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Original Investigation
February 22, 2021

Effect of Telephone Cognitive Behavioral Therapy for Insomnia in Older Adults With Osteoarthritis Pain: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle
  • 2Kaiser Permanente Washington Health Research Institute, Seattle
  • 3Department of Psychology, Université Laval, Quebec City, Quebec, Canada
  • 4College of Nursing and Health Sciences, University of Massachusetts Boston, Boston
  • 5Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Seattle
JAMA Intern Med. 2021;181(4):530-538. doi:10.1001/jamainternmed.2020.9049
Key Points

Question  What is the effectiveness of brief telephone cognitive behavioral therapy for insomnia (CBT-I) in reducing chronic insomnia symptoms among older adults with moderate to severe osteoarthritis pain?

Findings  In this randomized clinical trial of 282 participants 60 years and older across Washington state, 56.3% of participants receiving CBT-I remained in remission (Insomnia Severity Index score, ≤7) at 12 months compared with 25.8% of participants in the education-only control group.

Meaning  Telephone CBT-I may improve access to an individualized and effective treatment for chronic insomnia among older persons with osteoarthritis pain, including those in rural and medically underserved areas.


Importance  Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment.

Objective  To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain.

Design, Setting, and Participants  This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up.

Interventions  Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA.

Main Outcomes and Measures  The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale).

Results  Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of −3.5 points (95% CI, −4.4 to −2.6 points; P < .001). Results were sustained at 12-month follow-up (adjusted mean difference, −3.0 points; 95% CI, −4.1 to −2.0 points; P < .001). At 12-month follow-up, 67 of 119 (56.3%) participants receiving CBT-I remained in remission (ISI score, ≤7) compared with 33 of 128 (25.8%) participants receiving EOC. Fatigue was also significantly reduced in the CBT-I group compared with the EOC group at 2 months posttreatment (mean between-group difference, −2.0 points; 95% CI, −3.1 to −0.9 points; P = <.001) and 12-month follow-up (mean between-group difference, −1.8 points; 95% CI, −3.1 to −0.6 points; P = .003). Posttreatment significant differences were observed for pain, but these differences were not sustained at 12-month follow-up.

Conclusions and Relevance  In this randomized clinical trial, telephone CBT-I was effective in improving sleep, fatigue, and, to a lesser degree, pain among older adults with comorbid insomnia and OA pain in a large statewide health plan. Results support provision of telephone CBT-I as an accessible, individualized, effective, and scalable insomnia treatment.

Trial Registration  Clinical Trials.gov Identifier: NCT02946957

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