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CHEST 2023 On Demand Pass
Insomnia! What to Do if You Do Not Have a Sleep Ps ...
Insomnia! What to Do if You Do Not Have a Sleep Psychologist Available: A Case-Based Approach
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Alright, good morning everyone. Aloha and I hope you are enjoying your stay here in Hawaii. Thank you for joining us this morning and we're very excited to present our session to you all and hope that it ends up being helpful in your own clinical practices. Now what I'll do is I'll introduce our distinguished panel. So our first speaker is going to be Dr. Miriam Lewis, who is Professor of Medicine at the University of Florida in Jacksonville, where she's also the Director of the Sleep Center. And then within CHESS, she is FCCP and is the Chair of the Non-Respiratory Section of the CHESS Sleep Network. Our second speaker is going to be Dr. Kelly Barron, who is Professor in the Division of Public Health and the Department of Family and Preventive Medicine at the University of Utah. She is a CBT specialist and at the University of Utah, she's also the Director of the Behavioral Sleep Medicine Training Program and the Director of the Behavioral Sleep Medicine Lab, which is currently funded by several NIH R01 and R25 grants. And then my name is Paul Chung. I'm a clinical instructor at Northwestern University in Chicago. I'm also a T32 postdoc research fellow in the Center for Circadian and Sleep Medicine. I don't have any academic directorships, so I'll just say that I am a co-director and co-chair with my wife of our family. So there you go. So just before we get started, two additional logistical items I'd like to go through. First is that we ask that you save all your questions till the end, after all the speakers have given their talk. So we'll open up for till now for those questions. The second thing is that there will be some ARS, so audience response system questions that we can go through. So if you want to get your cell phone handy, now is the time. Okay. Now without further ado, we'll get started. Dr. Lewis? Good morning, everybody. Everybody's recovering from their jet lag? So I'm going to talk to you today about components of cognitive behavioral therapy for insomnia or CBTI. I have no relevant disclosures pertaining to this talk. So the objectives today are to really provide you a very brief overview of insomnia, as well as then go into detail about the different components or elements of CBTI and how you might be able to implement some of them in your practice. So insomnia is a common complaint. 30 to 50% of the population have insomnia symptoms. However, chronic insomnia occurs in 5 to 15% of the population. And as you all remember, it's much more common amongst women, those from a lower socioeconomic status as well as those with comorbid illnesses. Unfortunately, it's associated with significant morbidities, including reduced quality of life and depression, as well as impaired functionality. As a matter of fact, 90% of insomnia-related healthcare costs are attributable to work absenteeism as well as reduced productivity. So to make a diagnosis of chronic insomnia, the International Classification of Sleep Disorder Third Edition stipulates that all of the following criteria must be met. First, there must be a complaint of difficulties with sleep. It could be initiation, maintenance, or both. Second, there has to be some kind of daytime impairment. That could be a change in cognition, mood, fatigue, et cetera. The patient must have had opportunities to sleep. The symptoms must occur at least three times per week for at least three months' duration, and the symptoms are not attributable to something else. Now, the proposed pathophysiology of insomnia is way beyond this talk, and it's really poorly understood. With that said, we know that there are some genetic vulnerabilities, that then you may have a precipitating event or stressor with some moderators, which then leads to abnormalities in neurobiological processes. That can then lead to neurophysiological hyperarousal stage, which then have a bidirectional relationship with some psychological as well as some behavioral processes, which then can lead to insomnia and continue to worsen the insomnia. CPTI really aims to address some of these psychological and behavioral processes and tries to modify them so that we can stop, if you will, or ameliorate the insomnia. So what is CPTI? It's a multi-component treatment over several weeks' duration, typically four to eight sessions, that targets behavioral, cognitive, as well as physiological factors, which perpetuate the insomnia. It aims to modify and alter maladaptive behaviors, as well as the distorted beliefs that patients may have about their sleep and insomnia, and it can be delivered in different formats. It could be face-to-face, it could be individual, it could be group therapy, it could be guided or unguided digitally delivered self-help formats. Regardless of the format, CPTI really should be provided and supervised by a trained CPTI therapist, which for most of us who do sleep medicine, we're not actually trained in CPTI and we don't have a certificate in it. So here's what a typical session-by-session outline would look like. First week is an assessment, an introduction, followed by several weeks where the different components and elements of CPTI are integrated, and then typically ending with a relapse prevention session. So CPTI is recommended as first-line non-pharmacological treatment of chronic insomnia by several societies, including the American Academy of Sleep Medicine, as well as the American College of Physicians. And why is it first-line? Simply put, it's very efficacious. Both short-term trials, lasting less than 12 months, and long-term trials have found that CPTI alone, or CPTI in combination with pharmacotherapy, were superior than pharmacotherapy alone. In 1999, Morn and his group found that following CPTI, 50% of patients achieved clinically meaningful outcomes, and that 30% actually became good sleepers. And then in a more recent meta-analysis that included 4,000 patients in 2021, similar numbers were reported. So if it's great, why don't we offer more of it, or why can't we get it to our patients? The issue is access. Access to CPTI remains very limited, and there's a