Cognitive Behavioral Therapy for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I)

Pharmacy Association of Saskatchewan2016 Annual Conference

April 30 , 2016AJ Rémillard and K. Jensen

common health problem affecting an estimated 3.3 million Canadians

often associated with medical &/or mental conditions. Becomes risk factor for the latter

defined as difficulty initiating sleep, maintaining sleep or early morning awakenings (or combinations) leading to impaired daytime functioning

chronic insomnia persists > 1 month

Insomnia Background

Predisposing factors◦ ↑risk factors: ↑age, female

Precipitating factors◦ events leading to insomnia: illness, job loss

Perpetuating factors◦ strategies used to cope with insomnia: sleeping in

Pavlovian factors◦ process of classical conditioning; promoting an

association of the bedroom with wakefulness performing stimulating activities- watching TV etc.

4P Model of Insomnia

is a psychotherapeutic method used to treat a variety of conditions: anxiety, depression, chronic pain, sleep…

focusses on addressing and re-structuring dysfunctional thoughts and behaviors that contribute to the perpetuation of these conditions

CBT-I is the first-line treatment recommendation for insomnia, with studies reporting it to be more effective than hypnotics in the long run

 

What is CBTi?

does not have the associated adverse effects and risk of tolerance & dependence that hypnotics do

is widely underutilized due to a lack of education, awareness, and trained providers

however recent research has investigated and proven the efficacy of the provision of CBT-I by non-sleep experts

CBTi

insomnia associated with an acute illness insomnia not likely the result of maladaptive

behaviors comorbid illness which interfere with the

CBTi steps (depression, pain) comorbid illness which can be aggravated

by CBTi steps (epilepsy, bipolar) uncontrolled or unstable comorbid illness

(medical &/or mental)

When is CBTi not recommended?

sleep hygiene and bedroom environment

stimulus control therapy

sleep restriction therapy**

cognitive restructuring

relaxation techniques

Components of CBTi

exercise routinely but not close to bedtime create a comfortable sleep environment

(temperature, loud noises, lighting) control use of alcohol, caffeine and nicotine avoid consuming large quantities of liquids

or meals late in the evening do something relaxing and enjoyable before

bedtime avoid daytime and long naps

Sleep Hygiene

re-associate your bedroom with feelings of sleepiness and avoid stimulating activities

establish regular times to wake up and go to sleep

if unable to fall asleep get up and got to another room. Stay up for 30, 60 or 120 minutes◦ want to minimize anger/anxiety of trying to fall asleep◦ leads to sleep loss; but will be captured in the sleep log

Stimulus Control Therapy

most important step in CBTi aim is to match total time spent in bed vs

actually sleeping in bed (sleep efficiency) this is done by increasing the pressure to

sleep through partial sleep deprivation◦ will lead to daytime sedation in acute phase of

therapy sleep logs are used to measure efficiency

◦ TIB – time in bed TST – total sleep time◦ WASO - wake after sleep onset SL –sleep

latency

Sleep Restriction

complete morning sleep log (assess previous nights sleep) & sleep hygiene log (captures lifestyle factors)

collect 1-2 weeks of data to determine TST set standard wake time

◦ ie. TST 6 h, want to wake at 7 AM would go to bed at 1 AM

calculate sleep efficiency (TST/TIB)◦ > .90 ↑ 15 m; .85-.90 keep the same; < .85 ↓15m

minimum 5 h; continue till patient feels rested

Sleep Logs

Cognitive therapy is based on the concept that:

◦ “thoughts cause feelings”

Beck identified the negative thoughts triad:

◦ “oneself - the world - the future”

minor component of CBTi and does not require formal training in CBT

useful for patients who are overly anxious and have unhealthy beliefs about sleep

eliminate or challenge disruptive/negative thoughts/emotions regarding sleep and effects of sleep loss & engage the patient in realistic expectation

Cognitive Re-structuring

goal is to identify, label (classify), reframe (challenge) and restructure (replace)

◦ “if I do not sleep tonight I will lose my job”

◦ Reframe Double standard technique:

“would you say this to same thing to someone else?” Reflection

“has this happened before and what was the outcome?”◦ Restructure

get them to rephrase “if I do not sleep tonight I will still do a good job.”

