Cognitive behavioural therapy for insomnia in cancer survivors: an updated systematic review and meta-analysis

Squires, Lauren (2021) Cognitive behavioural therapy for insomnia in cancer survivors: an updated systematic review and meta-analysis. Masters thesis, Memorial University of Newfoundland.

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Abstract

Background: Cancer survivors are at greater risk of insomnia relative to the general population. The evidence for the efficacy of cognitive behavioural therapy for insomnia (CBT-I) amongst cancer survivors continues to grow. The objective of this systematic review and meta-analysis was to provide an up-to-date assessment of the efficacy of CBT-I in cancer survivors and explore its effect on comorbid symptoms. Method: Searches were conducted of PubMed, EMBase, PsycINFO, clinicaltrials.gov and the World Health Organization’s international clinical trials registry for studies published up to August 2020. Studies were included if they assessed the efficacy of CBT-I for improving insomnia severity in adults diagnosed with cancer. Our primary measure of interest was insomnia severity. Secondary outcomes included: actigraphy and diary measured sleep continuity, subjective sleep quality, fatigue, mood, quality of life, and pain severity. The protocol for this systematic review and meta-analysis was pre-registered on PROSPERO (CRD42020169986). Results: Twenty-two studies including 1461 participants met the eligibility criteria. CBT-I significantly improved insomnia severity (Hedges’ g = 0.78 and a 7.81-point decrease in mean ISI score), with durable benefits at 3- and 6-month follow-up. CBT-I produced significant small to large effects for the following secondary outcomes: sleep efficiency (sleep diary: g = 0.71 and a 12.32% increase), wake after sleep onset (actigraphy: g = 0.21 and a 10.61-minute decrease; sleep diary: g = 0.60 and a 26.24-minute decrease), total sleep time (actigraphy: g = 0.30 and a 23.29-minute decrease; sleep diary: g = 0.21 and a 30.12-minute increase), sleep onset latency (actigraphy: g = 0.29 and a 3.40-minute decrease; sleep diary: g = 0.65 and a 20.58-minute decrease), sleep quality (g = 0.70 and a 4.62-point decrease in mean PSQI score), anxiety (g = 0.28), depression (g = 0.31), fatigue (g = 0.35), and overall quality of life (g = 0.31). There were insufficient data to analyse the effect of CBT-I on pain outcomes. Subgroup analyses revealed no significant difference between in-person and self-help CBT-I, and effects were stronger for trials that used non-active comparison groups. Conclusion: Our results demonstrate the robust efficacy and durability of CBT-I for the treatment of insomnia in cancer survivors and supports that CBT-I can produce concomitant benefits on other symptoms. Implementation efforts are needed to ensure that people with cancer have access to CBT-I as the recommended first-line treatment for insomnia.

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