Goals. Brief Behavioural Interventions for Insomnia. What is insomnia? RCPsych International Congress, London 2014

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1 Brief Behavioural Interventions for Insomnia RCPsych International Congress, London 2014 Dr David O Regan PhD MRCPsych, ST5 Higher Trainee Insomnia Clinic, Royal London Hospital for Integrated Medicine Goals To promote a practical understanding of insomnia. To demonstrate how to incorporate brief behavioural interventions for insomnia into our everyday practice. 2 What is insomnia? Difficulty in initiating or maintaining sleep, or having sleep of subjectively poor quality which leads to daytime symptoms. Short sleep in the absence of daytime symptoms is not insomnia. Not getting enough sleep due to reduced sleep opportunity is not insomnia. How tablets and phones before bed could lead to a stroke: Insomnia sufferers have higher risk than those who sleep soundly 18 to 34 year olds most effected April 2014 How insomnia can triple your risk of heart failure March 2013 Insomnia can double the risk of prostate cancer in men May Why insomnia can trigger arthritis November

2 Making the diagnosis Duration of symptoms Comprehensive sleep history. Use of rating scales i.e. Insomnia Severity Index and the Epworth Sleepiness Scale. Consideration of investigations e.g. blood investigations, actigraphy or PSG. 5 6 Duration of symptoms The numbers Diagnostic Manual ICD -10 (F51.0 Non Organic Insomnia) DSM V ICSD3 Duration 1 month (Symptoms at least 3 times per week) 1 month 3 months (Chronic Insomnia) UK prevalence of 1 in 10 adults. Prevalence estimates vary between 10-48% cost of sleep disorders in the UK was 5,630 million. Insomnia costs the US $63 billion/year. 7 References

3 How does insomnia develop? Insomnia Severity Insomnia Threshold Precipitating Perpetuating Predisposing No Insomnia Acute Insomnia Chronic Insomnia 9 The 3P Model of Insomnia adapted from reference 4 10 Mental illness and insomnia Moving away from primary & secondary insomnia. The vast majority of insomnia exists in a co-morbid state. Insomnia is a powerful risk factor for psychiatric illness. Patients with insomnia have worse clinical outcomes than those without. % Remission in MDD % Remission in Insomnia Independent treatment of insomnia can also improve the co-morbid psychiatric condition. 0 CBTI Sham 0 CBTI Sham e.g. References SLEEP 2008;31(4):

4 How do we treat this? Historically Cognitive Behavioural Therapy for Insomnia February Effective in about 80% patients. This includes insomnia comorbid with physical and psychiatric illnesses. Cheap groups of 5-6 over 5 sessions with 1 therapist. Reduces the amount of hypnotics needed leading to savings later on. Reduces the burden of insomnia on society. References

5 Evidence for brief behavioural interventions? Components of CBT-I Psycho-education Increasing intensity Individual Group 1-day workshop 2 x Session Telephone Stimulus Control Sleep Scheduling Sleep Hygiene Behavioural Therapies Self-help e.g. internet Delivery methods for CBTI Relaxation Cognitive Therapy e.g. References Stimulus Control Stimulus Control Video TV/Radio Computer Talking on phone Texting Exercise Eating Ironing Studying Paying bills Reading!! Meditating Arguing Etc, etc, etc Sleep Intimacy Getting Dressed 19 Goodnight Britain, clips from episodes 2&7, BBC

6 Sleep Scheduling an example Now he lies awake for 3 hours instead of 2!!!! Mr B goes to bed at 10pm sharp every night. He lies awake until 12am before falling asleep. He then drifts in and out of un-refreshing sleep for the rest of the night, before reluctantly dragging himself out of bed at 7am to go to work. In total he thinks he gets about 6 hours of sleep. In an attempt to get more sleep he starts going to bed at 9pm Sleep Scheduling Sleep Scheduling This strengthens the association between the bed and wakefulness. It confirms his inability to sleep. We therefore advise him to: Get up at the same time seven days a week. This anchors his circadian rhythm and allows him to accumulate adequate fatigue through the day. Or worse he may have little micro-sleeps which reduce his chance of getting good, consolidated sleep. So, If Mr B only sleeps 6 hours he should not be in bed for more than 6 hours. 23 He should not go to bed earlier than 6 hours before his rising time. Only once he has reached this threshold time AND he is sleepy should he go to bed. Once he is falling asleep quickly and his sleep fills up at least 90% of his time in bed, he can then move his threshold time backwards or his waking time later by 15 minutes. 24 6