number of reasons why this is. First and foremost is there's just a lack of certified therapists in the country. Second, even if you have access to a CPTI therapist, sometimes insurance doesn't cover it. And for example, where I work, which is a safety-net hospital, patients take public transportation, and so transportation may be an issue, or time commitment. So there's many reasons why full-component CPTI may be difficult for you to offer for your patients. So if you can't offer it to your patients, what, if any, of these elements can you in your practice do to help your patients? And so to help address this question, the ASM recently published two papers on CPTI in 2021. The first was a systemic review meta-analysis as well as a grade assessment, which then led to the publication of a clinical practice guideline addressing behavioral and psychological treatment for chronic insomnia. And I'm going to be referring to these two papers frequently throughout the rest of this talk. So depending on who you ask, there are between four to five essential elements or components of CPTI. These are the core elements. And they include sleep consolidation or restriction, stimulus control, relaxation techniques, cognitive therapy or restructuring, as well as sleep hygiene. Different protocols will incorporate different components of CPTI. So what I want to do today is review these five core components. So let's begin with sleep consolidation restriction. You all have our patients who spend 12 hours in bed because they fear the insomnia and they think that by staying 12 hours in bed they're going to sleep more. So what sleep consolidation or restriction aims to do is limit the amount of time in bed and addresses the perpetuating factors. It aims to increase the pressure or the drive to sleep. And how would you go about doing this in your practice? So based on a two-week sleep diary, total sleep time as well as sleep efficiency are calculated. If the sleep efficiency is less than 85%, then the total time in bed should be equal the number of hours of sleep that the patient thinks that they are getting, but never less than six hours. This is assuming that your patient is willing to commit to a consistent bedtime and rise time each morning and no napping. Now if the next visit, based on the sleep diaries, the sleep efficiency is improved above 90% and the patient is sleepy, then you know that the restriction is working and you can go ahead and increase time in bed, typically by 15-minute intervals. Conversely, if the sleep efficiency is still below 85% and the patient is not sleepy, then you would go ahead and decrease their sleep time, sorry, their time in bed by 15 minutes. On the other hand, if the sleep efficiency is in that sweet spot between 85% to 90%, you maintain the current sleep schedule. And so based on the evidence, the ASM has made a conditional recommendation for the use of sleep restriction therapy as a single component treatment for insomnia. Now there are some precautions when performing sleep restriction. Remember that there are certain patients in whom sleep deprivation may not be tolerated. These might be patients, for example, who have poorly controlled seizure disorder, those with bipolar disorders who have a history of manic episodes triggered by sleep loss. If you have a patient who's had a recent health change, surgery, illness, accident, et cetera. Somebody who's already sleepy throughout the day, for example, from untreated OSA. Or somebody in whom there is an unacceptable occupational risk as a result of increased sleepiness. So think of your patient who works as a truck driver and is part of the Department of Transportation. In those patients, you may want to consider something called sleep compression, which is the inverse of sleep restriction. So instead of initially restricting the number of hours in bed and then gradually increasing, you do the opposite. You give them a time in bed and then you start to slowly reduce the time in bed in 30-minute increments until the desired sleep efficiency is achieved. Okay, let's move on then to the second component, which is stimulus control. This was developed by Richard Bootson and its aim is to extinguish the negative associations between the bed and unwanted outcomes such as frustration, worry, and anxiety. And fortunately, these negative associations often become conditioned arousals to the bed and sleep. And so by using a very specific set of instructions, the aim of stimulus control is to restore positive associations to the bed and reestablish the bed and the bedroom as a discriminative stimuli for sleep. And here are those instructions. You all probably know them, but I'll repeat them anyways. Go to bed only when sleepy. Use the bed and bedroom only for sleep and sexual activity. If you are in bed and unable to sleep after approximately 20 to 30 minutes, get out of the bed and return only when sleepy. Get up at the same time every morning regardless of how much sleep you got the night before and no napping during the day. So based on the current evidence, the ASM has made a conditional recommendation for the use of stimulus control as a single component treatment for insomnia in your practice. All right. Let's move on then to relaxation techniques. These are structured methods or exercises whose aim is to reduce the arousals in bed. Some examples include abdominal or diaphragmatic breathing, progressive muscle relaxation, autogenic training, which I had to learn about because I don't do relaxation techniques. But these are essentially asking your patient to focus on different parts of the body and sensations such as warmth. It might also include some cognitive arousal training with guided imagery and meditation, and it may be combined with feedback. Based on the current evidence, the ASM has made a conditional recommendation for the use of relaxation therapy, if you are comfortable and trained to do them, as a single component treatment for insomnia. The fourth component, cognitive therapy or restructuring. Cognitive therapy addresses the idea that cognitive distortions or thoughts that the patient may have contribute to and sustain the unhealthy emotions and behaviors that the patients have regarding sleep and insomnia. Its aim is to correct the faulty expectations and false beliefs by psychoeducation, Socratic questioning, and