Upload
pasaskatchewan
View
735
Download
1
Embed Size (px)
Citation preview
Cognitive Behavioral Therapy for Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I)
Pharmacy Association of Saskatchewan2016 Annual Conference
April 30 , 2016AJ Rémillard and K. Jensen
common health problem affecting an estimated 3.3 million Canadians
often associated with medical &/or mental conditions. Becomes risk factor for the latter
defined as difficulty initiating sleep, maintaining sleep or early morning awakenings (or combinations) leading to impaired daytime functioning
chronic insomnia persists > 1 month
Insomnia Background
Predisposing factors◦ ↑risk factors: ↑age, female
Precipitating factors◦ events leading to insomnia: illness, job loss
Perpetuating factors◦ strategies used to cope with insomnia: sleeping in
Pavlovian factors◦ process of classical conditioning; promoting an
association of the bedroom with wakefulness performing stimulating activities- watching TV etc.
4P Model of Insomnia
is a psychotherapeutic method used to treat a variety of conditions: anxiety, depression, chronic pain, sleep…
focusses on addressing and re-structuring dysfunctional thoughts and behaviors that contribute to the perpetuation of these conditions
CBT-I is the first-line treatment recommendation for insomnia, with studies reporting it to be more effective than hypnotics in the long run
What is CBTi?
does not have the associated adverse effects and risk of tolerance & dependence that hypnotics do
is widely underutilized due to a lack of education, awareness, and trained providers
however recent research has investigated and proven the efficacy of the provision of CBT-I by non-sleep experts
CBTi
insomnia associated with an acute illness insomnia not likely the result of maladaptive
behaviors comorbid illness which interfere with the
CBTi steps (depression, pain) comorbid illness which can be aggravated
by CBTi steps (epilepsy, bipolar) uncontrolled or unstable comorbid illness
(medical &/or mental)
When is CBTi not recommended?
sleep hygiene and bedroom environment
stimulus control therapy
sleep restriction therapy**
cognitive restructuring
relaxation techniques
Components of CBTi
exercise routinely but not close to bedtime create a comfortable sleep environment
(temperature, loud noises, lighting) control use of alcohol, caffeine and nicotine avoid consuming large quantities of liquids
or meals late in the evening do something relaxing and enjoyable before
bedtime avoid daytime and long naps
Sleep Hygiene
re-associate your bedroom with feelings of sleepiness and avoid stimulating activities
establish regular times to wake up and go to sleep
if unable to fall asleep get up and got to another room. Stay up for 30, 60 or 120 minutes◦ want to minimize anger/anxiety of trying to fall asleep◦ leads to sleep loss; but will be captured in the sleep log
Stimulus Control Therapy
most important step in CBTi aim is to match total time spent in bed vs
actually sleeping in bed (sleep efficiency) this is done by increasing the pressure to
sleep through partial sleep deprivation◦ will lead to daytime sedation in acute phase of
therapy sleep logs are used to measure efficiency
◦ TIB – time in bed TST – total sleep time◦ WASO - wake after sleep onset SL –sleep
latency
Sleep Restriction
complete morning sleep log (assess previous nights sleep) & sleep hygiene log (captures lifestyle factors)
collect 1-2 weeks of data to determine TST set standard wake time
◦ ie. TST 6 h, want to wake at 7 AM would go to bed at 1 AM
calculate sleep efficiency (TST/TIB)◦ > .90 ↑ 15 m; .85-.90 keep the same; < .85 ↓15m
minimum 5 h; continue till patient feels rested
Sleep Logs
Cognitive therapy is based on the concept that:
◦ “thoughts cause feelings”
Beck identified the negative thoughts triad:
◦ “oneself - the world - the future”
minor component of CBTi and does not require formal training in CBT
useful for patients who are overly anxious and have unhealthy beliefs about sleep
eliminate or challenge disruptive/negative thoughts/emotions regarding sleep and effects of sleep loss & engage the patient in realistic expectation
Cognitive Re-structuring
goal is to identify, label (classify), reframe (challenge) and restructure (replace)
◦ “if I do not sleep tonight I will lose my job”
◦ Reframe Double standard technique:
“would you say this to same thing to someone else?” Reflection
“has this happened before and what was the outcome?”◦ Restructure
get them to rephrase “if I do not sleep tonight I will still do a good job.”
