Cognitive behavioral therapy, a type of “talk” therapy, may help ease the severity of insomnia, fatigue, and anxiety in people with multiple sclerosis (MS), improving the quality of their sleep, data from a single-site trial suggest.
The study “Feasibility and Treatment Effect of Cognitive Behavioral Therapy for Insomnia in Individuals with Multiple Sclerosis: A Pilot Randomized Controlled Trial” was published in the journal Multiple Sclerosis and Related Disorders.
Estimates point to almost 70% of MS patients having difficulties sleeping, and at least 40% report chronic insomnia. Poor sleep also worsens the daily fatigue that affects quality of life.
These difficulties are thought to arise either from the damage to myelin (the protective layer of nerve cell axons) and to brain regions that control sleep, or from physical pain, spasticity (muscular stiffness and contractions), medication effects, bladder problems, or psychological factors including depression and anxiety.
Insomnia is characterized by trouble falling asleep, difficulty maintaining sleep, or waking up too early for at least three nights each week for three consecutive months.
Cognitive Behavioral Therapy for Insomnia (CBT-I), a type of psychotherapy or “talk” therapy for insomnia, focuses on changing behaviors or thoughts that influence sleep. This type of therapy is currently the most recommended non-pharmacological treatment for insomnia.
CBT-I techniques include stimulus control, restrictions on time spent in bed, education on sleep hygiene and cognitive strategies, and relaxation techniques to help patients to improve their sleep quality.
Previous studies have demonstrated that long-term use of CBT-I is more effective in improving sleep than medications. Yet few studies have addressed CBT-I with MS patients reporting sleep difficulties, and the numbers of participants in those that have were very small, so that “the interpretation of these results is difficult,” the researchers wrote.
A randomized clinical trial (NCT03216889), conducted at University of Kansas Medical Center (KUMC) in collaboration with the National Multiple Sclerosis Society, assessed the feasibility and efficiency of CBT-I in a larger group of MS patients with insomnia symptoms.
A total of 33 people (30 women and three men, mean age of 53), diagnosed with relapsing-remitting MS (RRMS, 30 patients) and secondary progressive MS (SPMS, three patients), were divided into three groups: CBT-I group, active control group, or to a one-time brief sleep education control group.
The CBT-I program included an in-person session, lasting 45 to 60 minutes, once every six weeks. Participants in the active control group underwent a six once-weekly sessions of gentle stretching for up to 10 minutes, then a self-selected light or sedentary activity (i.e., playing games on Wii, playing Uno or Sudoku, or coloring in a book) accompanied by a researcher. Those in the brief education group were given a single-page handout on sleep promotion, tailored by a researcher to each person.
Overall, 90.9% of patients (30 out of 33) completed the study. Adherence to therapy was on average 5.6 sessions (out of 6) in the CBT-I group, and 4.9 (out of 6) for the active control group.
Researchers used the Insomnia severity scale (ISS) to assess the impact of insomnia on each patient. ISS is a seven-item self-reported questionnaire assessing the nature, severity, and impact of insomnia. Scores vary from zero to 28, with increasing scores meaning more severe insomnia.
Those in the CBT-I group and brief education group had significant improvements in their ISS scores compared to the study’s start (a baseline measure): a score reduction of 13.8 in CBT-I group, and 8.1 in the brief education group. No significant differences were seen over this time in the active control group (a drop of 5.8 in ISS scores).
The CBT-I group and brief education group also showed significant improvements in their sleep quality at six weeks, as shown by a significant decrease in the Pittsburgh Sleep Quality Index (PSQI). These two groups also experienced a lessening of fatigue, as shown by results on the Modified Fatigue Impact Scale (MFIS).
In PSQI, higher scores indicate worse sleep quality. In the CBT-I group, the PSQI dropped from 13.1 to 6.4, and in the brief education group from 12.5 to 7.9. No significant differences were seen in the active control group (a decrease from 9.4 to 8.5).
In MFIS, higher scores indicate a greater impact of fatigue on a person’s activities. This score dropped from 34.1 to 14.8 in the CBT-I group, and from 50.7 to 32.6 in the brief education group.
Patients in the CBT-I group were the only ones showing a significant reduction on Fatigue Severity Scale scores, and significant differences on the sleep self-efficacy (SSE) index. The SSE, which assesses a person’s perception of quality sleep via higher scores, increased from 24.3 to 35.5 in this group.
CBT-I also had a positive impact on anxiety, shown in a moderate reduction of scores in the Generalized Anxiety Disorder Assessment test.
These results suggest that “CBT-I is feasible in people with MS, and produces promising improvements in insomnia severity, sleep quality, sleep self-efficacy, and comorbid symptoms of fatigue, depression, and anxiety,” they added.
“Future studies are needed to determine mechanisms for these improvements, and expand the scope of individuals with MS who may benefit from CBT-I.”
The team also noted that more than one strategy can be used to address insomnia, and suggested a potential step-by-step approach starting with sleep education and followed by CBT-I.
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