Efficacy of Cognitive–Behavioral Therapy for Insomnia in Women Treated for Nonmetastatic Breast Cancer Catherine Quesnel, Jose ´e Savard, Se ´bastien Simard, Hans Ivers, and Charles M. Morin Universite ´ Laval This study investigated the efficacy of a multimodal cognitive– behavioral intervention for women who had been treated for nonmetastatic breast cancer. Ten participants were enrolled in the treatment protocol in a multiple-baseline design. Intervention time series analyses of daily sleep diary data revealed significant improvements of sleep efficiency and total wake time. These results were corroborated by polysomnographic data. In addition, insomnia treatment was associated with significant improvements of mood, general and physical fatigue, and global and cognitive dimensions of quality of life. These findings suggest that cognitive– behavioral therapy, previously found effective for primary insomnia, is also of clinical benefit for insomnia secondary to cancer. A diagnosis of cancer is frequently associated with a heightened level of psychological disturbances. The impact of cancer and its treatment on psychological and psychophysiological problems, such as depression, anxiety, pain, nausea, and vomiting, is well documented (Breitbart & Payne, 1998; Massie & Popkin, 1998; Noyes, Holt, & Massie, 1998; Portenoy et al., 1994; Redd et al., 1991). However, much less attention has been devoted to sleep disturbances, even though between 30% and 50% of patients with a recent cancer diagnosis complain of sleep disturbances (Savard & Morin, 2001). A recent study found that, compared with other groups of cancer patients, women with breast cancer reported more frequent sleep difficulties (Davidson, MacLean, Brundage, & Schulze, 2002). There is also indication that insomnia becomes chronic in a sig- nificant proportion of breast cancer patients. Studies revealed that insomnia symptoms were present in 23%– 44% of breast cancer patients 2 to 5 years following their cancer treatment (Couzi, Helzlsouer, & Fetting, 1995; Lindley, Vasa, Sawyer, & Winer, 1998). In another study, 51% of women treated for nonmetastatic breast cancer had insomnia symptoms, and 19% met diagnostic criteria for an insomnia disorder (Savard, Simard, Blanchet, Ivers, & Morin, 2001). The vast majority (95%) of these cases had chronic insomnia (i.e., insomnia with a duration of 6 months and more). This prevalence rate of insomnia disorder is considerably higher than the rate of 9%–12% found in the general population when using a similar definition (Ford & Kamerow, 1989; Mel- linger, Balter, & Uhlenhuth, 1985). Despite the high prevalence of sleep disturbances observed in cancer patients and the potential negative effects associated with insomnia (e.g., fatigue, psychological symptoms, quality of life impairments), little research has been conducted on the treatment of insomnia in this population. Although pharmacotherapy appears to be the most frequently used intervention (Derogatis et al., 1979), cancer patients are often reluctant to take hypnotic drugs, fearing the added side effects to those of the cancer treatments and because of concern about dependence (Savard & Morin, 2001). Indeed, limitations to using drug therapy are well known and include risks of tolerance, dependence, and drug interactions. Because of these shortcomings, psychological interventions are often recommended as a preferable alternative for the treatment of chronic insomnia (Hall, 1998; Holbrook, Crowther, Lotter, Cheng, & King, 2000; Morin, 1993; National Institutes of Health, 1984, 1991, 1996). The efficacy of these treatments for primary insomnia has been well documented (Morin, Culbert, & Schwartz, 1994; Murtagh & Greenwood, 1995). Two recent studies have supported the efficacy of psychological treatment for chronic insomnia secondary to a medical or psychi- atric condition. The first study (Currie, Wilson, Pontefract, & deLaplante, 2000), conducted with 60 patients suffering from insomnia secondary to chronic pain, showed that a multimodal treatment combining sleep restriction and stimulus control therapy, relaxation training, cognitive therapy, and sleep hygiene education was effective to improve several subjectively assessed sleep pa- rameters and nocturnal motor activity measured by actigraphy. Therapeutic gains were well maintained at a 3-month follow-up. The second study (Lichstein, Wilson, & Johnson, 2000), con- ducted with 44 elderly persons with insomnia secondary to a medical or psychiatric condition, provided evidence about the efficacy of combined relaxation and stimulus control treatment. Treated participants experienced greater improvements in subjec- tive measure of time awake after sleep onset, sleep efficiency (SE), and sleep quality compared with control participants. Catherine Quesnel, Jose ´e Savard, Se ´bastien Simard, and Hans Ivers, School of Psychology and Cancer Research Center, Universite ´ Laval, Que ´bec, Que ´bec, Canada; Charles M. Morin, School of Psychology, Uni- versite ´ Laval. This research was based on the master’s dissertation of Catherine Quesnel, under the direction of Jose ´e Savard and Charles M. Morin. This study was supported in part by scholarships from the Fonds Pour la Recherche en Sante ´ du Que ´bec and the Fond Pour la Formation de Chercheurs et l’Aide a ` la Recherche held by Catherine Quesnel and by an operating grant from the Medical Research Council of Canada. We thank Ce ´lyne Bastien and Meagan Daley for their contributions. Correspondence concerning this article should be addressed to Jose ´e Savard, Laval University Cancer Research Center, 11 Co ˆte du Palais, Que ´bec, Que ´bec G1R 2J6, Canada. E-mail: josee.savard@crhdq.ulaval.ca Journal of Consulting and Clinical Psychology Copyright 2003 by the American Psychological Association, Inc. 2003, Vol. 71, No. 1, 189 –200 0022-006X/03/$12.00 DOI: 10.1037/0022-006X.71.1.189 189 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.