Computerized CBT for treating insomnia in a primary care setting Norah Vincent, Ph.D. Overview of Talk Insomni osts Treatments for insomnia Effectiveness Good candidates Impact on comorbid conditions Patient acceptance Delivery in primary care setting Abnormal Slee nsomnia Disorder Difficulty with falling asleep, staying asleep, awakening too early, or non-restorative sleep* Daytime impairment *Associated with twice as many healthcare visits relative to other symptoms Edinger et al. (2004). Research Diagnostic Criteria for Insomnia Disorder. Prevalence of Insomnia 40% difficulty sleeping 9% (US, NZ, UK, CD) 69% in primary care 19% Only 52% of patients discuss Focus Group Dat atient 16need to convince physician of seriousness open to behavioral treatment even if medication user Physician ssess underlying cause expect resistance to discontinuing with medications Management of insomnia Considered symptom rather than disorder "I didn't get a chance to ask him last night (one of those nights when we were both out and too tired to talk when we got home" (senior oncologist) " wasn't able to think of anything that fully fit the situation (mind you he's been pretty exhausted most of this week)" (radiologist) Costs of Insomnia Direct Treatments behavioral pharmacological transportation to health setting Costs of Disturbed Sleep Total direct costs of insomnia to USA $13.9 (1995) and $15.4 billion (1990) health care services $11.9 billion prescription medications $1.97 billion 20% of nursing home admissions are due to caregivers primary difficulty with elder's sleep27 27Sanford (1975). Br Med J 3, 471-473. Cost of Insomnia Membership of insurance plans in USA 138 829 adults with insomnia vs matched control sample Direct (outpatient, emergency, drugs) Indirect (absenteeism, short-term disability) Cost Study Conclusion 31Costs were $1253 greater for those with insomnia (6 month) Cost Study Members of insurance plan (150 000 covered) in mid-western USA 1254 with Insomnia diagnosis vs 1175 (randomly selected controls) Divided sample based on severity Insurance Stud osts of Insomnia Annual direct costs subthreshold $912 moderate/severe $125 no insomnia control $64 Costs were 75% larger for group with moderate/severe insomnia relative to controls Costs of Insomnia Physician consultation 10-12 per year (mild to moderate insomnia) vs 5 (good sleepers) Hospitalization rate 1.9% (severe) vs 12% (good sleepers) Costs of Insomnia Indirect Losses related to disorder Cognition Emotional regulation Quality of life Accidents Absenteeism (reduced earnings) Presenteeism (reduced advancement) Neuropsychological Consequences Neuropsychological Large impairments Fine motor coordination (ES = 1.2) Moderate impairments Executive functioning (ES = .73) Visual processing (ES = .55) No impairment General intellectual/verbal function Neuropsychological Consequences Restricting the sleep of healthy individuals to 4, 6, or 8 hours over a 2-week period leads t 20Costs of Disturbed Sleep Drowsy Driving Canadian study (2006) showing that 1.3 million fell asleep or nodded off while driving at least once in the past year3 Costs of Disturbed Sleep Absenteeism and Productivity - twice as likely to miss work (managers, women) -Insomnia predicts days sick leave (propsectively) Costs of Disturbed Sleep one week of poor sleep per month is associated with a 3-fold reduction in productivity at work (self-report) Costs of Disturbed Sleep Workplace Accidents National telephone survey of users of a healthplan Retrospective assessment of accidents costing >= $500 in the past year Insomnia verified by interviewer-administered questionnaire Costs-Accidents Average cost of insomnia related accidents or errors $32 000 vs $22 000 (other accidents) Lost Productivity Costs Lost Productivity (self-report) No insomnia 6.2 hrs/wk ($1035) Sub-threshold 8.5 hrs/wk ($1323) Moderate/severe 9.4 hrs/wk ($1554) Emotional Regulation increases responsiveness of the amygdala to negatively emotionally-toned stimuli22 22Walker et al. (2003). Current Biology, R877-8. Costs of Insomnia Costs of Insomnia Sleep Duration and Mortality Sleep duration < 6 hrs or > 7 hrs7 < 5 hrs or > 7 hrs* < 4 hrs or > 7 hrs