thought records that interfere with sleep via three concepts. First is disputing dysfunctional beliefs. No, not everybody needs eight hours of sleep, right? Two, it's to de-escalate the catastrophe. If I don't get enough sleep, my day will be horrible. And three, using behavioral experiments to try to challenge some of these dysfunctional beliefs and catastrophic thoughts. So, for example, if your patient is worried they'll look horrible if they don't sleep enough, ask them to take daily selfies every day, right? And then you could compare. Actually you don't look as bad as you think you do, right? So, even though many of us do cognitive therapy to some degree for our insomnia patients, the ASM actually makes no recommendation for the use of cognitive therapy as a single component treatment for insomnia. It doesn't mean that you shouldn't combine it with a multi-component, but as a single component, there's no recommendation. There's just no data yet. All right. Finally, I'm going to move on to sleep hygiene. So, sleep hygiene's aim, if you will, is to promote healthy sleep, just like dental hygiene, we have sleep hygiene, right? It targets behavioral habits that negatively impact sleep. And you could find a set of do's and don'ts on any website or self-help app, right? Unfortunately, by itself, sleep hygiene is not an effective treatment for insomnia. The ASM actually recommends against the use of sleep hygiene as a single component treatment for insomnia. Once again, it doesn't mean you cannot use it as a multi-component, but if all you will be providing your patient is some sleep hygiene instructions, it's not going to be effective. Now, there are other recommendations that the ASM made in their publication, which are part of those core four or five elements of multi-component CBTI that I just mentioned. The first recommendation that the ASM made was a conditional one for the use of something called brief therapies for insomnia, or BTI. This is essentially an abbreviated version of a multi-component CBTI that usually lasts only one to four weeks, if you can, again, get it for your patient. There are other recommendations that they made for single component CBTI. The ASM makes no recommendation for the use of biofeedback. This is a variant of relaxation techniques that employs a device that provides the feedback to the patients. It also makes no recommendation on the use of paradoxical intention, which is something that we used to do a lot when I was a fellow many years ago, and that was asking the patient to remain awake as long as possible after going to bed. The ASM also makes no recommendation on something called intensive sleep training. This is something new, which is following a night of severe sleep restriction, the patient is provided an opportunity to sleep every 30 minutes in a laboratory setting, and if sleep does occur, they are awakened after three minutes and then asked to stay awake until the next trial. I think it's a little cruel, but... And finally, the ASM makes no recommendation on the use of mindful interventions, whether they're single or multi-component, and these include meditation and self-acceptance. In conclusion, multi-component CBTI is the most efficacious therapy for insomnia. However, depending on your patient and the circumstances of your practice, certain elements of CBTI may be considered and incorporated to help manage your patient's insomnia symptoms. There's currently ongoing research examining how to best deliver CBTI, either as multi-component or single-component, as well as what is the best format for delivering it, whether it's in person or via digital formats. And with that, I thank you for your attention, and I turn it over. Thank you so much, Dr. Lewis, and it is so meaningful to have physician colleagues who have such a good understanding of CBTI and the importance it is for our patients. My name is Kelly Barron. I'm a clinical psychologist and a sleep psychologist at University of Utah. I also conduct research in behavioral sleep medicine, and the title of my talk, from what I understood, was How to Do This Without Me, which is so kind of funny. But, I mean, the truth is that I've seen fellows go through for 20 years, and most of them go to a setting that they don't have one of me. And so, like, realistically, I can't even keep up with the demand. It's like saying, how do we treat hypertension? It is so prevalent in the population, and we need to have multiple modalities of doing this. And the psychologists, there just aren't enough of us. So, I plan to briefly go over CBTI, but I don't think I have to because we have that great background. But I'm going to talk about three different ways that you can deliver effective treatment. What's the data for that? What are the pros and cons? You can deliver this without having a psychologist in your clinic. And the disclaimer is that behavioral sleep medicine is a lot more than just insomnia treatment. We see patients with nightmares, hypersomnia, parasomnia, circadian disorders, PAP non-adherence, etc. And so insomnia is just one slice of it and one of the disclaimers of this literature is all these brief therapies, patients are screened for having insomnia and that are tracked in different treatments if they have these other disorders. So you know as you've just heard cognitive behavioral therapy for insomnia or CBTI is multi-component. It's brief, it's six to eight sessions. You know as a psychologist a lot of our treatments protocols are like 20 sessions. So six to eight that is like very fast for us. It's usually in about a three-month period. It's interactive and so it's not just giving out these recommendations, it's also having them come back in, talking about the troubleshooting, adjusting, and then setting them back out with the next layer. So I tell patients it's kind of a layered approach. Each time you come in we'll add a new piece. And then it's delivered by a trained professional. And so not every psychologist is trained to do CBTI. You know I wish it was in every grad school but it's not. And so that means that just because somebody says they're a psychologist or a social worker or a mental health counselor they're not going to necessarily be trained in these techniques. So they need to seek additional training outside of graduate school. And so as we were just reviewing