Dirksen, S. R., & Epstein, D. R. (2008). Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors. Journal of Advanced Nursing, 61, 664–675.

The intervention was delivered by a master’s prepared nurse and consisted of four weekly classes and two weeks of treatment conducted through individual weekly telephone sessions. Each class followed a standard format using a treatment manual. The cognitive-behavioral therapy (CBT) intervention consisted of stimulus control instructions, sleep restriction therapy, sleep education, and hygiene content, including cognitive strategies. The aim of the stimulus control interventions was to shape cognitions to reassociate the bed and bedroom with rapidly falling asleep or falling back to sleep. The aims of stimulus control were to acquire a consistent sleep pattern, strengthen the bed and bedroom as cues for sleep, and weaken them as cues for activities that interfere with sleep. Sleep restriction therapy was based on the observation that people with insomnia spend too much time in bed attempting to sleep. The treatment focused on developing a sleep-wake schedule that consolidates sleep and limits it to a specific time by restricting the amount of time spent in bed. Sleep education and hygiene consisted of giving basic information about sleep processes and functions, developmental sleep changes, circadian rhythms, individual sleep needs, sleep deprivation, and supportive information. Dysfunctional cognitions that may contribute to sleep difficulty were also challenged.

• Seventy-two women with breast cancer were included.
• Mean age was 58 years. 
• Patients were at least three months postcompletion of primary treatment and without current evidence of disease.
• Patients were predominantly Caucasian (96%) and married (68%).
• Of the patients, 68% were either retired or employed full-time.
• Most patients had stage I (50%) or II (29%) disease at diagnosis.
• The exclusion criteria included cognitive impairment as determined by Mini-Mental State Examination and/or suspicion of sleep apnea, restless leg syndrome, or periodic limb movement disorder.

• Large university in the southwestern United States
• Women were recruited primarily from newspaper advertising, doctor referral, and breast cancer support groups.

This was a randomized, controlled trial with assignment to either CBT for insomnia or a control group that received education about sleep and sleep hygiene.

Profile of Mood States Fatigue/Inertia Subscale (POMS-F/I)

Women in the intervention group demonstrated significantly lower fatigue compared to those in the control group. The authors concluded that because mediation analyses indicated that the intervention had no direct effect on any of the psychosocial outcomes, that the intervention had an indirect effect on the outcome of fatigue due in part to improvements in sleep quality (both groups demonstrated improvements in mean scores for insomnia severity across the course of the study, and in a study reported elsewhere, they also demonstrated significant improvements in other sleep outcome indicators and favorable changes in actigraphy).

• Outcomes were evaluated immediately following the intervention; therefore, the long-term sustainability of the intervention effects is not known.
• It was difficult to isolate the components of the intervention that produced improvement because both the intervention and the control group received psychological and peer group and individual support, as well as the sleep education and hygiene component of the CBT intervention.

A modest amount of continuing education, as well as access to some instructional materials for patients, are needed to prepare health care professionals to deliver CBT interventions for insomnia.