Costs of Insomnia Medications that May Cause Insomnia Anti-hypertensives Beta Blockers Bronchodilators Corticosteroids Decongestants/antihistamines Certain antidepressants Thyroid hormones Gastrointestinal drugs Anti-epileptics Causes of Insomnia Cancer Parkinson's Disease Incontinence Gastroesophageal Reflux Chronic Obstructive Pulmonary Disease Sleep Disorders (RLS) Possible Causes of Insomnia Pain (arthritis, fibromyalgia, osteoporosis) Head injury Cystic fibrosis Thyroid disorder Chronic fatigue syndrome Diabetes Cardiovascular disease Psychiatric Disorders Stress Don't get caught up with causes Causes important but maintaining factors may be more important Treatment of Chronic Insomnia Cognitive Behavioral Model of Insomnia Gold Standard Treatment for Insomnia Sleep Restriction Therapy Stimulus Control Relaxation Training Cognitive Therapy (Sleep Hygiene) Behavioral Interventions Sleep Restriction Therapy Calculation of sleep window Setting of arousal time Time-limited Variable adherence6, Behavioral Intervention Stimulus Control Goal not a technique Involves sleep scheduling as a secondary element Behavioral Intervention Relaxation Therapies Abdominal breathing Progressive Muscle Relaxation Hypnosis Mindfulness Meditation Cognitive Intervention Identification and alteration Defusion from struggle of trying to sleep Worry scheduling Behavioral Intervention Sleep Hygiene Most talked about, least efficacious Effect Sizes for CBT-i Effectiveness of CBT-i Effectiveness persists up to 2 years Sleep duration shows least improvement Need more placebo-controlled studies CBT-i AASM conclusion Stimulus control Relaxation Sleep Restriction therapy Combination CBT-I Drug Treatmen ffectiveness of z-drugs Meta-analysis of 13 z-drug studies sent to FDA (Placebo) Small effect sizes (.30) SOL 7 minutes (22 minute G) Young females had best outcomes No other significant outcomes Large placebo effects Meta-analyses of Pharmacotherapy studies Benzodiazepines and z-drug oderate and equivalent effect sizes Adverse events, tolerance, rebound insomnia, abuse-dependency haven't been studied enough Pharmacotherapy vs CBT-i Meta-analysis of 5 trials comparing CBT-i to zopiclone, zolpidem, temazepam, triazolam Sleep diary, PSG/actigraphy CBT-I more effective at followup 30-45 min SOL 30-60 min TST SE 8-16% Is CBT-i Effective? Patients more satisfied with CBT-i than meds Impact of CBT-I on major depressive disorder Impact of CBT-I on anxiety disorders Lessens anxiety symptoms absenteeism suicide risk relapse rate Treatment of insomnia on anxiety disorders pharmacotherapy lessens anxiety symptoms Improves remission rates (63% vs 49%) Impact of CBT-I on chronic pain alertness executive functioning fatigue pain interference pain catastrophizing No change in pain severity Impact of CBT-I on diabetes Preliminary data from RCT Type 1 and 2 diabetes Web-based CBTi vs stress management Control Condition Impact of CBT-i on Fatigue and Sleep in Diabetes Impact of CBT-i on Coping in Diabetes Common Problems in Primary Care Who's a Candidate for Cognitive Behavioral Therapy? Primary or comorbid insomnia Sleep exceeds that which is normal Medication dependent Who's a Candidate for Cognitive Behavioral Therapy? Person who is very tired at bedtime, but wide awake in bed Sleep extending behaviors Hyper-aroused Who's Not a Candidate? epilepsy/seizure disorders Mania/psychosis fall risk (orthostatic hypotension) shift workers How can CBT-I be delivered in primary care? Telehealth Study RCT of 78 rural adults with chronic insomnia 6 weeks of CBT-i (telehealth) 6 weeks of CBT-i (web) 6 weeks of on-site group (urban) Sleep Efficiency Outcomes Sleep Quality Outcomes Daytime Fatigue Outcomes Patient Satisfaction with CBT-i Delivery in Primary Care Pilot study Brochures prepared for physicians detailing CBT-I Contact information for web-based service Once patient completes program, discharge summary back to physician Brochure Feedback from Physicians Interested in referring Liked potential to reduce prescribing of hypnotics Took no time from clinic Wanting advice on how to motivate patients to pursue This will help you to control the problem 80-90% improvement rates