Dr June Brown Senior Lecturer in Clinical Psychology Institute of Psychiatry

Dr June Brown Senior Lecturer in Clinical Psychology Institute of Psychiatry

Background to insomnia Design of study Methods Results Conclusions Where next?

Insomnia is the most common mental health symptom in the UK and its prevalence is increasing (Singleton et al 2001). Symptoms of insomnia affect at least one third of the population, with 5-10% within the clinical range (Stewart, et al., 2006; Morin et al, 2006b). As it increases with age (Ohayon, 2002) insomnia is diagnosable in 20-30% of older adults (Petit et al, 2003). Insomnia is often comorbid with depression and anxiety (Ohayon and Roth, 2003). It is strongly associated with an increased risk of depression, and increasing the risk two-fold (Baglioni et al 2011). Insomnia has also been found to predict relapse of depression (Ohayon and Roth, 2003).

Insomnia can be detrimental to quality of life, being associated with complaints of fatigue, impaired concentration and memory, difficulties with daily tasks and reduced enjoyment in social activities (Roth and Ancoli-Israel, 1999). The economic impact of insomnia is considerable, especially the costs of insomnia-related absenteeism and lower productivity (Metlaine et al 2005; Daley et al 2009). It has also led to increased health care utilisation (Simon et al 1997).

In the UK, it is clearly recommended that non-medical treatments, especially CBT for Insomnia (CBT-I) are considered before hypnotics for insomnia (National Institute for Clinical Excellence, 2004). The evidence for the efficacy of CBT-I is substantial, showing a reduction of insomnia symptoms and enduring benefits (Morin et al., 2006a). However, there are few available services (Lamberg, 2008) and few seek help (Morin et al., 2006b). Hypnotic prescription remains high (12million prescriptions per annum) and untreated people with insomnia may be exposed to further health risks (e.g. self-medication with alcohol). Because of the low awareness of, and the limited availability of CBT-I, which is usually offered on a 1:1 basis by a few specialists, there is a large unmet need for services.

A CBT-I programme based on Morin and Espie (2003) was adapted into a one-day workshop format It was specifically designed to improve capacity (up to 30 people per workshop) and give access to members of the general public (Brown et al, 1999). The workshops, delivered by clinical and counselling psychologists, used a self-referral system Promising results had previously been obtained in a pilot study (Archer et al 1999).

Can psycho-educational Insomnia workshops reach and help members of the public? June Brown, Rob Stewart, Jeni Beecham, Andiappan Manoharan and Colin Espie

The primary aim of this study was to evaluate the clinical effectiveness of these CBT-I workshops using an RCT design (with a waiting list control). A secondary aim was to attract at least 50% of people who had not previously sought help for their difficulties. Another secondary aim was to provide treatment with which participants would feel satisfied.

Participants who gave informed consent were randomly allocated to either an experimental group, where they received the CBT-I workshop soon after recruitment, or to a waiting list control group, where they received the same intervention, but three months later. Baseline measures were taken at recruitment and repeated three months later, after the experimental group had attended the workshop and just before the control group received their workshop. Baseline and follow-up measures in both groups were then compared.

Flyers advertising How to improve your sleeping workshops, were distributed in GP surgeries and posted through letterboxes throughout five London boroughs in South West London Telephone and e-mail contact details for the research worker were on the flyer. When contacted by interested participants, the research worker offered a time to attend an one hour-long introductory talk on two Sundays in November 2008. During the talks, the workshop programme and the study were explained, and people were given information sheets about the study. For those willing to participate, informed consent was obtained and baseline measures completed.

Inclusion/Exclusion criteria The aim of the study was to be as inclusive as possible to increase ecological validity. All individuals over age 18 and living in the five boroughs were included, providing they had the mental capacity to consent to the study and the ability to complete the assessment questionnaires. To make the workshops available to all those in the community who self-referred, participants were not required to be formally diagnosed with insomnia. Individuals were only excluded if undergoing concurrent psychological treatment for insomnia, as this was likely to be similar to the material in the workshop.

Insomnia Severity Index (ISI) (Bastien et al., 2001) This was the primary outcome measure. Total scores are categorised into no clinically significant insomnia (0-7), sub threshold insomnia (8-14), moderate clinical insomnia (15-21) and severe clinical insomnia (22-28). Sleep Diary (Morin and Espie, 2003) This is used to calculate average sleep efficiency (SE), sleep onset latency (SOL) and time spent awake after initial sleep onset (WASO) by recording participants sleep patterns over a week. Beck Depression Inventory (BDI) (Beck et al., 1961) The BDI is a well-validated and commonly used measure of depressive symptoms..

