Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial

Michael V Vitiello, Susan M McCurry, Susan M Shortreed, Benjamin H Balderson, Laura D Baker, Francis J Keefe, Bruce D Rybarczyk, Michael Von Korff, Michael V Vitiello, Susan M McCurry, Susan M Shortreed, Benjamin H Balderson, Laura D Baker, Francis J Keefe, Bruce D Rybarczyk, Michael Von Korff

Abstract

Objectives: To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive-behavioral therapy for pain and insomnia (CBT-PI), a cognitive-behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes.

Design: Double-blind, cluster-randomized controlled trial with 9-month follow-up.

Setting: Group Health and University of Washington, 2009 to 2011.

Participants: Three hundred sixty-seven older adults with OA pain and insomnia.

Interventions: Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants' primary care clinics.

Measurements: Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms.

Results: CBT-PI reduced insomnia severity (score range 0-28) more than EOC (adjusted mean difference = -1.89, 95% confidence interval = -2.83 to -0.96; P < .001) and CBT-P (adjusted mean difference = -2.03, 95% CI = -3.01 to -1.04; P < .001) and improved sleep efficiency (score range 0-100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44-4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85-4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results.

Conclusion: Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes.

Trial registration: ClinicalTrials.gov NCT01142349.

Conflict of interest statement

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Figures

Figure 1
Figure 1
CONSORT flow diagram for enrollment of potentially eligible participants. Eligible individuals were identified by screening survey of persons with osteoarthritis visits (N = 3,321); 1,210 respondents (36%) reported clinically significant arthritis pain and insomnia, and 998 of 1,210 persons initially eligible (82.5%) agreed to medical record review and contact by the study. “Baseline missing” is the number of individuals excluded because of missing baseline information; “2, 9 mo missing” is the number excluded because they were missing 2- and 9-month follow-up information. CBT-P = cognitive–behavioral therapy for pain; CBT-PI = cognitive–behavioral therapy for pain and insomnia; EOC = education-only control.
Figure 2
Figure 2
Mean primary and secondary sleep and pain outcome scores at baseline, posttreatment, and 9-month assessments for the education-only control (EOC), cognitive–behavioral therapy for pain (CBT-P), and cognitive–behavioral therapy for pain and insomnia (CBT-PI) groups. Lower scores indicate improvement on Insomnia Severity Index and pain severity; higher scores indicated improvement on sleep efficiency and arthritis symptoms.

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