7 Sleep Hygiene Do not chase sleep NOT effective as a mono-therapy. Many tenants are not tested. Best tailored to the individual. Sleep (is like) a dove which has landed near one s hand and stays there as long as one does not pay any attention to it; if one attempts to grab it, it quickly flies away 25 Viktor E. Frankl, Discourage napping If fatigue is the fuel that drives sleep, then every nap is like stealing some of that sleep fuel from the night. It is better to push through the sleepy periods during the day and save that fatigue for the night. Once their sleep improves it will be easier to avoid napping. A final few words of advice for your patients with insomnia Wake up at the same time EVERY day. Yes, even on weekends. Yes, even if you ve slept badly. Sticking to a constant bed time can be a very bad idea. Go to bed when, and only when, you feel sleepy tired. If you are not asleep in minutes get out of bed and out of the bedroom. 27 Use the extra time out of bed to do something relaxing and enjoyable. 28 7

8 Teach the mantra Thank you I am not doing this to sleep better tonight. I may actually sleep worse tonight. I am doing this to sleep better in a month References References II 1. Morphy H; Dunn KM; Lewis M et al. Epidemiology of Insomnia: a Longitudinal Study in a UK Population. SLEEP 2007;30(3): Fineberg N; Haddad PM; Carpenter L et al. The size, burden and cost of disorders of the brain in the UK Journal of Psychopharmacology 2013; 27(9): Kessler RC; Berglund PA; Coulouvrat C et al. Insomnia and the performance of US workers: results from the America Insomnia Survey. SLEEP 2011;34(9): Spielman AJ;Caruso LS; Glovinsky PB. A behavioural perspective on insomnia treatment. Psychiatr Clin North Am 1987;10(4): Taylor DJ, Mallory LJ, Lichstein KL, et al. Co-morbidity of chronic insomnia with medical problems. Sleep 2007;30(2): Ford DE; Kamerow DB. Epidemiological study of sleep disturbances and psychiatric disorders. J. Am. Med. Assoc. 1989; 262, Dew MA, Reynolds CF, Houck PR, et al. Temporal profiles of the course of depression during treatment. Predictors of path-ways toward recovery in the elderly. Arch Gen Psychiatry 1997;54: Thase ME, Buysse DJ, Frank E, et al. Which depressed patients will respond to interpersonal psychotherapy? The role of abnor-mal EEG sleep profiles. Am J Psychiatry 1997;154: Fava M; McCall WV; Krystal A, et al. Eszopiclone co-adminis-tered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biol Psychiatry 2006;59: Manber R, Bernert RA, Suh S, et al. CBT for insomnia in patient with high and low depressive symptoms severity: adherence and clinical outcomes. J Clin Sleep Med. 2011;7 (6): Watanabe N, Furukawa TA, Shimodera S, et al. Brief behavioral therapy for refractory insomnia in residual depression: an assessor-blind, randomized controlled trial. J Clin Psychiatry. 2011;72: Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioural treatment of insomnia: update of the recent evidence ( ). Sleep. 2006;29(11): Morin CM, Hauri PJ, Espie CA et al. Nonpharmacologic treatment of chronic insomnia. Sleep. 1999; 22: Mimeault V, Morin CM. Self-help treatment for insomnia: bibliotherapy with and without professional guidance. J Consult Clin Psychol. 1999; 67: Ritterband LM, Thorndike FP, Gonder-Frederick LA, et al. Efficacy of an internet-based behavioral intervention for adults with insomnia. Arch Gen Psychiatry. 2009; 66: Currie SR, Clark S, Hodgins DC, et al: Randomized controlled trial of brief cognitivebehavioural interventions for insomnia in recovering alcoholics. Addiction. 2004; 99: Bastien CH, Morin CM, Ouellet MC, et al. Cognitive-behavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations. J Consult Clin Psychol. 2004; 72: Swift N, Stewart R, Andiappan M, et al. The effectiveness of community day-long CBT-I workshops for participants with insomnia symptoms: a randomized controlled trial. J Sleep Res. 2012;21: