CBT for Insomnia: Past, Present, and Future Directions J. Todd Arnedt, Ph.D. Associate Professor of Psychiatry and Neurology Director, Behavioral Sleep Medicine Program Acting Director, Sleep and Circadian Research Laboratory University of Michigan Medical School
X Conflict of Interest Disclosures for Speakers 1. I do not have any relationships with any entities producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients, OR 2. I have the following relationships with entities producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Type of Potential Conflict Details of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
Learning Objectives 1. Understand rationale, indications, and current best practices for CBT for insomnia. 2. Learn research evidence supporting CBT for insomnia as a first-line treatment 3. Learn about recent research that may impact future clinical care: How? What? To Whom?
Treatment options for insomnia Prescription medications: o Benzodiazepine receptor agonists (BzRAs): zolpidem (Ambien)*, zolpidem tartrate (Intermezzo)*, eszopiclone (Lunesta)*, zaleplon (Sonata)* o Antidepressants: doxepin (Silenor)*, trazodone (Desyrel), mirtazepine (Remeron) o Anticonvulsants: gabapentin (Neurontin) o Antipsychotics: quetiapine (Seroquel) o Melatonin receptor agonists (MelRAs): ramelteon (Rozerem)* Over-the-counter (non-prescription) agents: o Antihistamines: diphenhyramine (Sominex), doxylamine (Unisom) o Herbal remedies: melatonin, chamomile, valerian o Alcohol Non-medication treatments: o Cognitive Behavioral Treatment for Insomnia o Chronotherapeutics *FDA-approved for insomnia
CBT is a First-Line Treatment for Insomnia CBT and benzodiazepine receptor agonists have been shown to be beneficial in the acute management of chronic insomnia (NIH Consensus and State of the Science Statement, 2005) 1 CBT-based treatment packages for chronic insomnia including sleep restriction and stimulus control are effective and therefore should be offered to patients as a first-line treatment (British Association for Psychopharmacology Consensus Statement, 2010) 2 1 J Clin Sleep Med 2005;1(4):412-21; 2 Wilson SJ. J Psychopharmacol 2010;24:1577-601.
General Treatment Considerations: CBT for Insomnia Advantages Demonstrated efficacy Good durability of treatment gains Minimal side effects Increases patient selfefficacy Disadvantages Delayed gains Greater patient burden Close follow-up needed
INSOMNIA INTENSITY Model of Acute and Chronic Insomnia 100 80 60 THRESHOLD 40 PERPETUATING FACTORS 20 PRECIPITATING FACTORS 0 PRE-MORBID ACUTE INSOMNIA EARLY INSOMNIA CHRONIC INSOMNIA PREDISPOSING FACTORS Adapted from Spielman A. Psychiatr Clin North Am 1987; 10: 541-53
CBT Indications/Contraindications Indications: o o o Chronic insomnia symptoms ( 3 x/wk for 3 months) Poor sleep practices and/or excessive sleep focus/worry Medication tolerance, adverse side effects, or contraindication o Patient preference Contraindications: o o o o o Short-term insomnia Symptoms of circadian rhythm sleep wake disorder Certain medical/psychiatric conditions (e.g., seizure disorder, bipolar disorder) Unstable comorbid condition (e.g., depression, chronic pain) Patient preference
Cognitive Behavioral Therapy (CBT) for Insomnia: Treatment Components BEHAVIORAL Sleep Restriction Stimulus Control Relaxation TREATMENT TARGETS Excessive time in bed Irregular sleep schedules Sleep incompatible activities Hyperarousal Adapted from Morin CM. COGNITIVE Beliefs/Attitudes TREATMENT TARGETS Unrealistic sleep expectations Misconceptions about sleep Sleep anticipatory anxiety Poor cognitive coping skills EDUCATIONAL Sleep Hygiene TREATMENT TARGETS Inadequate sleep hygiene
Stimulus Control Relaxation Specific Therapy CBT, with or without relaxation Multicomponent therapy (without cognitive therapy) Sleep Restriction Paradoxical Intention Biofeedback Sleep Hygiene Cognitive Therapy Existing Practice Parameters Morgenthaler T. Sleep 2006;29(11):1415-9. Level of Evidence STANDARD STANDARD STANDARD GUIDELINE GUIDELINE GUIDELINE GUIDELINE INSUFFICIENT EVIDENCE INSUFFICIENT EVIDENCE Standard: High degree of clinical certainty Guideline: Moderate degree of clinical certainty Option: Uncertain clinical use
University of Michigan CBT Treatment Session Protocol Core Content 0 Treatment Overview Sleep Diary Orientation 1 Sleep Restriction Therapy Stimulus Control Therapy 2 Sleep Hygiene Education 3 Cognitive Therapy 1 4 Cognitive Therapy 2 5 Adjunctive Strategies (e.g., Relaxation) 6 Sleep Maintenance Relapse Prevention
Clinical Case HPI: Med hx: 61 yo man with 33-year h/o nightly sleep onset and maintenance insomnia (TST 2-3 hrs/night); daytime fatigue and anxiety; worries about sleep; good sleep hygiene. high cholesterol, generalized chronic pain Psych hx: Sleep hx: Panic disorder without agoraphobia, MDD currently in treatment and improving No other sleep disorders (negative PSG); previous sleep hygiene intervention yielded temporary symptom improvement Psychosocial hx: married, retired professor, consultant 1 week/month Meds: Paxil 15 mg, Xanax.5 mg prn, previous trials of Serax, Valium, Doxepin, Chloral hydrate, Benadryl, Trazodone, Ambien, Lunesta
Clinical Case: Session 1 Summary Sleep Latency (SL; min) 60.0 Frequency of Night Awakenings (FNA) 3.4 Wake After Sleep Onset (WASO; min) 118.0 Early Morning Awakenings (EMA; min) 12.0 Total Sleep Time (hrs) 3.8 Sleep Efficiency (SE; %) 53.0 BL 1. SRT: TIB = 5.5 hours (12:00 am - 5:30 am) 2. Follow stimulus control procedures 3. Wind-down 30-60 minutes before bedtime
Clinical Case: Session 2 Summary BL Wk1 SL (min) 60.0 22.0 FNA 3.4 2.2 WASO (min) 118.0 59.0 EMA (min) 12.0 13.0 TST (hrs) 3.8 4.1 SE (%) 53.0 75.0 1. SRT: TIB = 5.8 hours (11:40 pm - 5:30 am) 2. Continue stimulus control and wind-down 3. S/H: regularize snack, enhance bedroom comfort and temp 4. Introduced cognitive therapy for insomnia
Clinical Case: Session 7 Summary BL Wk1 Wk3 Wk5 Wk7 SL (min) 60.0 22.0 25.0 27.0 20.0 FNA 3.4 2.2 2 1.6 1.5 WASO (min) 118.0 59.0 42.0 31.0 31.0 EMA (min) 12.0 13.0 6.0 15.0 8.6 TST (hrs) 3.8 4.1 4.7 4.5 5.5 SE (%) 53.0 75.0 80.0 75.0 85.0 1. Continue extending sleep schedule if desired 2. Follow sleep maintenance procedures 3. Consider discontinuing Xanax entirely
Efficacy of CBT: Meta-Analyses Sleep Parameter Morin et al. (1994) Murtagh & Greenwood (1995) Smith et al. (2002) Sleep Latency 0.88 0.87 1.05 Wake after Sleep Onset 0.65-1.03 Number of Awakenings 0.53 0.63 0.83 Total Sleep Time 0.42 0.49 0.46 Sleep Quality - 0.94 1.44 Morin CM et al., Am J Psychiatry 1994;151:1172-80. Murtagh DRR & Greenwood KM, JCCP 1995; 63:79-89. Smith MT et al., Am J Psychiatry 2002;159:5-11. 80 th percentile 70 th percentile
% patients achieving remission Efficacy of CBT comorbid with mental disorders 30 patients with co-morbid insomnia and MDD received 12 weeks of escitalopram with 7 weeks of individual CBT-I or behavioral placebo 75 60 p=0.05 CBT-I Placebo 62 p=0.13 45 50 30 33 15 0 8 Insomnia MDD Manber R. Sleep 2008;31(4):489-95.
Total Wake Time (min) 200 150 100 CBT vs. Pharmacotherapy: Direct comparison 46 older adults with chronic insomnia randomized to 6 weeks of CBT, zopiclone, or placebo * * * Pre-tx Post-tx (6 wks) 6 mos f/u 50 *p<.001 0 Placebo CBT Zopiclone 7.5 mg Sivertsen B. JAMA 2006;295:2851-8.
% Change from Pre-treatment Long-term Efficacy of CBT 30 24 Month Follow-Up 20 10 0-10 -20 Wake after sleep onset Total sleep time Sleep efficiency -30-40 CBT Medication (temazepam) Morin CM. JAMA 1999;281:991-9.
Clinical Case: 8-week Follow-up BL Wk1 Wk3 Wk5 Wk7 Wk15 SL (min) 60.0 22.0 25.0 27.0 20.0 20.0 FNA 3.4 2.2 2 1.6 1.5 1.5 WASO (min) 118.0 59.0 42.0 31.0 31.0 29.0 EMA (min) 12.0 13.0 6.0 15.0 8.6 3 TST (hrs) 3.8 4.1 4.7 4.5 5.5 6.5 SE (%) 53.0 75.0 80.0 75.0 85.0 87.0
Future of CBT for Insomnia
Stepped Care Model of Insomnia www.sleepwa.com.au; Adapted from Espie CA. Sleep 2009; 32(12):1549-58
Self-Help CBT: Meta-Analysis OR=2.61 Cohen s d SE = 0.80; Cohen s d SL =0.66; Cohen s d WASO=0.55 Ho FY-Y. Sleep Med Rev 2015;19:17-28.
ISI Score Sleep Efficiency (%) Format: Internet-Based CBT 20 Baseline Post-tx 6-mo f/u 100 Baseline Post-tx 8-wk f/u 16 90 12 8 4 80 70 60 0 50 N=45 SHUTi WLC N=164 ecbt IRT Ritterband LM. Arch Gen Psychiatry 2009;66(7):692-8; Espie CA. Sleep 2012;35(6):769-81.
Scale Score National Dissemination of CBT for Insomnia in Veterans 30 Baseline Post-tx 102 VA Mental Health Providers 21 Social Workers 74 Psychologists 25 20 15 d=2.2 N=182 d=0.6 2 Psychiatrists 5 Nurses 10 5 0 ISI BDI-II *60% had decrease 8 points on ISI Karlin BE. J Consult Clin Psychol 2013;81(5):912-7.
% participants Brief Behavioral Treatment in Older Adults with Insomnia 79 older adults with chronic insomnia received 2 sessions of Brief Behavioral Treatment of Insomnia (BBTI) or Information Control (IC) 70 60 50 X 2 =16.9, p<.001 BBTI IC 40 30 20 10 0 Remission Response Partial Response No Response Buysse DJ. Arch Intern Med 2011;171(10):887-895.
% Responders (ISI change 8 points) Dismantling CBT for Insomnia Treatment Components 188 adults with chronic insomnia received 8 weekly individual sessions of CBT, BT, or CT with 6-month follow-up 100 80 60 OR=2.8 OR=2.8 OR=2.6 CBT BT CT OR=2.1 40 20 0 Post-treatment 6-mos f/u Harvey AG. J Consult Clin Psychol 2014;82(4):670-83.
% patients achieving remission Combination Therapy: Maintenance treatment 160 chronic insomnia patients received 6 weeks of acute treatment and then no vs. monthly (CBT-I group) or prn vs. taper (CBT/zolpidem) 100 80 CBT - none CBT - monthly Comb - prn Comb - taper Overall remission rates after follow-up: 43% (CBT-I alone) vs. 56% (CBT-I + zolpidem) 60 40 20 44 60 57 42 42 38 42 68 0 6-mo f/u Morin CM. JAMA 2009;301(19):2005-15. 12-mo f/u
% participants 40 adults with acute insomnia (DSM-V insomnia disorder of <3 mos duration) received 1 60-70 minute session of CBT with 4-week follow-up 100 80 60 Indications: Acute Insomnia X 2 =8.6, p<.003 CBT X 2 =7.6, p<.01 Wait-list 40 20 0 Response (ISI <10) Remission (ISI <8) Ellis AG. Sleep 2015;38(6):971-8.
Indications: Side Effects 16 insomnia patients received 4 weeks of sleep restriction therapy (SRT) and were evaluated with performance testing (PVT) and polysomnography PVT Lapses Polysomnography Kyle SD. Sleep 2014;37(2):229-37.
Indications: At-Risk Insomnia Subgroups 1395 adults assessed at baseline for insomnia and objective sleep duration (with PSG) and followed up after 7.5 years for incident hypertension. Fernandez-Mendoza J. Hypertension 2012;60(4):929-35.
Summary and Conclusions CBT is a first-line treatment for chronic insomnia with a strong evidence base Emerging research findings will present opportunities and challenges to the clinical practice of CBT for insomnia Future research needed on utility of insomnia risk stratification, predictors of treatment response, efficacy of CBT for insomnia phenotypes, and benefits of increased CBT personalization