Journal Article Annotations
2023, 4th Quarter

Pain

Annotations by Alissa Hutto, MD
January, 2024

A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes

PUBLICATION #1 — Pain

A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes

Scott G Ravyts, Alexander J Erickson, Donna L Washington, Elizabeth M Yano, Gwendolyn C Carlson, Michael N Mitchell, Monica Kelly, Cathy A Alessi, Sarah Kate McGowan, Yeonsu Song, Jennifer L Martin, Joseph M Dzierzewski

Abstract: J Psychosom Res. 2023 Dec:175:111536. doi: 10.1016/j.jpsychores.2023.111536. Epub 2023 Oct 21.

Objective:
Insomnia is known to exacerbate pain symptoms. The purpose of the present study was to compare the secondary effects of cognitive behavioral therapy for insomnia (CBTI) against a novel treatment for insomnia called acceptance and behavioral changes for insomnia (ABC-I) among individuals with comorbid pain. Differences in the potential mechanisms through which these treatments impact pain were also examined.

Methods:
Data consisted of a secondary analysis from a randomized comparative effectiveness trial of CBT-I and ABC-I among women veterans with insomnia and comorbid pain. Pain outcomes, beliefs about sleep, and psychological flexibility were assessed at baseline, post-treatment, and at three-months follow-up.

Results:
At baseline, 93 women veterans reported comorbid insomnia and pain (mean age = 46.7; 33.3% Black, 24.7% Hispanic/Latina). Both CBT-I (n = 48) and ABC-I (n = 45) were associated with decreased pain intensity (p < .001, Cohen’s d = 0.41-0.67) and pain interference (p < .001, Cohen’s d = 0.71-0.77) at post-treatment and three-months follow-up, with results indicating that ABC-I was non-inferior to CBT-I for pain improvement. Both conditions were associated with greater psychological flexibility post-treatment, and CBT-I resulted in larger reductions in dysfunctional beliefs about sleep (p = .01, Cohen’s d = 0.59).

Conclusion:
CBT-I and ABC-I both had positive secondary effects on pain with ABC-I being non-inferior to CBT-I with respect to its impact on pain. The mechanisms of change associated with these treatments may differ with CBT-I leading to greater reductions in dysfunctional beliefs. Hybrid treatments which incorporate an acceptance and commitment approach to both insomnia and pain warrant further examination.

Annotation

The finding:
This randomized comparative effectiveness trial of cognitive behavioral therapy for insomnia (CBT-I) versus acceptance and behavioral changes for insomnia (ABC-I) examined pain outcomes, beliefs about sleep, and psychological flexibility among women veterans with insomnia and comorbid pain. This was a secondary analysis with sleep effects discussed elsewhere. ABC-I is a relatively novel (2020) insomnia treatment based in Acceptance and Commitment Therapy (ACT) principles. Both treatments were associated with small but significant pain improvement, with ABC-I being non-inferior to CBT-I despite CBT-I resulting in larger reductions in dysfunctional beliefs about sleep.

Strength and weaknesses:
The focus on women veterans stands out, and the participant group reflects the overrepresentation of Black and Latina women among the female veteran population. The breakdown of therapy targeting dysfunctional beliefs versus psychological flexibility is particularly interesting. Unfortunately for wide applicability to our psychiatric patient population, veterans with severe mental illness were excluded. However, the average PHQ-9 score was consistent with moderate depression and over 40% of participants endorsed PTSD symptoms above a clinical threshold. They did not make a distinction between the therapies’ efficacy for people with versus without depression or PTSD, but the distribution was even across both groups. Most lacking in this study was a discussion of functional improvement gained from a decrease in pain; without a functional measure (such as the Pain Disability Questionnaire) it is hard to interpret the impact on quality of life from the average one-point decrease on the pain scale.

Relevance:
As the field of psychiatry borrows more analgesic use (i.e. suboxone, ketamine) from pain management, we may in turn lend more of our non-pharmacologic interventions to pain treatment. This study and others show that there may be a wider application of therapy techniques to pain management than we may expect, and more research may elucidate more effective pain-focused therapy components.