earlier there's a strong recommendation for a multi-component CBTI and then conditional recommendations for things like brief therapies as well as single interventions. Okay so as you might know already sleep psychologists are relatively uncommon. This publication is a little bit old right now but you know even now California still has the highest number. At the time of the publication it had 57 sleep psychologists for the whole state that were registered in the Society of Behavioral Sleep Medicine. There's also a relatively greater number in the Mid-Atlantic region about like New York, New Jersey as well as Ohio and the upper Midwest. Thank you Chicago. I think there were about five of us in Chicago at that time when I was there. And then relatively underserved areas such as Kentucky and Tennessee. I currently am in Salt Lake City, Utah. The state of Utah at this time has five psychologists listed in the Behavioral Sleep Medicine directory. So for the whole state of Utah there is five of us. And then you can also see the representation across the world. Obviously many more certified in this technique in the in the U.S. and Canada compared to other countries. So what are you going to do if you don't have a psychologist? I'm going to talk about telehealth, abbreviated models, and digital therapies. So telehealth there's been really a revolution in psychology with this PSYPACT inter-jurisdictional certification process. So it started by like a work group in 2014 and in 2016 the first state joined this pact which was Arizona. And now there are 40 states. So I joined as a PSYPACT provider in 2020 where they they had a big push to get more people certified. And so like physicians and other other certified practitioners, psychologists have a state-by-state license. And so at this point there are 40 states that have agreed into this this this interstate agreement to provide telehealth. Which means that you can provide telehealth across state lines to other participating states. And so you know this has been amazing especially because you know in Utah we have a lot of people who might like be snowbirds go down to Arizona for the for the winter. But also people who drive in from relatively underserved states like Idaho, Wyoming. And I would like lose all my Wyoming patients every winter because they was just too dangerous for them to drive in. And so this has been great. But I'm looking at you Montana. We really need to get them because they're very underserved in mental health. But you can see this is really growing. And so now there there are approved ways to provide telehealth. And so this allows for the practitioner license in the state they're in to provide services across state lines to another participating state in telehealth. They also have another version where you can temporarily in-person provide services in that state. And that's presumably you know when people would move or during the pandemic or that sort of thing. So this so now that telehealth does open up the borders for more psychologists to participate across state lines. Is it equivalent? The data are good. This is a study from Gehrman in 2021. There were similar studies from Arnett and and also McCurry did this study in older adults with chronic pain. And what they found was that there was a similar decrease in the telephone CBTI compared to the in-person in their insomnia severity index. And it was much greater than just through a waitlist control group. And so telehealth can open up opportunities for providers. And there are several practices in the country that advertise certified providers that that will deliver telehealth across state lines. The pros of telehealth are that it's effective. It reduces barriers even without doing the video even just doing the phone. It reduces barriers of care and it is effective. But there's remaining challenges of finding a provider who's going to do it. And also you know personally completing sleep diaries over the phone can be hard because they have to somehow get them to you. So for patients who are less tech savvy who can't like send you an attachment or attach it in my my chart it can be challenging. But you know I'm willing to do anything. I have some patients that I'm just like okay read it off to me. Keep a notebook or you know like there's if there's a will there's a way. I had one patient who had learning disability, severe epilepsy, was blind, could only use one hand and she in in a wheelchair and she had a talking clock and she had a talking computer and she could keep a sleep diary. So where there's a will there's a way you can get around it. And about now I'd say about half of my patients are telehealth. You know we live in a pretty distributed area in the Mountain West and also the best thing about telehealth in sleep is if your patients have delayed sleep phase and they sleep in and miss their appointment you just call them and wake them up. It's great. Okay now I want to talk about abbreviated models and Dr. Lewis introduced this a bit before. So the things that there's been lots of different abbreviated models. There's been the probably the best known is by Dr. Bicey and colleagues BBTI. But there's also been some by Edinger and other like primary care version. And I'd say that the main components of them that there's fewer sessions usually about two to four sessions. They focus mostly on the behavioral components so they're not as much getting into the cognitive restructuring. That's more of a psychotherapeutic process. And they still require you know a trained provider at least one follow-up and use the sleep diaries. And these techniques and literature I'd say have mainly been used by nurse practitioners or nurses and in medical settings. So an example here is BBTI and this is a manual published by Troxel when she was with Bicey's group at Pittsburgh. So session one was 60 to 90 minutes and it involves education about the two process model of sleep behaviors that help sleep behaviors that interfere with sleep. And so that's essentially sleep hygiene. And then also how to complete a sleep log. And so this is you know getting to know the patient getting to know their goals. And 60 to 90 minutes if you think about in a medical setting is a pretty long time for a medical visit. But in that time they're meeting and they're going through a structured PowerPoint slides. And