Journal Article Annotations
2023, 4th Quarter
Annotations by Alissa Hutto, MD
This randomized comparative effectiveness trial of cognitive behavioral therapy for insomnia (CBT-I) versus acceptance and behavioral changes for insomnia (ABC-I) examined pain outcomes, beliefs about sleep, and psychological flexibility among women veterans with insomnia and comorbid pain. This was a secondary analysis with sleep effects discussed elsewhere. ABC-I is a relatively novel (2020) insomnia treatment based in Acceptance and Commitment Therapy (ACT) principles. Both treatments were associated with small but significant pain improvement, with ABC-I being non-inferior to CBT-I despite CBT-I resulting in larger reductions in dysfunctional beliefs about sleep.
Strength and weaknesses:
The focus on women veterans stands out, and the participant group reflects the overrepresentation of Black and Latina women among the female veteran population. The breakdown of therapy targeting dysfunctional beliefs versus psychological flexibility is particularly interesting. Unfortunately for wide applicability to our psychiatric patient population, veterans with severe mental illness were excluded. However, the average PHQ-9 score was consistent with moderate depression and over 40% of participants endorsed PTSD symptoms above a clinical threshold. They did not make a distinction between the therapies’ efficacy for people with versus without depression or PTSD, but the distribution was even across both groups. Most lacking in this study was a discussion of functional improvement gained from a decrease in pain; without a functional measure (such as the Pain Disability Questionnaire) it is hard to interpret the impact on quality of life from the average one-point decrease on the pain scale.
As the field of psychiatry borrows more analgesic use (i.e. suboxone, ketamine) from pain management, we may in turn lend more of our non-pharmacologic interventions to pain treatment. This study and others show that there may be a wider application of therapy techniques to pain management than we may expect, and more research may elucidate more effective pain-focused therapy components.