Cognitive behavioral therapy vs. Tai Chi for late life insomnia and inflammatory risk: a randomized controlled comparative efficacy trial

Abstract

Study objectives: To investigate the comparative efficacy of cognitive behavioral therapy (CBT), Tai Chi Chih (TCC), and sleep seminar education control (SS) on the primary outcome of insomnia diagnosis, and secondary outcomes of sleep quality, fatigue, depressive symptoms, and inflammation in older adults with insomnia.

Design: Randomized controlled, comparative efficacy trial.

Setting: Los Angeles community.

Patients: 123 older adults with chronic and primary insomnia.

Interventions: Random assignment to CBT, TCC, or SS for 2-hour group sessions weekly over 4 months with follow-up at 7 and 16 months.

Measurements: Insomnia diagnosis, patient-reported outcomes, polysomnography (PSG), and high-sensitivity C-reactive protein (CRP) levels.

Results: CBT performed better than TCC and SS in remission of clinical insomnia as ascertained by a clinician (P < 0.01), and also showed greater and more sustained improvement in sleep quality, sleep parameters, fatigue, and depressive symptoms than TCC and SS (all P values < 0.01). As compared to SS, CBT was associated with a reduced risk of high CRP levels (> 3.0 mg/L) at 16 months (odds ratio [OR], 0.26 [95% CI, 0.07-0.97] P < 0.05). Remission of insomnia was associated with lower levels of CRP (P < 0.05) at 16 months. TCC was associated with improvements in sleep quality, fatigue, and depressive symptoms as compared to SS (all P's < 0.05), but not insomnia remission. PSG measures did not change.

Conclusions: Treatment of late-life insomnia is better achieved and sustained by cognitive behavioral therapies. Insomnia treatment and remission reduces a marker of inflammatory risk, which has implications for cardiovascular morbidity and diabetes observed with sleep disturbance in epidemiologic surveys.

Trial registration: ClinicalTrials.gov NCT00280020.

Keywords: behavioral treatment; inflammation; insomnia; late life; randomized controlled trial.

© 2014 Associated Professional Sleep Societies, LLC.

Figures

Figure 1

Screening, randomization, and completion of post-intervention, 7-month, and 16-month evaluations. CBT, cognitive behavioral therapy; TCC, Tai Chi Chih; SS, sleep seminar.

Figure 2

Percentage of participants with remission of DSM-IV-TR insomnia at 4 months (post-intervention) in the CBT, TCC, and SS treatment groups. Insomnia diagnosis was made by clinician interview using DSM-IV-TR criteria. At post-intervention, the rate of remission was 54.2% in CBT vs. 29.7% in TCC (χ2 = 7.25, P < 0.05) and 20.8% in SS (χ2 = 5.1, P < 0.01); the rate of remission was similar in the TCC and SS groups. Conversely, the percentage of participants who continued to have DSM-IV-TR insomnia was lower in the CBT group (45.8%) than in the TCC (70.3%) and SS groups (79.2%). The percentage of participants with insomnia was similar in the TCC and SS groups (χ2 = 0.60, P = 0.44). CBT, cognitive behavioral therapy; TCC, Tai Chi Chih; SS, sleep seminar.

Figure 3

Change in global sleep quality from baseline to month 16 follow-up in the CBT, TCC, and SS treatment groups. Total scores on the Pittsburgh Sleep Quality Index (PSQI) range from 0 to 21, with higher scores indicating worse sleep quality. Values are means; bars indicate standard error of measurement. Measurements were obtained at baseline and months 2 and 3 (mid-intervention), 4 (post-intervention), and 7 and 16 (follow-up). Shaded area indicates period of administration of intervention following baseline assessment. * Significant linear trend contrasts between CBT vs SS (t522.7 = 2.70; P < 0.01). # Significant linear trend contrasts between CBT vs TCC (t531.3 = 2.64; P < 0.05). + Significant pairwise comparisons between TCC vs SS. CBT, cognitive behavioral therapy; TCC, Tai Chi Chih; SS, sleep seminar.

Figure 4

Change in depressive symptoms severity from baseline to month 16 follow-up in the CBT, TCC, and SS treatment groups. Total scores on the Inventory of Depressive Symptomatology-Clinician Rating Scale (IDS-C) range from 0 to 84, with higher scores indicating more severe depressive symptoms. Values are means; bars indicate standard error of measurement. Measurements were obtained at baseline and months 2 and 3 (mid-intervention), 4 (post-intervention), and 7 and 16 (follow-up). Shaded area indicates period of administration of intervention following baseline assessment. * Significant linear trend contrasts between CBT vs SS (t521.1 = 1.98.; P < 0.05). # Significant linear trend contrasts between CBT vs TCC (t523.0 = 1.98; P < 0.05). + Significant pairwise comparisons between TCC vs SS. Similar results were found when the sleep disturbance items of the IDS-C were removed. CBT, cognitive behavioral therapy; TCC, Tai Chi Chih; SS, sleep seminar.

Figure 5

Percentage of participants with high C-reactive protein (CRP) at baseline, 4 months, and 16 months in the CBT, TCC, and SS treatment groups. High CRP was defined by levels in excess of 3.0 mg/L. High CRP was less likely to be found in the CBT participants as compared to SS (χ2(1) = 4.0, P = 0.04). As compared to SS, CBT was associated with a reduced risk of having high CRP at 4 months (odds ratio [OR], 0.37 [95% CI, 0.11–1.18]; P = 0.08) and at 16 months (OR, 0.26 [CI, 0.07–0.97]; P < 0.05). As compared to SS, TCC was not associated with reduced risk of high CRP at 4 months (OR, 0.39 [CI, 0.11–1.3] P = 0.10), or at 16 months (OR, 0.8; [CI, 0.25–2.5] P = 0.47). In SS, change in percentage with high CRP from baseline to month 16 was not significant (P > 0.30). CBT, cognitive behavioral therapy; TCC, Tai Chi Chih; SS, sleep seminar.

Figure 6

Levels of C-reactive protein (CRP) in participants with and without remission of DSM-IV-TR insomnia. As compared to non-remitters, those with remission of insomnia had similar levels of CRP at 4 months (t = 0.18, P = 0.86), but significantly lower levels of CRP at 16 months (t = 1.7, P < 0.05).