so it's a very reproducible method as well. Session two it's about 30 minutes and it involves reviewing the logs and then adjusting the sleep window and then troubleshooting the barriers to progress. And so and then it's followed up by two phone calls. And so patients are asked to continue doing the sleep diaries at one in three weeks after the second session. And so what I think really the beauty of the BBTI perspective is that it simplifies CBTI to these four rules. And sometimes I'll get only one session with a patient. Let's say they're going back to college or they're they're moving or they just don't have the time to come in or let's say they're pregnant they're going to deliver soon. So this is what it's reduced down to. Number one match the time you spend in bed to the time you spend asleep. Don't spend nine hours asleep six. This is sleep restriction in one sentence. Number two get up at the same time each day. Number three don't go to bed until sleepy. And number four don't stay in bed unless you're asleep. And that's essentially stimulus control. And so how did this do in the intervention. Well and this was older adults in primary care and they had many comorbidities. This was a very realistic sample that all had significant insomnia. And so 67 percent in the intervention group had a clinically defined response compared to 25 in the control group and information control. And then about half of them were considered to be a remission of their insomnia. So I would say almost as good as full on CBT. But this is two in-person sessions and two follow up phone calls. And there were no differential effects for subgroups about who was on antidepressants or hypnotics or had had depressed high depression scores or that sort of thing. So in summary for abbreviated models nearly as effective as a full successions delivered by a variety of clinicians mostly nurses or nurse practitioners. And then remaining challenges are you know first of all what I found in our practice is time and interest of participating clinicians. Some are really excited about it and some would not rather not deal with insomnia and refer it out. And then I think the biggest challenge for those in a medical practice who want to practice this is to have that 60 minute session or a 30 minute follow up is longer than many appointment times will allow in a lot of practices. And then to have them come back in one or two weeks. That's nearly impossible. I mean all my colleagues it's a three month follow up if you're lucky. And then and then participant patients or participants they still have to complete sleep diaries. Patients don't always like doing this but in order for these treatments to work they have to set a goal and follow it up on a sleep log and then have a clinician review that it has to have that accountability. And then last I want to talk about digital therapies and so there are so many out there. So I'll just talk about what's the evidence and what do I tell patients and colleagues that are interested in using these techniques. And so the bottom line is online CBTI is not inferior to face to face. These are non inferior inferiority trials meaning that it's not different. But in summary there's been many well designed trials and CBTI can be delivered through an online format and it's effective. It's significant for improving all of the variables that they looked at including insomnia severity index time to fall asleep wake after sleep onset etc. So people feel better about their sleep. They feel like they sleep more efficiently efficiently and about 50 55 percent again in this study also received remission status and 70 percent were deemed to be treatment respondents responders. So the treatment is quite effective. And so you can see this is the insomnia pointer. Let's see if I can. This is an insomnia baseline to one year follow up so long follow up in the online and then this is the control group. So a bit a big effect size and then a really cool follow up study. Ritter band and colleagues looked at their shut eye intervention and they took the analysis of those who were either prescribed it or paid for it online on their own. And this was over 7000 patients in real life. And what they found was that you know there was the percent of responders increased over time. And so out of those who completed the whole intervention 61 percent were considered treatment responders. So they had an improvement in their symptoms. But what's also important to understand is that only half of people who started the intervention finished it which is typical of a online intervention. And also the longer they persist in it the more improvement they have. And so the million dollar question and I have I have no financial conflict interest in this but which one should I choose. There are so many out there and you know it's a moving target. You know I mean for example some risk was the first digital therapeutic that was approved by the FDA and then they filed Chapter 11 were recently bought by Knox and will be available again. But you know these things are constantly moving. They're very expensive to keep up Sleepio for example a lot of research on that one. It's now paid by insurer or employer. It's also covered by the National Health Service. But look at the seat insomnia coach is a free app developed by the Center for PTSD. And that one is more individual and user friendly than like this this this or there's CBT I see it's CBT I coach which is a broader one insomnia coach is just the self self guided. So the CBT I coach the first one is like meant to be led by a clinician. This is a individual guided like standalone. But look at these other costers conquering and insomnia by Harvard. I just did a Google search and pulled these up. That one's 49 to 79 depending on how much back and forth email you want with the clinician. Stellar sleep is a more kind of tech savvy online interaction one that has a membership for three months and then do greet the reset by Duke that I couldn't figure out how much it costed without taking a survey which I didn't want to. And then some Lee. This is by Jack Anninger and colleagues and he's trained sleep coaches and this is the high price of 549 including consultation and feedback and it's a six week program. So there are all kinds of things and many of them are empirically supported. So I wouldn't