Negative Sleep Thought

diaphragmatic breathing◦ promotes relaxation and allows more oxygen thru

deeper breathing guide imagery

◦ imagine a place, event or thing that elicits feelings of relaxation

◦ based on theory that the mind and body are connected

progressive muscle relaxation◦ involves tightening then relaxing various muscles

throughout the body

Relaxation Techniques

CBT-I in Practice

Case example Mary Jones, 48 year old female insomnia for 20 years medical history: peri-menopausal symptoms medication profile:

◦ Alesse (EE 20 mcg, levonorgestrel 0.1 mg)◦ Zopiclone 3.75 mg HS

non-smoker, occasional glass or two of wine in evening, at a social event

married, two daughters - 21 and 18 years old, living at home, going to University

Session 11. patient a candidate for CBT-I? 2. describe the program3. patient willing to invest time and effort

needed for success?4. if on sleep medications, willing to stop the

medication?5. provide sleep logs, explain how to use

Sample Sleep Log

Sample Sleep Hygiene Log

ensure medication prescribed only for insomnia before tapering

contact physician for authorization suggestions for tapering regimen

◦ individualized, flexible, negotiate with patient◦ RxFiles:

http://www.rxfiles.ca.cyber.usask.ca/rxfiles/uploads/documents/members/GeriRxFiles-Tapering-EXCERPT-TwoPages.pdf

◦ Empower: http

://archinte.jamanetwork.com/article.aspx?articleid=1860498

Tapering sleep medication

Session 21. summarize information on sleep logs

◦ mismatch between TIB (time in bed) and TST (total sleep time)

2. introduce behavioural model of insomnia3. explain sleep restriction and stimulus

control4. set sleep prescription based on TST 5. discuss strategies to stay awake before

bedtime, during time out of bed during the night

MJ’s initial sleep log data Bedtime: between 9:00 and 11:00 PM Sleep Onset Latency (SOL): 60 min Wake After Sleep Onset (WASO): 90 min Time in Bed (TIB): 540 min (9 hrs) Total Sleep Time(TST)=TIB–(SOL+WASO)=390 min Sleep Efficiency = TST/TIB = 72 % Sleep prescription = 6.5 hours

◦ 12:30 AM to 7:00 AM

Sessions 3-5 (or more if needed)1. review sleep log information at the

beginning of each session2. assess treatment gains and compliance3. determine if upward /downward titration is

warranted4. introduce cognitive therapy, relaxation

techniques as needed5. review sleep hygiene

MJ’s sleep log data at session 3 Bedtime: 12:30 AM 5 days; fell asleep early on

couch twice Sleep Onset Latency (SOL): 10 min Wake After Sleep Onset (WASO): 60 min Time in Bed (TIB): 410 min (6.8 hrs) Total Sleep Time(TST): 320 min (5.3 hrs)

TST = TIB – (SOL + WASO)

Sleep Efficiency = 78% SE = TST/TIB

MJ’s sleep log data - session 4 Bedtime: 12:30 AM Sleep Onset Latency(SOL): 6 min Wake After Sleep Onset(WASO): 30 min (no WASOs 3

nights) Time in Bed (TIB): 390 Total Sleep Time(TST): 365 min (~ 6 hrs)

TST = TIB – (SOL + WASO)

Sleep Efficiency = 90 % SE = TST/TIB

New Sleep prescription – 6.75 hrs (bedtime moved up 15 minutes to 12:15)

Last session1. review sleep log data (weekly values)

2. assess treatment gains

3. discuss relapse prevention• review behavioral perspective on insomnia• discuss the approach to maintaining gains

4. discuss what to do when insomnia returns

PharmaZzz project pilot project

◦ August 1st 2015 – July 31st, 2016

16 pharmacists◦ 13 community◦ 3 primary health care

workshop, training manual, tools for CBT-I

PharmaZzz Working Group: Fred Remillard, Karen Jensen, Loren Regier, Janelle Trifa

Future Directions assess results from pilot

o patient outcomeso pharmacist satisfactiono Barriers

larger study ?

open program to all interested healthcare professionals?

train all pharmacy students?

work on a payment for service?o proposal to Ministry of Healtho proposal to 3rd party payers

CBT for other indications?◦ weight loss ◦ chronic Pain◦ other conditions