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Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive Behavioral Therapy for Insomnia (CBT-I). Janet Constance, Ph.D. Components of this presentation were developed by a group of national VA CBT-I training consultants led by Elissa McCarthy, PhD and sponsored by Mental Health Services, VA Central Office

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Cognitive Behavioral Therapy for Insomnia (CBT-I)

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  1. Cognitive Behavioral Therapy for Insomnia (CBT-I) Janet Constance, Ph.D.

  2. Components of this presentation were developed by a group of national VA CBT-I training consultants led by Elissa McCarthy, PhD and sponsored by Mental Health Services, VA Central Office • Rachel Manber, PhD (Lead Developer of VA CBT-I Training Program) • Jason DeViva, PhD • Edward Haraburda, PhD • Christie Ulmer, PhD • Wendy Batdorf, PhD (VA CBT-I Program Coordinator) Acknowledgement

  3. Difficulty initiating sleep, difficulty maintaining sleep, or waking up too early • One or more is present at least 3 times a week, for at least 3 months • Poor sleep occurs despite adequate opportunity and circumstances for sleep • Poor sleep is associated with daytime impairment and distress What Is Insomnia Disorder?

  4. Insomnia Insomnia Threshold No Insomnia Premorbid Acute Chronic Insomnia Insomnia PrecipitatingFactors PerpetuatingFactors The Evolution of Insomnia PredisposingFactors Adapted from Spielman et al., 2000

  5. Conditioned Insomnia

  6. Approximately 10% - 15% of adults suffer from chronic insomnia • An additional 1/3 have transient or occasional insomnia • Approximately 40% of veterans seen by VA primary care • Approximately 19% of primary care patients in the general community Prevalence of Insomnia

  7. Insomnia is frequently comorbid with other medical and psychiatric disorders • Having another psychiatric disorder does not preclude diagnosis and treatment of insomnia disorder • Comorbid insomnia is often persistent • Unlike poor sleep, insomnia disorder does not spontaneously resolve even with successful treatment of a comorbid condition Medical and Psychiatric Comorbidity

  8. Associated with a variety of physical, cognitive, and emotional difficulties Disrupted sleep has been shown to reduce productivity, increase healthcare costs, and increase the risk of various medical and psychiatric disorders Poor sleep is associated with several medical conditions (e.g., hypertension, obesity, metabolic syndrome, type 2 diabetes mellitus, all-cause mortality) Personal and Societal Costs of Insomnia

  9. Comprehensive approach targeting factors that maintain insomnia Rooted in the science of sleep/wake regulation and principles of behavior change Skills-based & brief (4-8 sessions) Deliverable in individual or group format What is CBT-I?

  10. CBT-I Components

  11. Is effective among veterans and general population • 70% of patients experience full remission of insomnia or dramatic reduction in symptoms • Improves sleep initiation • Reduces time awake in the middle of the night • Recommended as a first-line of treatment of insomnia • Practice parameters published by the American Academy of Sleep Medicine • NIMH state of the science consensus statement CBT-I is Effective

  12. Comparative Efficacy: CBT-I for Sleep Onset Difficulties Jacobs et al., 2004

  13. 90 80 Comparative Efficacy: CBT-I for Sleep Maintenance Difficulties 70 60 CBTI (18) 50 Temazepam (20) Minutes awake after sleep onset 40 Combined (20) Placebo (20) 30 20 10 0 Baseline Post- 3Months 12 Months 24 months Treatment Follow-up Follow-up Follow-up Adapted from Morin et al., JAMA 1999

  14. Sleep Hygiene ≠ CBT-I

  15. No risk of drug interactions Minimizes risk for confused arousal upon awakening Benefits continue (and often increase) even after treatment is discontinued Brevity and effectiveness of approach Involves behavioral changes that improve quality of life in general such as winding down before bed Patients feel empowered by not relying on medication to sleep (increased self-efficacy) Reasons to Refer for CBT-I VA CBT for Insomnia Training Program

  16. Experienced CBT-I providers can tailor CBT-I for patients with complex presentations such as: • A history of alcohol and drug abuse (but are not currently abusing) • Comorbid psychiatric or medical conditions, even those known to impact sleep • For example, bipolar disorder, pain conditions, and seizure disorder • Comorbid sleep disorders such as sleep apnea CBT-IandComorbidities

  17. CBT-I is NOT indicated when patient: • Does not meets criteria for insomnia disorder (e.g., inadequate time allowed for sleep, shift work disorder) • Is engaged in exposure therapy for PTSD • Is working night or rotating shifts Contraindications

  18. American Board of Sleep Medicine • http://www.absm.org/BSMSpecialists.aspx • Society of Behavioral Sleep Medicine • http://www.behavioralsleep.org/FindSpecialist.aspx • American Academy of Sleep Medicine • http://www.aasmnet.org/ • National Sleep Foundation • http://sleepfoundation.org/find-sleep-professional CBT-I Referral Sources

  19. CBT-I Sharepoint (only accessible by VA providers) • https://vaww.portal.va.gov/sites/omhs/cbt_insomnia/default.aspx • VA CBT-I provider list • CBT-I patient brochures • CBT-I Clinician Factsheet VA CBT-I Resources

  20. Questions?

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