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

Conflict of Interest Disclosures for Speakers

X 1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR

2. I have the following relationships with entities producing, marketing, re-selling, 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

1J Clin Sleep Med 2005;1(4):412-21;2Wilson 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 self-efficacy

Disadvantages

• Delayed gains

• Greater patient burden

• Close follow-up needed

THRESHOLD

0

20

40

60

80

100

PRE-MORBID ACUTEINSOMNIA

EARLYINSOMNIA

CHRONICINSOMNIA

INSO

MN

IA IN

TEN

SITY

PERPETUATING

FACTORS

PRECIPITATING

FACTORS

PREDISPOSING

FACTORS

Adapted from Spielman A. Psychiatr Clin North Am 1987; 10: 541-53

Model of Acute and Chronic Insomnia

CBT Indications/Contraindications

• Indications:

o Chronic insomnia symptoms (≥3 x/wk for ≥3 months)

o Poor sleep practices and/or excessive sleep focus/worry

o Medication tolerance, adverse side effects, or contraindication

o Patient preference

• Contraindications:

o Short-term insomnia

o Symptoms of circadian rhythm sleep wake disorder

o Certain medical/psychiatric conditions (e.g., seizure disorder, bipolar disorder)

o Unstable comorbid condition (e.g., depression, chronic pain)

o Patient preference

Cognitive Behavioral Therapy (CBT) for Insomnia: Treatment Components

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

BEHAVIORAL Sleep Restriction Stimulus Control

Relaxation

TREATMENT TARGETS Excessive time in bed

Irregular sleep schedules Sleep incompatible activities

Hyperarousal

Adapted from Morin CM.

Specific Therapy Level of Evidence

Stimulus Control STANDARD

Relaxation STANDARD

CBT, with or without relaxation STANDARD

Multicomponent therapy (without cognitive therapy)

GUIDELINE

Sleep Restriction GUIDELINE

Paradoxical Intention GUIDELINE

Biofeedback GUIDELINE

Sleep Hygiene INSUFFICIENT EVIDENCE

Cognitive Therapy INSUFFICIENT EVIDENCE

Existing Practice Parameters

Standard: High degree of clinical certainty Guideline: Moderate degree of clinical certainty Option: Uncertain clinical use

Morgenthaler T. Sleep 2006;29(11):1415-9.

University of Michigan CBT Treatment Protocol

Session 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: 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.

Med hx: high cholesterol, generalized chronic pain

Psych hx: Panic disorder without agoraphobia, MDD currently in treatment and improving

Sleep hx: 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 BL

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

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

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 2 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

Clinical Case: Session 7 Summary

Efficacy of CBT: Meta-Analyses

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.

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

¥ 80th percentile §70th percentile

50

62

8

33

0

15

30

45

60

75

Insomnia MDD

CBT-I

Placebo

% p

atie

nts

ach

ievi

ng

rem

issi

on

p=0.05

p=0.13

Manber R. Sleep 2008;31(4):489-95.

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

0

50

100

150

200

Placebo CBT Zopiclone 7.5 mg

Pre-tx

Post-tx (6 wks)

6 mos f/u* *

*

Tota

l Wak

e Ti

me

(min

)

*p<.001

CBT vs. Pharmacotherapy: Direct comparison

Sivertsen B. JAMA 2006;295:2851-8.

46 older adults with chronic insomnia randomized to 6 weeks of CBT, zopiclone, or placebo

-40

-30

-20

-10

0

10

20

30

% C

han

ge f

rom

Pre

-tre

atm

ent

CBT Medication(temazepam)

Wake after

sleep onset

Sleep

efficiency

Total

sleep time

Morin CM. JAMA 1999;281:991-9.

24 Month Follow-Up

Long-term Efficacy of CBT

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

Clinical Case: 8-week Follow-up

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

Ho FY-Y. Sleep Med Rev 2015;19:17-28.

OR=2.61

Cohen’s d SE = 0.80; Cohen’s d SL =0.66; Cohen’s d WASO=0.55

§Ritterband LM. Arch Gen Psychiatry 2009;66(7):692-8; ¥Espie CA. Sleep 2012;35(6):769-81.

Format: Internet-Based CBT

0

4

8

12

16

20

SHUTi WLC

Baseline Post-tx 6-mo f/u

ISI S

core

50

60

70

80

90

100

eCBT IRT

Baseline Post-tx 8-wk f/u

Slee

p E

ffic

ien

cy (

%)

N=45 N=164

§ ¥

National Dissemination of CBT for Insomnia in Veterans

102 VA Mental Health Providers

21 Social Workers

74 Psychologists

2 Psychiatrists

5 Nurses

Karlin BE. J Consult Clin Psychol 2013;81(5):912-7.

0

5

10

15

20

25

30

ISI BDI-II

Baseline Post-tx

Scal

e S

core

d=2.2

d=0.6

*60% had decrease ≥8 points on ISI

N=182

Buysse DJ. Arch Intern Med 2011;171(10):887-895.

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)

0

10

20

30

40

50

60

70

Remission Response Partial Response No Response

BBTI IC

% p

arti

cip

ants

X2=16.9, p<.001

Harvey AG. J Consult Clin Psychol 2014;82(4):670-83.

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

0

20

40

60

80

100

Post-treatment 6-mos f/u

CBT BT CT

% R

esp

on

der

s (I

SI c

han

ge ≥

8

po

ints

)

OR=2.8

OR=2.8 OR=2.6

OR=2.1

44 38

42 42

60

42

57

68

0

20

40

60

80

100

6-mo f/u 12-mo f/u

CBT - none CBT - monthly Comb - prn Comb - taper

% p

atie

nts

ach

ievi

ng

rem

issi

on

Morin CM. JAMA 2009;301(19):2005-15.

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)

Overall remission rates after follow-up:

43% (CBT-I alone) vs. 56% (CBT-I + zolpidem)

Ellis AG. Sleep 2015;38(6):971-8.

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

0

20

40

60

80

100

Response (ISI <10) Remission (ISI <8)

CBT Wait-list

% p

arti

cip

ants

Indications: Acute Insomnia

X2=8.6, p<.003 X2=7.6, p<.01

Indications: Side Effects

PVT Lapses Polysomnography

Kyle SD. Sleep 2014;37(2):229-37.

16 insomnia patients received 4 weeks of sleep restriction therapy (SRT) and were evaluated with performance testing (PVT) and polysomnography

Indications: At-Risk Insomnia Subgroups

Fernandez-Mendoza J. Hypertension 2012;60(4):929-35.

1395 adults assessed at baseline for insomnia and objective sleep duration (with PSG) and followed up after 7.5 years for incident hypertension.

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