Cognitive Behavioral Therapy for Insomnia (CBT-I)JANET CONSTANCE, PH.D.

Acknowledgement

Components of this presentation were developed by a group of national VA CBT-I training consultants led by Elissa McCarthy, PhD and sponsored by Mental Health Services, VA Central Office

Rachel Manber, PhD (Lead Developer of VA CBT-I Training Program)

Jason DeViva, PhD

Edward Haraburda, PhD

Christie Ulmer, PhD

Wendy Batdorf, PhD (VA CBT-I Program Coordinator)

What Is Insomnia Disorder?

Difficulty initiating sleep, difficulty maintaining sleep, or waking up too early

One or more is present at least 3 times a week, for at least 3 months

Poor sleep occurs despite adequate opportunity and circumstances for sleep

Poor sleep is associated with daytime impairment and distress

The Evolution of Insomnia

Adapted from Spielman et al., 2000

Predisposing Factors

Precipitating Factors

Perpetuating Factors

Insomnia Threshold

Premorbid AcuteInsomnia

ChronicInsomnia

Insomnia

No Insomnia

Conditioned Insomnia

The bed becomes a cue for hyperarousal, rather than sleep

Conditioned Insomnia

With repeated pairing of bed with wakefulness (high arousal)

Tossing Turning Sleeplessness

Prevalence of Insomnia

Approximately 10% - 15% of adults suffer from chronic insomnia An additional 1/3 have transient or

occasional insomnia Approximately 40% of veterans seen by VA

primary care Approximately 19% of primary care patients in

the general community

Medical and Psychiatric Comorbidity

Insomnia is frequently comorbid with other medical and psychiatric disorders Having another psychiatric disorder does not preclude

diagnosis and treatment of insomnia disorder

Comorbid insomnia is often persistent Unlike poor sleep, insomnia disorder does not

spontaneously resolve even with successful treatment of a comorbid condition

Personal and Societal Costs of Insomnia

Associated with a variety of physical, cognitive, and emotional difficulties

Disrupted sleep has been shown to reduce productivity, increase healthcare costs, and increase the risk of various medical and psychiatric disorders

Poor sleep is associated with several medical conditions (e.g., hypertension, obesity, metabolic syndrome, type 2 diabetes mellitus, all-cause mortality)

What is CBT-I?

Comprehensive approach targeting factors that maintain insomnia

Rooted in the science of sleep/wake regulation and principles of behavior change

Skills-based & brief (4-8 sessions) Deliverable in individual or group format

CBT-I Components

Technique Aims

Stimulus Control Strengthen bed & bedroom as sleep cues

Sleep Restriction Restrict time in bed to increase sleep drive and consolidate sleep

Relaxation, buffer, worry time

Arousal reduction

Sleep Hygiene Address substance, exercise, eating, environment

Cognitive Restructuring

Address thoughts and beliefs that interfere with sleep and adherence

Circadian Rhythm Entrainment

Shift or strengthen the circadian sleep/wake rhythm

CBT-I is Effective

Is effective among veterans and general population 70% of patients experience full remission of insomnia or

dramatic reduction in symptoms

Improves sleep initiation

Reduces time awake in the middle of the night

Recommended as a first-line of treatment of insomnia Practice parameters published by the American Academy of

Sleep Medicine

NIMH state of the science consensus statement

Comparative Efficacy: CBT-I for Sleep Onset Difficulties

Jacobs et al., 2004

CBT Zolpidem Combination Placebo0

10

20

30

40

50

60

70

80

90

34.1

58.7

38.7

63.9

83.5

67.2

80.4

71.3

Sleep Onset Latency Sleep Efficiency

Post

-Tre

atm

ent

Comparative Efficacy: CBT-I for Sleep Maintenance Difficulties

0

10

20

30

40

50

60

70

80

90

Baseline Post-Treatment

3 MonthsFollow-up

12 MonthsFollow-up

24 monthsFollow-up

Temazepam (20)

Combined (20)

Placebo (20)

CBTI (18)

Adapted from Morin et al., JAMA 1999

Min

utes

aw

ake

afte

r sl

eep

onse

t

Sleep Hygiene ≠ CBT-I

How does Sleep Hygiene differ from CBT-I?

Sleep Hygiene Education CBT-I

• Avoid stimulants for several hours before bedtime.• Avoid alcohol around bedtime.• Exercise regularly.• Allow at least a 1-hour period to unwind before

bedtime.• Keep the bedroom environment quiet, dark and

comfortable.• Maintain a regular sleep schedule.

• Sleep Restriction• Stimulus Control• Relaxation Training• Cognitive Therapy• Sleep Hygiene Education (except for

regular bedtime)• Cognitive Therapy

Standard GuidelinesIndividualized Multi-Component

Intervention

Helps Normal Sleepers Maintain Sleep Health Treatment for Insomnia Disorder

Preventive Curative

The Dental Hygienist The Dentist

Minimal Impact on Insomnia DisorderVery Effective Insomnia Disorder

Treatment

Inactive Condition in Insomnia Research Active Condition in Insomnia Research

VA CBT for Insomnia Training Program

Reasons to Refer for CBT-I

No risk of drug interactions Minimizes risk for confused arousal upon awakening Benefits continue (and often increase) even after

treatment is discontinued Brevity and effectiveness of approach Involves behavioral changes that improve quality of

life in general such as winding down before bed Patients feel empowered by not relying on

medication to sleep (increased self-efficacy)

CBT-I and Comorbidities

Experienced CBT-I providers can tailor CBT-I for patients with complex presentations such as: A history of alcohol and drug abuse (but are not

currently abusing) Comorbid psychiatric or medical conditions,

even those known to impact sleepFor example, bipolar disorder, pain conditions,

and seizure disorder Comorbid sleep disorders such as sleep apnea

Contraindications

CBT-I is NOT indicated when patient: Does not meets criteria for insomnia

disorder (e.g., inadequate time allowed for sleep, shift work disorder)

Is engaged in exposure therapy for PTSD Is working night or rotating shifts

CBT-I Referral Sources

American Board of Sleep Medicine http://www.absm.org/BSMSpecialists.aspx

Society of Behavioral Sleep Medicine http://www.behavioralsleep.org/FindSpecialist.aspx

American Academy of Sleep Medicine http://www.aasmnet.org/

National Sleep Foundation http://sleepfoundation.org/find-sleep-professional

VA CBT-I Resources

CBT-I Sharepoint (only accessible by VA providers) https://

vaww.portal.va.gov/sites/omhs/cbt_insomnia/default.aspx

VA CBT-I provider list

CBT-I patient brochures

CBT-I Clinician Factsheet

Questions?