Negative Sleep Thought
diaphragmatic breathing◦ promotes relaxation and allows more oxygen thru
deeper breathing guide imagery
◦ imagine a place, event or thing that elicits feelings of relaxation
◦ based on theory that the mind and body are connected
progressive muscle relaxation◦ involves tightening then relaxing various muscles
throughout the body
Relaxation Techniques
CBT-I in Practice
Case example Mary Jones, 48 year old female insomnia for 20 years medical history: peri-menopausal symptoms medication profile:
◦ Alesse (EE 20 mcg, levonorgestrel 0.1 mg)◦ Zopiclone 3.75 mg HS
non-smoker, occasional glass or two of wine in evening, at a social event
married, two daughters - 21 and 18 years old, living at home, going to University
Session 11. patient a candidate for CBT-I? 2. describe the program3. patient willing to invest time and effort
needed for success?4. if on sleep medications, willing to stop the
medication?5. provide sleep logs, explain how to use
Sample Sleep Log
Sample Sleep Hygiene Log
ensure medication prescribed only for insomnia before tapering
contact physician for authorization suggestions for tapering regimen
◦ individualized, flexible, negotiate with patient◦ RxFiles:
http://www.rxfiles.ca.cyber.usask.ca/rxfiles/uploads/documents/members/GeriRxFiles-Tapering-EXCERPT-TwoPages.pdf
◦ Empower: http
://archinte.jamanetwork.com/article.aspx?articleid=1860498
Tapering sleep medication
Session 21. summarize information on sleep logs
◦ mismatch between TIB (time in bed) and TST (total sleep time)
2. introduce behavioural model of insomnia3. explain sleep restriction and stimulus
control4. set sleep prescription based on TST 5. discuss strategies to stay awake before
bedtime, during time out of bed during the night
MJ’s initial sleep log data Bedtime: between 9:00 and 11:00 PM Sleep Onset Latency (SOL): 60 min Wake After Sleep Onset (WASO): 90 min Time in Bed (TIB): 540 min (9 hrs) Total Sleep Time(TST)=TIB–(SOL+WASO)=390 min Sleep Efficiency = TST/TIB = 72 % Sleep prescription = 6.5 hours
◦ 12:30 AM to 7:00 AM
Sessions 3-5 (or more if needed)1. review sleep log information at the
beginning of each session2. assess treatment gains and compliance3. determine if upward /downward titration is
warranted4. introduce cognitive therapy, relaxation
techniques as needed5. review sleep hygiene
MJ’s sleep log data at session 3 Bedtime: 12:30 AM 5 days; fell asleep early on
couch twice Sleep Onset Latency (SOL): 10 min Wake After Sleep Onset (WASO): 60 min Time in Bed (TIB): 410 min (6.8 hrs) Total Sleep Time(TST): 320 min (5.3 hrs)
TST = TIB – (SOL + WASO)
Sleep Efficiency = 78% SE = TST/TIB
MJ’s sleep log data - session 4 Bedtime: 12:30 AM Sleep Onset Latency(SOL): 6 min Wake After Sleep Onset(WASO): 30 min (no WASOs 3
nights) Time in Bed (TIB): 390 Total Sleep Time(TST): 365 min (~ 6 hrs)
TST = TIB – (SOL + WASO)
Sleep Efficiency = 90 % SE = TST/TIB
New Sleep prescription – 6.75 hrs (bedtime moved up 15 minutes to 12:15)
Last session1. review sleep log data (weekly values)
2. assess treatment gains
3. discuss relapse prevention• review behavioral perspective on insomnia• discuss the approach to maintaining gains
4. discuss what to do when insomnia returns
PharmaZzz project pilot project
◦ August 1st 2015 – July 31st, 2016
16 pharmacists◦ 13 community◦ 3 primary health care
workshop, training manual, tools for CBT-I
PharmaZzz Working Group: Fred Remillard, Karen Jensen, Loren Regier, Janelle Trifa
Future Directions assess results from pilot
o patient outcomeso pharmacist satisfactiono Barriers
larger study ?
open program to all interested healthcare professionals?
train all pharmacy students?
work on a payment for service?o proposal to Ministry of Healtho proposal to 3rd party payers
CBT for other indications?◦ weight loss ◦ chronic Pain◦ other conditions