Therapy by Phone Helps Insomnia With Arthritis Pain

Telephone-based cognitive behavioral therapy for insomnia (CBT-I) was effective in older adults with osteoarthritis pain, the randomized OATS trial showed.

Insomnia Severity Index (ISI) scores dropped by 8.1 points on the 28-point scale by 2 months after the intervention compared with a decrease of 4.8 points among controls who got an equal amount of education-only contact (P<0.001).

A 3.0-point difference was maintained at 12-month follow-up (P<0.001), Susan McCurry, PhD, of the University of Washington in Seattle, and colleagues reported in JAMA Internal Medicine.

“Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment,” the group concluded, calling the benefits “large, robust, and sustained.”

Two-thirds of the study population lived in medically underserved or health professional shortage areas, “where access to individualized specialized treatment, such as CBT-I, is limited at best and often nonexistent,” McCurry’s group wrote.

However, there are also broader implications as the coronavirus pandemic “highlights the importance of being able to deliver effective health care remotely through a modality as widely available as the telephone,” they added.

“Given abundant evidence that CBT-I is efficacious for persons with other comorbid conditions, including older adults with chronic pain, we believe the OATS trial findings are likely to be generalizable beyond the present OA study population.”

The trial included 327 people age 60 and older insured by Kaiser Permanente Washington who were screened twice, 3 weeks apart, for moderate to severe insomnia and osteoarthritis pain. Participants were randomized to a control group with education on living with osteoarthritis pain or to the active intervention, which progressively managed patients’ time in bed, provided information on sleep hygiene, and taught strategies on constructive worry and mindfulness to reduce hyperarousal at night.

Both groups got six phone calls over 8 weeks by the coaches, who included an MS-level psychologist, a PhD nurse, and a PhD social worker.

The primary endpoint included the 282 participants with follow-up ISI data. The researchers reported other significant secondary endpoint benefits to CBT-I as well:

• More remained in remission at 12 months with an ISI score less than 7 (56.3% vs 25.8%)

• Less fatigue at 2 months post-treatment (−2.0 points on the Flinders Fatigue Scale vs controls) and 12-month follow-up (−1.8 points)

Pain also appeared to be reduced early on after CBT-I, but the difference between groups was not sustained at 12 months.

“Prior studies of CBT-I for pain, with smaller samples and less rigorous control groups, have yielded mixed results,” McCurry’s group pointed out. They called for further research to see if the short-term pain relief found in their study can be confirmed.

“Health plan participants were selected with few eligibility restrictions, increasing generalizability of study findings to primary care patients with OA who had limited or no access to CBT-I services,” the researchers noted, although acknowledging the largely white and highly educated population studied.

Other limitations were self-reported outcomes and unblinded interventionists.