necessarily suggest one urban over another but there is a free option. So that's that's a great great to know. So in terms of summary pros digital interventions are effective and they're preferred by some patients. Funny story when I left Northwestern to go to Rush they just gave out Sleepio for free during that time and patients by the time they get into a clinic sometimes they want a human. They don't want a computer. Some people want a computer and so it's important to know what who is your population what do they want. Remaining challenges are these platforms are expensive to maintain and update and so companies are going to ebb and flow. There's this prescription process for digital therapeutics which ultimately we hope will get it covered by insurance but that's a little bit cumbersome dropout is high. And so if you put a patient on this sort of treatment you should also follow up with them to see how it's going. Do they need to switch to another modality. And then some patients really want a human. They want they need the accountability. So a bit about our program and my last minute or so is there's two part time psychologists. My wait list is like a year long right now. I'm only there one day a week because I mostly research and then my colleague is there two days a week. So we don't we don't have enough demand even though we're psychologists in our clinic. So one of my colleagues has started primary care based CBT groups. She's a primary care psychologist. She's been to some trainings and she's trained and then also she has a lot of consultation and follow up. We're close friends so she's always messaging me or referring people if they've gone through her group and they need additional support. And then we're starting CBT groups in our sleep center and I'd really like to see this move into a step care model where everyone gets the basics gets a brief screening to the basics and then gets kind of funneled up the triangle to individual care. And so goals on our clinic for the future to move into a more step care model to do more training for APRNs and PAs and also have more like patient self help and video support. So just just really quick and a summary of how things are going in our primary care groups. This data is a little bit oldest from 2018. And so the CBT groups are well attended. They're always full and they're always they're always effective in most patients. And so in the most recent series in 2022 that we collected data there was a 83 percent completion rate of all five sessions. We cleared attendance of seven patients and it ranged from five to 12 patients and they're done totally over zoom which reduces some barriers. And then I also wanted to put up the billing data. So we are reimbursed for one hour of psychotherapy. One hundred forty nine one hour of health and behavior code which is a medical code and gets in. It gets it's more effective at billing some insurances like Medicaid. And you can see that it takes about five to seven group patients to equal one hour of the face to face time and so or telehealth time. So it's it's easily easily equal or better billing than doing that time in one on one. So I encourage you to seek additional training. There is the SPSM conference. CBTI web is a free online training and then there's always sessions and courses at the sleep 2024. So in summary you don't need a psychologist to do CBTI. You need training effective tools collaboration and the persistence and belief that you can do it and to follow through with patients. And then also keep in mind insomnia is not is only one of the disorders we treat which leads well into Paul's talk next. So thank you so much. And here's a beautiful picture of where I work at Salt Lake City Utah at the University of Utah Medical Campus. Thank you so much. All right. So actually that was a good segue into what I'm going to be talking about which is just trying to switch gears a little bit to give you some awareness of the other things that CBTI or CBT specialists can do. I have nothing to disclose but I do want to give many thanks and a shout out to Dr. Jennifer Mott who is our BSM specialist at our institution because she provided a lot of guidance as well as resources for me to do this talk. And then if you guys have your phones handy there's three cases that I'll go through. So you guys can use this QR code. All right. And here are the objectives. All right. So I think many of us many of you all know some of the evidence and practical ways to incorporate non pharmacologic care for the related issues that I've listed here. But from my own experience particularly before I went to fellowship during fellowship and even after fellowship I've seen that I didn't really know much else about the other CBT methods that can be utilized for specifically these three disorders that I will focus on for this final talk. And it's mainly to kind of increase awareness for some of the things that you can maybe use in your own practice but at least kind of encourage you to collaborate with and build a relationship with a CBT specialist in your locale. So this will be the first case 58 year old male no medical history coming in with what he's saying is insomnia. He's always been a bad sleeper waking up very frequently. But over the last year he's also started to have sleep onset issues. He feels tired and sleepy throughout the day and he saw his PCP order home sleep study sleep apnea is negative and he was prescribed clonazepam three milligrams. He doesn't really want to start the medication so it comes to you for a second opinion. These are his vitals point out the blood pressure and then he doesn't have any other significant findings on physical exam. As you talk to him more he actually starts telling you that he has nightmares and vivid dreams every single night and often they are waking up from sleep. And he also is starting to have difficulty going to sleep because he's kind of worried about what he's going to dream about. So what would you do next for this patient. Okay. All right. So I'm just going to go ahead. So the correct answer that I'm saying is A. So most of you got that. He already had a home sleep apnea test, and so we weren't really worried about doing another one. And then Prazosin, which I'll show you, has kind of fallen out of favor in terms of first line treatment. And also, I've