Are Refined Differential Diagnosis and Pharmacologic Treatment for Cancer-Related Insomnia Always Necessary Practical Recommendations for Cancer Care Providers

P E E R V I E W P O I N T Are Refined Differential Diagnosis and Pharmacologic Treatment for CancerRelated Insomnia Always Necessary? Practical Recommendations for Cancer Care Providers Josée Savard, PhD Commentary of “Pathogenesis and Management of Cancer-Related Insomnia” by Gina Graci, PhD (page 349). deed, diagnostic criteria of these disorders vary significantly across classifications (eg, Diagnostic and Statistical Manual of Mental Disorders, Version IV vs International Classification of Sleep Disorders) and are often difficult to operationalize. In particular, distinguishing whether insomnia is primary or secondary is often challenging, considering that insomnia is frequently found in association with other medical or psychologic conditions.2 This distinction is especially difficult in the context of cancer because of the multidimensional aspects of cancer-related insomnia. In fact, as pointed out by Dr. Graci, cancer-related insomnia is, in most cases, a biopsychosocial disorder in which emotional, behavioral, cognitive, physiologic, and environmental factors are all influential, albeit to various degrees across individuals. Although refined differential diagnosis may be essential in research settings or in specialized sleep clinics, emphasizing its importance among cancer care providers may discourage them from trying even to detect sleep difficulties among their patients, something that should clearly be avoided. Besides, in most cases, this distinction will not significantly alter the treatment plan, which generally involves behavioral or pharmacologic treatment or a combination of both. Exceptions to this rule are sleep difficulties that are clearly attributable to substance abuse (or withdrawal) or another treatable physical (eg, the presence of another sleep disorder such as sleep apnea) or psychologic disorder (eg, major depression), which is easier to rule out. I n this issue, Dr. Graci presents a comprehensive review of diagnostic and treatment issues of cancer-related insomnia. Dr. Graci’s objective to better inform clinicians about this largely underdiagnosed and undertreated problem is extremely relevant and timely considering its high prevalence and potential negative consequences on patients’ quality of life.1 I cannot agree more with the author’s conclusion that, with all the challenges cancer patients face, sleep problems should not be left untreated. Effective treatment strategies do exist for insomnia and should be more largely disseminated. Dr. Savard is Professor of Psychology, Laval University Cancer Research Center and School of Psychology, Laval University, Quebec, Canada. On the Necessity of Refined Differential Diagnosis My commentary will first challenge the necessity of refined differential diagnosis in the context of routine cancer care. In her article, Dr. Graci describes several distinct diagnostic categories, including primary, psychophysiologic, secondary (to a medical or a psychologic disorder), and adjustment sleep disorders, which may not be that simple to distinguish in routine clinical care. InThe author thanks Charles M. Morin, PhD, and Lynda Bélanger, PhD, for their comments on an earlier draft of this manuscript. This article was supported, in part, by an operating grant (MOP–69073) and a salary support award from the Canadian Institutes of Health Research. Correspondence to: Josée Savard, PhD, Laval University Cancer Research Center, 11 Côte du Palais, Québec, Québec, Canada, GIR 2J6; telephone: (418) 691-5561; fax (418) 6915562; e-mail: josee.savard@psy.ulaval.ca J Support Oncol 2005;3:361–362 © 2005 Elsevier Inc. All rights reserved. On the Necessity of Pharmacologic Treatment In her article, Dr. Graci comprehensively reviewed the pharmacologic agents that can be used VOLUME 3, NUMBER 5 ■ SEPTEMBER/OCTOBER 2005 www.SupportiveOncology.net 361 Peer Viewpoint: Pathogenesis and Management of Cancer-Related Insomnia for the treatment of insomnia. Hypnotic medications are by far the most commonly used insomnia treatment in cancer patients,3 presumably because cancer care providers feel more at ease with prescribing such medication than administrating behavioral strategies. Yet, recent clinical studies consistently supported the efficacy of psychologic interventions for cancerrelated insomnia.4–6 Therefore, it is my opinion that behavioral interventions should become the first-line treatment for cancer-related insomnia. For chronic insomnia treatment, sleep experts agree that psychologic approaches should be preferred because of the risks associated with prolonged hypnotic use.1 If behavioral interventions have consistently proven effective for more severe forms of insomnia, then there is no reason to continue favoring pharmacotherapy for treating less severe insomnia (eg, subclinical levels of insomnia). It has been shown that primary care providers can administer behavioral interventions for insomnia (ie, stimulus control and sleep restriction) effectively, provided they receive minimal training.7,8 This suggests that these treatment strategies could also be administered by cancer care providers (eg, oncologists, nurses, etc). Pharmacotherapy should therefore be reserved for acute sleep difficulties (eg, associated with surgery), for patients unable to invest time and effort in changing their behaviors, or for insomnia refractory to psychologic interventions. It could also be administered as an adjunct to psychologic strategies. However, empirical evidence has failed to show that treatments combining pharmacologic and psychologic strategies are superior to behavioral treatment alone.9 modifying the faulty beliefs about sleep that are believed to be instrumental in the maintenance of sleep difficulties over time. This includes