Conclusions Significant widespread healthcare problem Costly not to treat Current treatments are effective Frees up time in primary care END Randomized Controlled Trial 118 adults with primary (25%) or co-morbid insomnia (75%) Randomized to 5-week online program or to wait list Measurement at pre-test, post-test, and 4-6 week follow-up Participants' Ratings of Improvement Results Results Results Online Treatment version 2 Adherence Reinforcing response to submission of adherence Graph illustrating progress Re-ordering of modules Bedtime Calculator (sleep restriction) Addition of mindfulness meditation module More tailoring (Sneak Peak) Addition of blog Sleep Across the Lifespan Time to Fall Asleep Time Awake During the Night Abnormal Slee leep Apnea Repeated episodes of apnea and hypopnea during sleep (Apnea-hypopnea index >= 5/hr) Obstructive and central Evidence of disturbed/nonrestorative sleep Daytime sleepiness Abnormal Slee estless Legs Syndrome Unpleasant sensation in the legs at night or difficulty initiating sleep sensation of creeping inside the calves, crawling, burning, general aches and pain in legs Discomfort relieved by movements (irresistible urge) Abnormal Slee eriodic Limb Movement Repetitive stereotyped limb muscle movements, extension of big toe in combination with partial flexing of the ankle, knee, and sometimes hip (> 5/hour) Excessive daytime sleepiness Prevalence Insomnia disorder - 9.5% 1 Effect of disturbed sleep on hormones Reductions in glucose metabolism Leptin Increases in sympathetic nervous activity GH concentrations Cortisol insulin levels Ultimately reduction in insulin sensitivity Neuropsychological Consequences Sleep deprivation in healthy individuals may impai nique Features of Existing Sites Virtual token rewards for adherence Animation to identify poor sleep hygiene habits Automated reminders for adherence Sneak-peak questionnaires Graphs showing progress through site Access to adherence of others Mechanisms of Sleep Cycle Homeostasis -homeostatic drive for sleep accumulates during the day (adenosine) Concurrent Treatment Small study showed better results when CBT introduced first Vallieres, Morin, & Guay, 2006 Concurrent Treatment Results showed equivalent rates of response (60 vs 61%) and remission (39 vs 44%) after the 6-week treatment phase At the 2 year follow-up, high remission rate for combined therapy relative to CBT alone (57 vs 45%) Best for those who receive CBT alone during extended treatment phase Conclusio referable to discontinue with medications while patients are still receiving CBT, Morin et al. (2009). JAMA, 301, 2005-2015. Complementary Medicine Population-based Canadian study of 997 adults 2 with insomnia showed that 19% use complementary medicines (USA; 33%)2 Most common-chamomile, valerian, lemon balm, lavender, hops, magnesium2 Relative to those taking prescribed meds, users are younger, more educated females2 Sanchez-Ortuno et al. (2009). Sleep Medicine, 982-987.2 Chamomile Reputation for relaxing substance, facilitating2 sleep No data on efficacy2 Proposed that chamomile interacts 2 with anti-coagulant and anti-platelet drugs, benzodiazpines, and other drugs with sedative2 properties2 Brinker, F. (1998). Herb contraindications and drug interactions. Sand clectic Medical2 Publications Newall, C. A., Anderson, L. A., & Phillipson,2 J. D. (1996). Herbal medicine guide for healthcare professionals. London, U he2 Pharmaceutical Press. Valerian herb2 Systematic review of valerian herb ethanolic extraction 600mg2 Ineffective in improving sleep (subjective sleep quality)2 Side effects (dizziness, nausea, headache, fatigue)2 Not significantly different from placebo Fewer than with benzodiazepines2 Taibi, Landis, Petry, & Vitiello (2007). Sleep Medicine Reviews, 11, 209-230.2 Fernandez-San-Martin et al. (2010). Sleep Medicine, In press. Melatonin Systematic review of exogenous melatonin Dosage 1-6 mg Ineffective in improving sleep-onset latency and sleep efficiency in comorbid insomnia, jet lag, shiftwork Side effects (headaches, dizziness, nausea, drowsiness) Not significantly different from placebo Buscemi et al., (2006). Online Firs ritish Medical Journal, 1-9. Morbidity