noted that it also can cause orthostatic hyposensations. So he did have a much lower blood pressure than other people. All right. So it's shown there. So what is nightmare disorder? I think from the ICSD-3, really in a nutshell, it's a dysphoric dream that causes significant sleep disturbance as well as distress. And some of this you can see in daytime based on some of these things here. But more importantly, it's associated with increased anxiety, depression, and suicide, and it also causes additional insomnia as well as sleep disruption. In terms of quantifying it, the DSM-5 has noted that if you have more than one per week, it is considered clinically significant. So what's the prevalence? I found all kinds of numbers ranging between 2% to 10%, even higher in the psychiatric disorders that people may have. But one thing to note is that nightmares may be underreported in general. This study, what they did was they looked at two groups, a general population study as well as college-age students. And they found that it wasn't insignificant to find people who had at least severe to extremely severe problems or intensity for their nightmares. But less than 40% in the general population and just a little bit around 10% in the college-age group actually discussed this with their healthcare provider. In addition, a little less than a third of them actually felt that this was treatable. And what can we do for them? So recently, the ASM has changed their position such that image rehearsal therapy is actually now first line for PTSD-associated nightmares. But in addition, you can use cognitive behavior therapy as well as this ERRT, exposure, relaxation, and restricting therapy for PTSD-associated nightmares as well as general nightmare disorders. In regards to medications, so clonazepam and vanilfaxine are both not recommended for this for nightmare disorder. In addition, prazosin used to be kind of first-line therapy in terms of pharmacological management. And it was based on this study that had a small number, N of 10 for the control group and the prazosin group, that found a significant effect. But subsequent studies, particularly larger randomized control trials, hasn't found a significant effect for this, although you can still consider using it. I'm not saying that don't use it, but the evidence for it is not as great as we thought it used to be. So what about the IRT and ERT evidence? So both in PTSD and then also in some general nightmare disorder studies, they did find that it improved the nightmare frequency and the stress. But additionally, the secondary improvements also included decrease in suicidal ideation, improvements in insomnia, as well as certain sleep parameters. And then for PTSD patients, it actually improved a lot of their other symptoms, probably having an effect on their hyperarousal in general. So what is in IRT and ERT? So education, I want to highlight there, because that's something that all of us can definitely do. But then essentially, you're re-scripting the nightmare. And how or why is this working? The mechanism is thought to give back the patient a sense of control over their nightmares again. So they now have a sense of mastery that they haven't lost this time. So what can you do? So again, it's education. And then we kind of looked at some stimulus control things, as well as trying to educate people how to do a bedtime routine, which I've been finding is actually super helpful and something easy to implement for your patients. The other thing is, Dr. Barron has shown you about CBT-iWeb. There is a CBT nightmare web that's being currently developed. And as more and more evidence comes out with it, they will put it up soon. And that's the link. If you go there, that's literally what you'll see. So just wait till it actually comes out. All right, moving on to case two. So you have a 23-year-old female, narcolepsy with cataplexy. She's on Magsil, sorinephatol, and mixed salt oxybate twice nightly. She tells you that the cataplexy is fairly well controlled. She told me it was actually less than four times per week. But she's still sleepy. And she still has nightmares one or two times per week. She hasn't been able to tolerate any stimulants in the past. And she really doesn't want to use Pitocin because it messes with her OCP, which helps control her dysmenorrhea. And then she tried Prazosone in the past and got orthocyte hypertension from it. So she would like to discuss further management. So what would you do next? All right, so I will move forward. So the correct answer is adding scheduled MAPs and then referring for CPH. Both clomepramine and vermiflaxine can be used off label for cataplexy, but hers is fairly well controlled. And then changing the mixed salts twice daily to the long acting actually comes with some other problems that I don't have time to talk about. All right, in general, based on ASM guidelines, we are trying to affect these critical outcomes using medications. But for those of you who have taken care of narcolepsy or urtopathic hypersomnia patients, you'll note that a lot of them feel that even on two, three medications, that they still have a lot of residual sleepiness. Moreover, there are a ton of side effects. And then I think all of us can, unless you're an insurance company person, note that the annoyance level of insurance issues has gone up drastically. Moreover, people with central disorders of hypersomnia have a lot of other REM-related phenomena, as well as psychosocial aspects. So how can we manage or treat some of these things? A few years ago, this study was published. It was a pilot study using different components of CBT in order to help with hypersomnia. So it has been known as CBT hypersomnia or CBTH. Some of the components are shown here on the left side. And this was done over a six-week period. And you should note that a couple of things are things such as education, as well as structured daytime and nighttime activities. But this is the whole thing here. What they found was that it improved depression based on PHQ. And then particularly for those who had type 1 narcolepsy, as well as idiopathic hypersomnia, it improved sleepiness based on the ESS scores as well. Moreover, looking at the PROMIS measures, it helped to improve self-efficacy. And then in terms of how they did it, they used a telemedicine platform, as