Savard, J., Villa, J., Simard, S., Ivers, H., & Morin, C. M. (2011). Feasibility of a self-help treatment for insomnia comorbid with cancer. Psycho-Oncology, 20, 1013–1019.

To determine feasibility and assess patient satisfaction with a self-administered format of cognitive-behavioral therapy (CBT) for insomnia comorbid with cancer.

To provide initial information on the effect of self-administered CBT on subjective measures of sleep and other symptoms.

Patients were given a battery of self-report scales to complete for baseline evaluation and were then contacted by an interviewer. They underwent a 75-minute interview followed by instructions to complete a sleep diary for two weeks. Then, patients were given the self-help CBT module for insomnia. It was comprised of six modules, each with a video segment and booklet covering the following topics on sleep and insomnia:  (1) insomnia facts, (2) stimulus control therapy and sleep restriction strategies, (3) cognitive restructuring strategies, (4) revision of maladaptive sleep cognitions, (5) sleep hygiene, and (6) relapse prevention strategies. They were instructed to read one module per week for six weeks. At posttreatment and follow-up, they completed the same battery of self-report scales and sleep diaries.

• The sample was comprised of 11 female patients; seven participated in three-month follow up.
• Mean age was 51.5 years (range 37–74).
• Patients had received radiation therapy for breast cancer; 7 of 11 were undergoing active treatment versus 4 of 11 who had completed therapy 10 to 60 months before the study.
• Patients had insomnia symptoms (score of ≥8 on the Insomnia Severity Index [ISI]) or used psychotropic medications for sleep at least three nights per week.
• Patients were excluded if they had metastatic disease, cognitive impairment, or major mental or psychiatric illness.

• Single site  
• Outpatient
• Quebec radiation oncology clinic

Patients were undergoing the transition phase after initial treatment.

The study used a single-group, nonrandomized pre-/post design.

• Treatment Perception Questionnaire (TPQ)  
• Treatment Satisfaction Interview
• Insomnia Severity Index (ISI)
• Morin Sleep Diary
• European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Dysfunctional Beliefs and Attitudes about Sleep (DBAS)
• Hospital Anxiety and Depression Scale (HADS)
• Multidimensional Fatigue Inventory (MFI)

All patients adhered to the treatment, and all found the format to be excellent and interesting. All patients reported subjective improvement in their sleep quality and motivation to continue the strategies in the future. Sleep measures showed effect sizes of large magnitude in total ISI score, wake after sleep onset, sleep onset latency, sleep efficiency, and total DBAS score. There were moderate effect sizes of HADS–Depression (HADS-D) and QOL scores, with small effect sizes for total sleep time, hypnotics usage, HADS–Anxiety (HADS-A), and MFI scores. These results were sustained at three months.

A self-help CBT strategy for insomnia in patients with breast cancer is feasible. It appears to improve sleep outcomes and dysfunctional beliefs and may improve QOL and depression.

• The study had a small sample size, with less than 30 patients.
• The study had a high drop-out rate; only 7 of 11 patients completed all evaluations at all timepoints.
• The study lacked a control group, and the study was underpowered.

Self-administered CBT for insomnia may be a good first line strategy to treat insomnia in patients with cancer. It allows for treatment at a time that is convenient to the patient and for improved access to care because it can be performed without a sleep expert present.