As reported to Chris Pirschel by Sheila Garland, PhD, RPsych

Cognitive Behavioral Therapy Helps Patients With Cancer Manage Insomnia
Sheila Garland, PhD, RPsych, is a registered clinical psychologist and assistant professor of psychology and oncology at Memorial University in St. John’s, Newfoundland.

Simply put, sleep impacts everything. I consider it to be even more foundational than diet and exercise for some. If patients don’t sleep well, they are more likely to make poor food choices and not exercise. Individuals with insomnia symptoms are at higher risk for a number of physical health problems, including diabetes, obesity, and cardiovascular diseases. Insomnia has been linked to mood and anxiety disorders, higher levels of perceived stress, and impaired cognitive functioning.

Insomnia may be more prevalent in cancer for a few reasons. First, the psychological effects of a cancer diagnosis and the impact of treatments are enough on their own to lead to problems sleeping. But other behaviors may either make sleep worse or make it more likely that a short-term or temporary sleep problem becomes a chronic and long-standing disorder known as insomnia.

Behaviors that can lead to the development of insomnia include:

  • Going to bed earlier and “trying harder” to sleep
  • Spending time in bed worrying, planning, or ruminating
  • Sleeping longer in the morning to make up for lost sleep during the night
  • Canceling daytime activities, such as exercise or socializing, because of daytime tiredness or fatigue
  • Using sleeping medication on a more-than-occasional basis
  • Napping for longer than 30 minutes during the day or napping too close to bedtime
  • Spending time before bed or during the night on backlit devices, such as phones or tablets.

To manage insomnia and other sleep disorders, patients and providers must understand the two most powerful factors that control sleep: sleep drive and circadian rhythm. Sleep drive is a homeostatic mechanism whereby the longer the time that has elapsed since an individual has last slept, the stronger the sleep drive becomes and the easier it will be to fall asleep. Behaviors such as napping and sleeping in make it harder to fall asleep at night because they reduce sleep drive.

Our circadian rhythm, commonly known as our biological clock, is controlled by light and the production of melatonin, an important sleep hormone. When people have an irregular sleep and wake schedule, or they expose themselves to light at inappropriate times—such as using backlit devices before bed or during the night—it confuses our circadian rhythm, causing us to feel sleepy during the day and awake during the night.

Evidence for the effectiveness of cognitive behavioral therapy for insomnia (CBT-I) is substantial. ONS’s Putting Evidence Into Practice (PEP) resources list CBT-I as an intervention recommended for practice to treat sleep-wake disturbance in patients with cancer. In addition, the American College of Physicians’ official position is that CBT-I should be recommended as first-line therapy for insomnia, and pharmacotherapy should only be used for short-term or in combination with behavioral treatment, after discussion with patients regarding the limitations of this approach.

Oncology nurses are ideal health professionals to help patients with insomnia because of their contact time and through the supportive relationships they build with patients. With appropriate training and support, nurse-delivered CBT-I can be used to increase access and effectively address insomnia in patients. The ONS PEP resource includes a clinician guide about CBT-I to promote sleep.

Training in CBT-I is available through programs and continuing education offerings. The Society of Behavioral Sleep Medicine can serve as a source of information regarding training opportunities, and the Behavioral Sleep Medicine Group is a list serve for providers.

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