The Effects of Digital Cognitive Behavioral Therapy for Insomnia in Chronic Pain: A Randomized Controlled Trial

Introduction: Managing chronic pain is a significant healthcare challenge that requires a multimodal treatment approach. In particular, the frequent presence of comorbid insomnia symptoms and its complex bidirectional relationship with pain provides a challenge to adequate treatment. This study was set up to test whether the addition of digital cognitive behavioral therapy for insomnia (dCBT-I) to the regular treatment of chronic pain can improve symptoms in a population comorbid chronic pain and insomnia, when compared to a waitlist control (WLC) condition.

Participants meeting criteria for chronic pain and insomnia were randomized (1:1) to either dCBT-I or WLC. Assessments took place at baseline, 8 and 24 weeks post-randomization. The primary outcome was insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes included sleep- and pain-related symptoms as well as measures of well-being and dreams. Linear mixed models were calculated to determine between-group differences.

A total of 207 participants (182 women, mean age = 51.96 ± 12.97 years) were randomized to dCBT-I (n = 103) or WLC (n = 104). The dCBT-I group showed large improvements in the severity of insomnia compared to the WLC both after 8 (-4.36, p < 0.001; d = -1.18) and 24 weeks (-4.88, p < 0.001; d = -1.32). Pain-related impairments and life control also improved, favoring dCBT-I (ds = 0.22-0.35). Moderate-to-large treatment effects were also observed for secondary outcomes, including daytime sleepiness, fatigue, and dysfunctional beliefs and attitudes about sleep (ds = 0.47-1.12).

This study confirmed the effects of dCBT-I in reducing the severity of insomnia in individuals with chronic pain and insomnia. Improvements in symptoms of chronic pain further emphasize the potential of dCBT-I as a scalable, evidence-based intervention to address the complex challenges of dual pathology in clinical practice, and it presents a promising extension of multimodal pain management.