Digital Cognitive Behavioral Therapy Response Poorer Among Black Pregnant Women


Among those observed in the trial, Black pregnant women had a mean number of 4.20 sessions of cognitive behavioral therapy compared with 5.54 for White pregnant women.

Christopher Drake, PhD, section head, Sleep Research, Henry Ford Hospital

Christopher Drake, PhD

Results from a secondary analysis of a single-site trial highlighted several differences in outcomes and response to treatment with cognitive behavioral therapy for insomnia (CBT-I) in Black pregnant women with insomnia vs White pregnant women with the same condition.1

Presented at the 2022 SLEEP Annual Meeting, June 4-8, in Charlotte, North Carolina, senior investigator Christopher Drake, PhD, section head, Sleep Research, Henry Ford Hospital, concluded that "we must identify barriers to treatment response in Black women, thereby guiding refinement to CBT-I to provide better care for Black women during pregnancy."

In total, 24 women who self-identified as White and 15 Black women were assessed on the Insomnia Severity Index (ISI) after completing CBT-I during pregnancy. Despite no differences in ISI prior to treatment, White patients reported significantly larger decreases in ISI relative to Black individuals following CBT-I (–5.75 vs –2.13; P = .046). Investigators also noted that Black patients were less engaged than White patients, demonstrated by an average of 4.20 sessions vs 5.54 sessions (P = .013).

Multivariate regression models showed that posttreatment ISI was 4 points higher for Black women than White women (b = 4.10; P = .049) when controlling for baseline ISI (P = .001), obesity (P = .072), poverty (P = .091), sessions attended (P = .155), and short sleep (P = .406). When comparing the 2 groups, 41.7% and 26.7% of White and Black patients, respectively, remitted, which suggested that White women are 56% more likely to remit from CBT-I than Black women.

READ MORE: Insomnia Severity Index Responders Show Additional Benefits From Lemborexant

The precursor study to this included 150 postmenopausal women with perimenopausal or postmenopausal onset or exacerbation of chronic insomnia who were randomized to 3 treatment conditions: sleep hygiene education control (SHE), sleep restriction therapy (SRT), and CBT-I. Blinded assessments were performed at pretreatment, posttreatment, and 6-month follow-up.2

At posttreatment and 6 months later, CBT-I and SRT produced moderate-to-large improvements in fatigue, energy, sleepiness, and work function. Those treated with CBT-I reported better quality of life as indicated by substantial improvements in well-being and resiliency to physical and emotional problems, whereas the SRT and SHE groups only showed improvements in resiliency to physical problems. Additionally, insomnia remitters reported fewer daytime and nighttime hot flashes, although reductions were not associated with any specific treatment.

As CBT has become more common in recent years, there has been increased efforts to understand its impact based on race. In a recently published single-blind, 3-arm randomized clinical trial, Black women with insomnia were randomized to receive either an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi), a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS), or patient education about sleep. In a cohort of 333 Black women, those who received both the standard internet-delivered CBT intervention and the SHUTi-BWHS reported significantly greater insomnia improvement compared with those who received sleep education alone. Additionally, participants were more likely to complete the full intervention if they received the tailored program, with intervention completion associated with greater insomnia improvement.3

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1. Kalmbach D, Cheng P, Pitts D, et al. Racial disparities in patient outcomes and treatment engagement in cognitive behavioral therapy for insomnia among pregnant women. Presented at: SLEEP Annual Meeting, 2022; June 4-8.
2. Kalmbach D, Cheng P, Arnedt JT, et al. Improving daytime functioning, work performance, and quality of life in postmenopausal women with insomnia: comparing cognitive behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. J Clin Sleep Med. 2019;15(7):999-1010. doi:10.5664/jcsm.7882
3. Zhou ES, Ritterband LM, Bethea TN, et al. Effect of culturally tailored, internet delivered cognitive behavioral therapy for insomnia in black women: a randomized clinical trial. JAMA Psychiatry. 2022;79(6):538-549. doi:10.1001/jamapsychiatry.2022.0653
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