well as both individual and group platforms. And they found that it was highly acceptable with more than 90% of people actually completing the study. So then what can you think about or to do? So education is very important. The other thing that I've been really encouraging is actually for the patients to join support groups, which they've actually found super helpful. Moreover, scheduled naps is actually a recommendation in general. But sometimes people forget about this. So it's a powerful tool, especially for those who have narcolepsy type 1. And then some other things that you can do is like using strategy for managing sleep inertia in terms of when you give medications. And then of course, bright light therapy you can add as well. All right, and this is our final case. So 32-year-old male is coming to you with uncontrollable sleep eating. His bed partner with his phone has caught him eating while he's sleeping. And then a lot of times, he's woken up in the morning with empty wrappers and food containers in his pockets with crumbs all over himself. His bed partner cannot wake him up during his episodes. He's gained 25 pounds since this has happened. And they're particularly distressed because he started eating frozen food on his own. So he wants to discuss what he should do next with you. All right, so this is a little bit tricky. I don't know if I gave you enough information, but for this one I would say order an in-lab polysomnogram because you want to make sure you figure out if there's a precipitating factor to this before you refer to, before you provide multi-component CBT with hypnosis. All right, so what is non-REM parasomnia? It's a dissociated state between wake and non-REM sleep. The one that was presented here, sleep eating disorder, is actually a variant of sleepwalking. And then there's sleep terrors mainly seen in pediatric population, although you can see it in adults. And of course, confusion arousals. And I put sexomnia there because it is on our sleep board exams, although I still haven't yet seen it. But it does exist. In terms of pharmacological intervention, so we do have a medication that actually does work. However, it is, the evidence is based on large case series, case reports. So no real randomized control trials. Moreover, you do have to know that benzodiazepines in general can also precipitate non-REM parasomnia. So this is something that you have to monitor pretty well. What about data for non-pharmacologic methods? So this was a systematic review that looked at behavioral and psychosocial methods for treating non-REM parasomnias. And actually just recently published last month. And they found four things that were effective, including hypnosis, which I thought was kind of a hocus pocus. I watched a surgeon do it one time on an episode of House. But it actually works for non-REM parasomnias. And then of course, sleep hygiene, scheduled awakenings, and then multi-component CBT. So how does this work? I think the other speakers briefly mentioned the 3P model for insomnia. But there is also a 3P model for non-REM parasomnias, including predisposing vectors shown here, the priming factors and the precipitating factors that lead to these parasomnia episodes. And so the idea is to use CBT, different components of it, in order to treat some form of this. An example of this is based on a case series that was done to personalize CBT to help using these methods to help these specific patients with their non-REM parasomnias. Now the CBT small p is an actual randomized control trial that had a small number to it. And they're developing a larger one. So the components of this is still being worked out. But some of these things are listed there. So then what can you do? I think definitely, again, education and counseling. But also make sure to do safety precautions, which again is a recommendation. A lot of times I see providers just kind of list it on the instructions. But actually going through them is very helpful for the patients as well. And then as sleep providers, we definitely want to work on trying to eliminate any precipitating factors that may happen. And then I think when the trials come up, they'll be able to identify more things that you may want to learn in order to treat the non-REM parasomnias. And the last thing is just some evidence for some of the other things that I listed here that's out there. The one that I particularly am enjoying recently is this medication tapering. A lot of patients have been coming to me now to get tapered off their Xanax and things like that. So there's definitely evidence for doing that. And I've done it both by myself. And also working with a CVT specialist to help with their insomnia as well. And that's it. So thank you all for your attention.
Video Summary
The video features three speakers who discuss various aspects of cognitive behavioral therapy for different sleep disorders. Dr. Miriam Lewis discusses cognitive behavioral therapy for insomnia (CBTI), which aims to modify and alter maladaptive behaviors and distorted beliefs about sleep and insomnia. Dr. Kelly Barron explores how CBTI can be delivered without the need for a psychologist, including through telehealth, abbreviated models, and digital therapies. Dr. Paul Chung focuses on the use of CBT for nightmare disorder, non-REM parasomnias, and hypersomnia. He emphasizes the importance of education, behavioral interventions, and evidence-based treatments for these sleep disorders. The speakers provide information on the prevalence, diagnostic criteria, and recommended treatments for each sleep disorder. They also discuss the importance of collaboration between sleep specialists and CBT therapists to provide comprehensive care for patients with sleep disorders. Overall, the video provides an overview of CBTI and its applications for different sleep disorders, highlighting the importance of non-pharmacological approaches in sleep medicine.
Meta Tag
Category
Sleep Disorders
Session ID
1039
Speaker
Kelly Baron
Speaker
Paul Chung
Speaker
Mariam Louis
Track
Sleep Disorders
Keywords
cognitive behavioral therapy
sleep disorders
insomnia
CBTI
distorted beliefs
telehealth
digital therapies
nightmare disorder
non-REM parasomnias
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American College of Chest Physicians
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