Savard, J., Ivers, H., Savard, M.H., & Morin, C.M. (2014). Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial. Sleep, 37, 1305–1314.

To test the short-term efficacy of a video-based delivery of cognitive behavioral therapy for insomnia compared to a professionally administered method and a no-treatment group

Patients with breast cancer postradiation therapy who were 18 months post-treatment with insomnia were randomized into one of three groups: a video-based cognitive behavioral therapy intervention (VB-CBTI) (60 minute video with six booklets), a professionally delivered CBTI (six weekly, 50-minute, in-person sessions), or a no-treatment group.

• N = 242
• MEAN AGE = 54.4 years (SD = 8.8 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer; 18 months postradiation therapy for nonmetastatic cancer; poor sleep defined by Insomnia Severity Index scores; sleep medication use
• OTHER KEY SAMPLE CHARACTERISTICS: Able to read French; no cognitive impairments; no psychiatric disorders; no prior diagnoses of sleep disorders other than insomnia; no nightshift work; no psychotherapy for insomnia; no language, hearing, or visual deficits; 25.6% taking antidepressants; 31% taking anxiolytics; 73% receiving hormone therapy

• SITE: Single-site
• SETTING TYPE: Outpatient    
• LOCATION: Canadian oncology and radiology department (academic)

• PHASE OF CARE: Transition phase after active treatment

Randomized, controlled, three-arm intervention study

• Mini Mental State Exam (MMSE)
• Structured Clinical Interview for DSM Disorders (SCID)
• Insomnia Severity Index (ISI) (pretreatment)
• Sleep diary
• Multidimensional Fatigue Inventory (MFI)
• Hospital Anxiety and Depression Scale (HADS)
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (​EORTC-QLQ C30)
• Dysfunctional Beliefs and Attitudes Scale (DBAS)
• Actigraphy secondary outcomes

Group-by-time interactions were significant for sleep variables with video-based CBTI being associated with greater sleep improvements compared to the control group for sleep variables other than early-morning awakening and total sleep time (p < 0.001). There were no significant differences between in-person and video-based CBTI for sleep onset latency, wake after sleep onset, total wake time, and sleep efficiency. In-person treatment was associated with a greater reduction in ISI scores, early morning awakening, and total wake time compared to video-based CBTI. The magnitude of change over time was greater with in-person CBTI compared to video CBTI. Both interventions demonstrated a greater improvement in sleep outcomes than the control group. Actigraphy showed a significant reduction (pre/post) in the in-person group only. Secondary outcomes among the in-person group included a significant reduction in depression (p < 0.001), fatigue (p < 0.001), and dysfunctional beliefs about sleep (p < 0.001).

Both CBTIs were effective in improving sleep compared to usual care. The video format seems to be an effective treatment option, but in-person therapy continues to show better efficacy. CBTI also was associated with improvements in fatigue and depression scores.

• Subject withdrawals ≥ 10%
• Other limitations/explanation: There always is a risk for treatment contamination with randomized, controlled trials. This study was limited to patients who received radiation treatment and those willing to participate in CBTIs, which limits generalizability. There were significant baseline differences in the numbers of participants taking anxiolytics on a regular basis with the highest proportion concentrated in the control group; this could have led to an underestimation of the results of the intervention alone.

CBTIs can be challenging to implement because access to care for patients with cancer is varied. Although in-person therapy was most effective, the video-based intervention also was effective in improving sleep, fatigue, and depression outcomes. Providing options to rural populations without access to in-person care is essential for increasing efficacy in a wider population with insomnia. The findings of this study regarding the efficacy of a video-based CBTI provide nurses with another option that warrants its use as a treatment with longer effects.