Effects of CBT for Menopausal Insomnia on Depressive Symptoms
Cognitive Behavioral Therapy for Insomnia (CBT-I)
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Transcript of Cognitive Behavioral Therapy for Insomnia (CBT-I)
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?