Cognitive Behavioral Therapy vs. Tai Chi for Late Life Insomnia and Inflammatory Risk: A Randomized Controlled Comparative Efficacy Trial

Abstract

Treatment of late-life insomnia is better achieved and sustained by cognitive behavioral therapies. Insomnia treatment and remission reduces a marker of inflammatory risk, which has implications for cardiovascular morbidity and diabetes observed with sleep disturbance in epidemiologic surveys.

The “Anti-Inflammatory” Properties of CBT-I

“…While trials cannot comprehensively inform on mechanisms, it is worth speculating on what may have accounted for the reduction in CRP in the report by Irwin and colleagues. 17 Consistent with several CBT-I investigations, subjective and objective total sleep time did not improve post-treatment or follow-up; ruling out a parsimonious sleep-time explanation. Similarly, self-reported physical activity and BMI-variables known to be associated with CRP levels-remained unchanged across the groups.…”

“…It would be prudent, also, in future studies to sample additional markers of inflammation, cognitive and somatic arousal, and sleep micro-architecture, and, perhaps in the context of larger, more long-term trials, assess incidence of disease. 27 The results of Irwin et al 17 are likely to have an important impact on the insomnia and sleep field. The study provides further robust evidence that CBT-I effectively improves both night and daytime symptoms of insomnia, and, conversely, contributes the first data to suggest that TCC is unlikely to be an effective treatment for insomnia disorder.…”

“…16 It is in this context that a recent trial by Irwin and colleagues, appearing in this issue of SLEEP, 17 is particularly noteworthy. They report on a randomized, controlled, three-arm trial of multicomponent CBT-I, Tai Chi Chih (TCC; structured, movement-based meditation, previously shown to impact positively on sleep quality), and sleep seminar (SS) education.…”

“…Importantly, elevated CRP levels have been observed after experimental sleep curtailment, 18 and, while still tentative, have been associated with insomnia symptoms. [19][20][21] The main trial results were that CBT-I outperformed both TCC and SS education with respect to proportion of insomnia 17 included a number of important methodological strengths, including matched therapist contact time across treatments arms; rigorous participant screening; assessment of subjective and objective sleep; focus on daytime functioning variables; clinically meaningful end-points; long-term follow-up; parity of treatment arm acceptability; and the novel collection of CRP to index inflammatory risk. In contrast to most CBT-I studies-although not atypical of CBT for other psychological disorders-therapist contact time was extensive, involving 32 hours over a 4-month period.…”

Psychological Aspects of Cardiac Care and Rehabilitation: Time to Wake Up to Sleep?

“…CBT for insomnia (CBT-I) is an effective treatment with an efficacy that is better sustained than pharmacotherapy [166], but access is limited due to the lack of appropriately trained providers [167]. Although it is not yet an established component of cardiovascular care [168], there is emerging evidence that CBT-I improves biomarkers that may contribute to the CVD risk [169]. Looking forward, although sleep disturbance is clearly associated with increased risk cardiovascular disease, large randomized controlled trials are needed to determine whether ameliorating insomnia, or optimizing sleep more generally, improves cardiovascular outcomes.…”