Demographics and treatment-seeking questionnaire This was used to collect demographic information and data on previous help-seeking. Client satisfaction Questionnaire (CSQ-8) (Attkisson 1987) This is an eight item scale which measures client satisfaction as a broad single construct. It was used to assess participants satisfaction with the service.

Session 1: Sleep Basics Education about the nature and science of sleep including; The 4 sleep stages and REM sleep Common contributors to sleep disturbance Addressing myths about sleep (e.g. everyone needs at least eight hours per night ) Session 2: Explanation of CBT-I model Explaining how thoughts, feelings and behaviour can be linked to make sense of poor sleep quality. Session 3: Sleep Hygiene Education Discussing habits and behaviours known to interfere with sleep and ways of reducing them. These may be lifestyle factors, such as caffeine, or bedroom factors, such as noise, and room temperature.

Session 4a: Sleep Restriction Teaching people a technique where the initial requirement is to restrict the time spent in bed to the average estimated time spend asleep each night, with the aim of bringing the total sleep time as close to the time spent in bed as possible. As this sleep efficiency improves, the time spent in bed can be increased accordingly. Session 4b: Stimulus Control Helping people to reduce the association between sleep incompatible behaviours and the bedroom. This involves limiting bedtime activities to sleeping and sex only, going to bed only when sleepy, getting up at the same time everyday, and leaving the bedroom and engaging in a relaxing activity if lying awake for 15 minutes or more, only.

Session 5: Sleep Cognitions Revisiting the cycle of thoughts, feelings and behaviours and learning how to challenge thoughts and irrational worries about sleep, and replace them with more adaptive thoughts. Also challenging other attitudes and beliefs about sleep that may be unhelpful. Session 6: Relaxation Techniques and Preparing for Sleep Learning to plan a bedtime wind-down routine, involving stopping work and other stimulating activities at least an hour before bed. Learning relaxation exercises and techniques which can be repeated at home before bed (A relaxation training CD was also made available to participants). Session 7: Overview and Action Planning Brief summary of content of the day s workshop, then opportunity to set goals to achieve over the following weeks and discuss these with workshop facilitators.

200 people self-referred to the introductory talk about the workshops 151 consented to take part and 75 were allocated to the experimental group and 76 were allocated to the control group. All had chronic insomnia (ie over 6 months) 112 (74.1%) people returned follow-up assessments, 49 in the experimental group, and 63 in the control

As efficacy studies of CBT-I have been conducted on people with clinical insomnia, I will only report on the 99 participants whose sleep efficiency was less than 85% at baseline, who could be termed as having clinical problems of insomnia. Of these, 72% were female and the mean age was 58 years. Over half (54.1%) had never consulted their GPs for their insomnia problems. 61.6% were experiencing some degree of depression (BDI scores over 9).

Of the 99 participants, 85 (85.9%) completed follow-up assessments. The workshops were found to be effective in reducing insomnia, with a significant decrease in ISI scores in the experimental group (p<0.001) but not the control group. Effect size was large (d=1.0) Significant changes were also found on the WASO (Time spent awake after initial sleep onset). Although mean BDI scores decreased in the experimental group, no significant changes were found.

Insomnia Index 10 12 14 16 18 20 Mean and 95% Confidence Interval for Insomnia Index Baseline Post-therapy Experimental Group Control Group

Satisfaction ratings with the workshops were very high, with 98% rating the quality as being good or excellent.

These self-referral CBT-I workshops did successfully attract participants with insomnia, over 50% of whom had not previously sought help from their GPs. They also seemed to lead to significant reductions in insomnia three months afterwards. Health economic benefits of the CBT-I workshops appear positive. A larger RCT needs to be carried out. Given the gap in services, the workshops may have the potential to meet the unmet need for services for people with insomnia problems given their ability to offer effective, accessible, and acceptable treatment.

4 year follow-up study, also looking at preventative aspects on depression St Thomas Sleep Clinic want these! Imparts?

Swift, N., Stewart, R., Andiappan, M., Smith, A., Espie, C.A. and Brown, J.S.L. (2012) The effectiveness of community day-long CBT-I workshops for participants with insomnia symptoms: a randomised controlled trial. Journal of Sleep Research. 21, 270-280.