CBT-I for insomnia

[thelastpsych]

I understand that CBT-I is the gold standard for insomnia, but in my area, very few professionals actually do it, some for a price that most of my patients can't pay. Now, I don't want to actually be a CBT-I trained professional myself, but I was wondering if there is any material that I can access that offers the gist of it or at least a few techniques that I can actually apply in my practice.
Thanks in advance!

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[WisNeuro]

While the sentiment is appreciated, half-assed CBT-I is probably worse than no CBT-I. This protocol is pretty intensive, relatively speaking, and requires pretty much total buy-in and effort from the patient and practitioner. If not done fully, pretty high chance of failure, in which case you have no turned some people off from CBT-I, and possibly CBT in the future.

Better yield would be sleep hygiene discussions. Sleep hygiene isn't that great for people with things like REM related parasomnias, or primary insomnia with already good sleep practices, but there are plenty of people for which their sleep hygiene is mostly contributory. Things like high amounts of caffeine close to bed, watching TV/tablet/phone right until bedtime, etc. More bang for your buck there.

As for CBT-I providers, check with your state psychology association. Many have practice listservs that they'd likely let you post on that you are seeking out referral sources for these services and woudl like to get contact info. You'd be surprised at how many providers there are that are not searchable through the internet all that easily that you instead need to find via networking.

 

[clausewitz2]

Better yield would be sleep hygiene discussions. Sleep hygiene doesn't great for people with things like REM related parasomnias, or primary insomnia with already good sleep practices, but there are plenty of people for which their sleep hygiene is mostly contributory. Things like high amounts of caffeine close to bed, watching TV/tablet/phone right until bedtime, etc. More bang for your buck there.

Unfortunately, while you are absolutely right about things that should in principle lead to improvements for people who actually do them, the evidence supporting the actual efficacy of sleep hygiene discussions in terms of actual difference it makes in sleep for patients is very poor. While implementing these things would be a good idea and probably be helpful, discussing them with people in a less formal way does not seem to lead to much change.

 

[Fan_of_Meehl]

I understand that CBT-I is the gold standard for insomnia, but in my area, very few professionals actually do it, some for a price that most of my patients can't pay. Now, I don't want to actually be a CBT-I trained professional myself, but I was wondering if there is any material that I can access that offers the gist of it or at least a few techniques that I can actually apply in my practice.
Thanks in advance!

If you want to do CBT-i, Oxford U. Press Treatments That Work series has therapist/client manuals of the protocol. Also the CBT-i Coach smartphone app is good. Of course, to use any of this competently, you need to be a trained/experienced cognitive behavioral psychotherapist.

If you want sleep hygiene psychoed instructuons, those are available via Google search, but I don't think there is robust evidence that psychoed alone is particularly effective

Edit: this is in NO WAY directed at the poster, but it does irritate me that (as a society) we have no problems with legal or medical specialists charging high rates for their services but, when you have a basically 95% effective psychotherapeutic tx protocol (like CBT-i), the notion of paying for (or funding) a pro to implement it seems odd, unjustifiable, or out of the ordinary.

 

[WisNeuro]

Unfortunately, while you are absolutely right about things that should in principle lead to improvements for people who actually do them, the evidence supporting the actual efficacy of sleep hygiene discussions in terms of actual difference it makes in sleep for patients is very poor. While implementing these things would be a good idea and probably be helpful, discussing them with people in a less formal way does not seem to lead to much change.

While I would agree in general, the literature is not that cut and dry. Many large scale studies do not rigorously exclude verifiable sleep disorders, with research suggesting that many people with undiagnosed sleep disorders (RBD, RLS, OSA etc) engage in poor sleep hygiene as coping mechanisms for the underlying disorder. Including these individuals is a huge confound. RLS prevalence is anywhere from 5-15%, OSA may be up to 26%, etc. There have been some dismantling type studies of components of sleep hygiene with more tightly regulated populations that were somewhat promising.

In short, the data are not all that unequivocal when you do a deep dive and understand the limitations. I'd want to do a decent job of ruling out medically related causes for sleep disruptions first, but I do think that sleep hygiene is helpful for certain subgroups.

 

[Fan_of_Meehl]

While I would agree in general, the literature is not that cut and dry. Many large scale studies do not rigorously exclude verifiable sleep disorders, with research suggesting that many people with undiagnosed sleep disorders (RBD, RLS, OSA etc) engage in poor sleep hygiene as coping mechanisms for the underlying disorder. Including these individuals is a huge confound. RLS prevalence is anywhere from 5-15%, OSA may be up to 26%, etc. There have been some dismantling type studies of components of sleep hygiene with more tightly regulated populations that were somewhat promising.