unrealistic expectations of sleep requirements (“I absolutely need 8 hours of sleep to function well during the day”), misconceptions about the causes of insomnia (“Cancer is the cause of my insomnia and nothing can be done to change it”), and distorted perception of insomnia consequences (“If I continue not sleeping well, my cancer will recur”).11 Although no study has yet examined the efficacy of cognitive therapy for insomnia when used alone, it has been suggested that cognitive therapy is especially useful in the maintenance of treatment gains over time. However, cognitive therapy is less easily implemented in routine cancer care. Referrals to a cognitive-behavioral therapist therefore should be considered when the treatment effect is limited or in cases of relapse. Practical Recommendations for Practitioners Hereafter are some practical recommendations for practitioners for the assessment and management of insomnia in the context of cancer routine care: • Screen systematically for the presence of insomnia symptoms (eg, “Do you have sleep difficulties?”). • Briefly assess the nature, severity, and duration of sleep difficulties (eg, “How many nights do you take more than 30 minutes to fall asleep or are you awake for more than 30 minutes during the night or do you wake up too early in the morning?”; “How long have you been having these sleep difficulties?”). • Rule out the possibility that sleep difficulties are attributable to substance abuse (or withdrawal) or another treatable medical or psychologic condition. Refer to a sleep specialist or another mental health professional if further assessment is warranted. • Initiate stimulus control strategies with or without sleep restriction. The use of a sleep diary may be extremely useful at this point, particularly when using sleep restriction (eg, to establish an initial sleep window and subsequent time in bed increases). Explain the rationale of these strategies to reinforce adherence. • If these steps are ineffective or only partly effective, refer to a sleep specialist or another mental health specialist (eg, a cognitive-behavioral therapist) who will target dysfunctional beliefs about sleep. Alternatively, introduce a hypnotic medication, but ideally on a short-term basis only. A Gradual Approach to the Management of Cancer-Related Insomnia Dr. Graci also reviewed the most commonly used psychologic strategies in the treatment of insomnia. A meta-analysis on the treatment of primary insomnia has found that the most effective treatments included stimulus control, sleep restriction, and multicomponent treatments.10 Multicomponent approaches have become the standard in clinical studies because patients with chronic insomnia will often need a combination of strategies to achieve significant improvements. Nevertheless, a large proportion of patients seen in clinical practice, with various degrees of sleep difficulties, will significantly benefit from receiving a single strategy. A gradual approach is thus possible, starting with the more straightforward and less time-consuming behavioral strategies, such as stimulus control therapy and sleep restriction, which are relatively simple to explain to patients (see the Graci article or Savard and Morin1 for a description). However, a clear explanation of the rationale underlying these treatment strategies and followup visits are necessary to maximize patient adherence to the strategies and, ultimately, the treatment efficacy. ON THE UTILITY OF COGNITIVE THERAPY Conclusion Insomnia is a widespread problem among cancer patients. Cancer care providers should integrate the screening of sleep difficulties in routine patient care. Several effective treatment strategies for cancer-related insomnia can easily be integrated in routine cancer care when health professionals are provided minimal training, especially in behavioral strategies. Although a lot can be done by first-line cancer care providers, appropriate referrals for further assessment or more intensive insomnia treatment should be considered for more complex cases. References appear on page 388 A treatment component that was overlooked by Dr. Graci is cognitive therapy. Cognitive therapy for insomnia aims at 362 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY Continued from Savard on page 362 References 1. Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 2001;19:895–908. 2. McCrae CS, Lichstein KL. Secondary insomnia: diagnostic challenges and intervention opportunities. Sleep Med Rev 2001;5:47–61. 3. Stiefel FC, Kornblith AB, Holland JC. Changes in the prescription patterns of psychotropic drugs for cancer patients during a 10-year period. Cancer 1990;65:1048–1053. 4. Davidson JR, Waisberg JL, Brundage MD, MacLean AW. Nonpharmacologic group treatment of insomnia: a preliminary study with cancer survivors. Psychooncology 2001;10:389–397. 5. Quesnel C, Savard J, Simard S, Ivers H, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastatic breast cancer. J Consult Clin Psychol 2003;71:189–200. 6. Savard J,Simard S,Ivers H,et al.A randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer:I - sleep and psychological effects. J Clin Oncol 2005;23:6083–6096. 7. Baillargeon L, Demers M, Ladouceur R. Stimuluscontrol: nonpharmacologic treatment for insomnia. Can Fam Physician 1998;44:73–79. 8. Childs-Clarke A. Stimulus control techniques for sleep onset insomnia. Nurs Times 1990;86:52–53. 9. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for latelife insomnia: a randomized controlled trial. JAMA 1999;281:991–999. 1 0 . M o r i n C M , Cu l b e r t J P, S c h wa r t z S M . Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry 1994;151:1172–1180. 11. Morin CM, Savard J, Blais FC. Cognitive therapy. In: Lichstein KL, Morin CM, eds: Treatment of Late-life Insomnia. Thousand Oaks, Calif: Sage Publications; 2000:207–230. 388 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY