Cognitive-behavioral therapy for comorbid insomnia and chronic pain

Insomnia and chronic pain harbor a high rate of comorbidity, and have been regarded as reciprocally related conditions. Four RCTs have investigated the efficacy of CBT-I and 2 RCTs have investigated the efficacy of hybrid CBT-I/CBT-P interventions in reducing insomnia and pain symptoms. In general, these interventions demonstrate clinically meaningful improvements in sleep symptoms. Improvements in pain-related outcomes have been observed in functional domains, such as pain interference and disability, with limited evidence supporting the short-term efficacy of CBT-I or hybrid interventions for pain severity. Hybrid interventions are feasible, and one large-scale RCT now supports the findings of 2 pilot studies, suggesting that hybrid interventions, as currently designed, improve sleep, but not pain severity. Future clinical trials should consider using more comprehensive pain assessments with longer-term follow-up assessment of at least 1 year or more. Measurement strategies that permit the analysis of time-variant contingencies in sleep, pain, and associated psychosocial variables may also be particularly informative. Larger-scale investigations are needed to clarify the limited efficacy data from the small pilot RCTs on hybrid interventions. Future studies aimed at developing hybrid interventions should be designed to investigate issues related to the sequencing of pain and sleep components, and should address the trade-off between the number of new skills patients are expected to master and the quality and mastery of critical components. Hybrid approaches that combine sleep and pain intervention components continue to hold promise for improving the treatment of chronic pain among patients with comorbid insomnia.