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CBT for insomnia and hot flashes lifts mood in midlife


Key clinical point: Four sessions of cognitive-behavioral therapy significantly improved sleep and mood for women in midlife.

Major finding: Patient-reported and clinician-assessed depression scores dropped after the intervention (P = .001 for both).

Data source: Randomized controlled trial of 40 midlife women with insomnia and hot flashes.

Disclosures: The National Institutes of Health and the Hogg Foundation for Mental Health funded the study. Dr. Nowakowski reported no conflicts of interest.


AT NAMS 2017

– Cognitive-behavioral therapy tailored to perimenopausal and postmenopausal women who were experiencing both insomnia and vasomotor symptoms effectively improved both sleep and mood, according to a small controlled study.

When 40 women were randomized to receive either cognitive-behavioral therapy for menopausal insomnia (CBTMI) or education about menopause and sleep, those who received CBTMI had significantly reduced scores on both objective and subjective scales of depression, and their sleep also improved.



The CBTMI intervention was effective even for women with high scores on the depression scales at baseline, Sara Nowakowski, PhD, said at a top abstracts session at the annual meeting of the North American Menopause Society.

Over the 8 weeks of the study intervention, women in the CBTMI arm received four 50-minute individual sessions with either a social worker or a psychologist in a gynecology clinic outpatient setting. Counseling during the sessions focused both on hot flashes and insomnia, using evidence-based CBT techniques to address both. These included sleep restriction, changing behaviors to strengthen the association of the bed with sleep, cognitive therapy to address maladaptive beliefs about both sleep and host flashes, general sleep hygiene, hot flash coping mechanisms, and relaxation training.

Those in the menopause education control arm had a 1-hour educational session about menopausal symptoms and sleep hygiene, received written material, and were told they could make any changes desired.

Participants, whose mean age was 55 years, were included if they reported at least one nocturnal hot flash per night and met criteria for the sleep disorder of insomnia. Although patients who met criteria for major depression were not excluded, women with surgical menopause or cancer treatment–related menopause were excluded, as were those with substance use disorder, significant other psychiatric comorbidities, and those with obstructive sleep apnea or periodic limb movements/restless leg syndrome.

Dr. Nowakowski, a clinical psychologist in the department of obstetrics and gynecology, University of Texas, Galveston, and her colleagues administered the Insomnia Severity Index (ISI), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Hamilton Depression Rating Scale (HDRS) both before and after the 8-week intervention.

The investigators used a mixed-models statistical analysis, finding a significant improvement over time during the study period in both patient-reported (P = .001) and clinician-assessed (P = .001) ratings of depression for the CBTMI group.

When the effect of the treatment arm was analyzed, CBTMI also offered significantly greater improvement in patient-reported (P = .009) and clinician-assessed (P = .022) depression ratings.

Patients were divided into high and low depression severity, with a score over 8 on the CES-D and 16 on the HDRS putting the participant into the high-severity category. Both groups had significant improvement on the ISI from baseline. “Treatment response for insomnia severity did not differ based on baseline depression severity,” Dr. Nowakowski said.

The efficacy of the relatively brief intervention has clinical relevance to those caring for the 39%-60% of women in midlife who have symptoms of insomnia and the 8%-40% of midlife women who report elevated depression symptoms. “Comprehensive interventions that simultaneously improve sleep and mood in midlife women are greatly needed,” she said.

The National Institutes of Health and the Hogg Foundation for Mental Health funded the study. Dr. Nowakowski reported no conflicts of interest.
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