2024; https://doi.org/10.1200/JCO.23.02330). “We were able to demonstrate for the first time that improving sleep using CBT-I was directly responsible for improvements in cognitive function in cancer survivors,” Garland said. Study Details The study included 132 survivors of any type or stage of cancer who had completed cancer treatment at least 6 months before entering the study and were considered in remission or cancer-free. Being on maintenance or hormonal treatment was acceptable for study participation. “We wanted a fairly diverse sample in terms of cancer diagnosis and stage,” Garland said. Approximately 50 percent of the sample was made up of patients with cancers other than breast cancer. “This strengthens the evidence that CBT-I is acceptable for a variety of cancers,” she said. All patients met the DSM-5 criteria for insomnia disorder, had a score of 8 or higher on the Insomnia Severity Index, and reported cancer-related cognitive impairment as indicated by a score of quite a lot or always on at least one of the two items that assess concentration and memory from the EORTC Core QOL Questionnaire. Patients were randomly assigned to receive the same seven-session, CBT-I treatment protocol for insomnia immediately (63 patients) or after an 8-week waiting period (69 patients). CBT-I was delivered virtually in 50-minute sessions by trained doctoral students. Participants completed assessments of their insomnia symptoms (the ISI) and cognitive function (Functional Assessment of Cancer Therapy-Cognitive Function version 3 questionnaire) at baseline, after 1 month (during CBT-I treatment), and after 2 months (after the completion of treatment). Data from both groups were pooled to assess the durability of the effects at 3 and 6 months. A waitlist control group was chosen for the trial because a comparable intervention for insomnia treatment has not been established and it would be unethical to refuse patients the opportunity to receive the recommended treatment, the study authors noted in the paper. The key findings included the following: The treatment group had an 11.35-point reduction in insomnia severity compared with a 2.67-point reduction for the waitlist control group. The treatment group had a greater overall improvement than the waitlist control group on perceived cognitive impairment (14.26-point improvement vs. 4.23), perceived cognitive abilities (5.51-point improvement vs. 1.20), and impact on quality of life (4.94-point improvement vs. 1.09). Change in insomnia symptoms fully mediated the effect of CBT-I on subjective cognitive outcomes. “A change of 8.4 points has been determined to be a clinically meaningful change that would positively impact a patient's functioning,” Garland said about the ISI scores, explaining why the 11.35-point change was indeed significant. “A 2.67 reduction in the waitlist group would not be considered meaningful,” she said. Future Data Research Cancer patients rarely have just one bothersome symptom or side effect after undergoing cancer treatment. “We wanted to know whether we could improve cognitive function by helping people sleep better, thus improving two highly prevalent and extremely impairing symptoms with one treatment,” Garland said. The data from this research suggest that addressing insomnia with CBT-I can also directly help cognitive impairment. However, despite CBT-I being the gold standard treatment for people with insomnia (including cancer patients), the issue that remains is about access. “CBT-I is not accessible for the general population,” Garland said. “It is even less accessible for people with a cancer diagnosis who have rates of insomnia that are 2-3 times greater than the general population.” Other research, which Garland was not a part of, shows that a majority of cancer centers screen fewer than 25 percent of patients for sleep-related issues (J Cancer Surviv 2017; https://doi.org/10.1007/s11764-016-0564-1). And when problems are identified, most of those patients are prescribed medications and only 13 percent refer patients to CBT-I. Garland is collaborating on a project to develop and test a mobile app (iCANSleep) to help patients with cancer who have insomnia symptoms. The group is currently recruiting patients for a clinical trial to test the app (drsheilagarland.com/icansleep-app). It's meant to help tackle the problem of accessibility of CBT-I for cancer patients. In the meantime, Garland said addressing sleep problems in cancer patients is one that cancer care teams can help address. “Clinicians need to ask their patients about sleep and administrators need to ensure adequate funding availability of evidence-based interventions like CBT-I,” she said. “Sleep is one of the main reasons why people struggle during and after cancer. And it is a major reason why people delay or decide not to go back to work. Investing in sleep is an investment in all areas of health.” Sarah DiGiulio is a contributing writer.

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