In short, the data are not all that unequivocal when you do a deep dive and understand the limitations. I'd want to do a decent job of ruling out medically related causes for sleep disruptions first, but I do think that sleep hygiene is helpful for certain subgroups.

And just to amplify (and agree with) this...

If I have an individual client with horrible sleep habits and IF I can successfully get him to correct those habits, then it is likely that his sleep will improve.

 

[WisNeuro]

And just to amplify (and agree with) this...

If I have an individual client with horrible sleep habits and IF I can successfully get him to correct those habits, then it is likely that his sleep will improve.

Yeah, ruling other things out is the key do all teh sleep hygiene you want, but if someone has untreated OSA/RBD/RLS/etc, sleep hygiene is only going to lead to minimal improvements in sleep quality and daytime tiredness. A significant portion of my patients report that they have longstanding "insomnia." And when I talk to them and their spouse we suddenly find out that there is a lot of snoring, gasping for air, moving in sleep, etc. And, very few of these people have gotten a sleep evaluation, or even been referred to sleep medicine. And this is a service that is fairly easily available in this area, I can get most of my patients in within 2-3 months.

 

[Fan_of_Meehl]

Yeah, ruling other things out is the key do all teh sleep hygiene you want, but if someone has untreated OSA/RBD/RLS/etc, sleep hygiene is only going to lead to minimal improvements in sleep quality and daytime tiredness. A significant portion of my patients report that they have longstanding "insomnia." And when I talk to them and their spouse we suddenly find out that there is a lot of snoring, gasping for air, moving in sleep, etc. And, very few of these people have gotten a sleep evaluation, or even been referred to sleep medicine. And this is a service that is fairly easily available in this area, I can get most of my patients in within 2-3 months.

You are absolutely right, gotta rule these things in/out first.

 

[clausewitz2]

And just to amplify (and agree with) this...

If I have an individual client with horrible sleep habits and IF I can successfully get him to correct those habits, then it is likely that his sleep will improve.

Le bon Dieu, c'est dans le detail

 

[clausewitz2]

Yeah, ruling other things out is the key do all teh sleep hygiene you want, but if someone has untreated OSA/RBD/RLS/etc, sleep hygiene is only going to lead to minimal improvements in sleep quality and daytime tiredness. A significant portion of my patients report that they have longstanding "insomnia." And when I talk to them and their spouse we suddenly find out that there is a lot of snoring, gasping for air, moving in sleep, etc. And, very few of these people have gotten a sleep evaluation, or even been referred to sleep medicine. And this is a service that is fairly easily available in this area, I can get most of my patients in within 2-3 months.

Similarly to the availability of neuropsychological evaluation based on our past conversations in my area versus yours, your neck of the woods appears to be far more blessed with availability of these things. I would love to be able to consistently get someone seen by sleep medicine in two months.

 

[WisNeuro]

Similarly to the availability of neuropsychological evaluation based on our past conversations in my area versus yours, your neck of the woods appears to be far more blessed with availability of these things. I would love to be able to consistently get someone seen by sleep medicine in two months.

I'll definitely acknowledge that we're not the US norm here. I live in a state that is usually in the top 5/10 of most healthcare metrics, including access. Neuropsych testing can still be spotty, most of the healthcare systems are booking out about 9 months at the moment. Some of us PP folk are sitting at 2-3 months, but that's because some of us only work with a selective network of referral sources and purposely do not advertise our services.

 

[FlowRate]

I didn't see it mentioned yet--the VA has a pretty well done, free CBTI app CBT-i Coach One does not need to be a veteran to access the app.

Sleep hygiene handouts sometimes miss the most important "sleep hygiene" components of CBT-i:
* Don't get in bed until you're feeling sleepy. The exact time you go to bed is less important.
* Use the bed only for sleep or sex, not for TV, or worrying, or anything else.
* If it's been long enough that you're feeling frustrated or worried about not falling asleep, get out of bed and do something calming and low-stimulation like reading a book until you start to feel sleepy again.
* Set your alarm and intend to wake up and get out of bed at the exact same time, every single day, including weekends, even if you stay out late.
* Try your best to never nap at all, even if you're feeling very tired.

You'll want to feel fairly certain that the patient, as mentioned earlier, does not have another sleep disorder, especially OSA and narcolepsy/IH, before giving all of this advice.

The CBT-i stuff that I usually leave out from my short overview for patients is the stuff that's probably best done with an actual trained professional: the sleep log, sleep phase restriction (and related extensive psychoeducation on increasing sleep efficiency), and the more CBT components around correcting distorted sleep-related thoughts and perpetuating behaviors.

 

[Sushirolls]

I found a Sleep Medicine physician who does CBTi.
So nice and easy to simply refer.

Agree with sentiments of don't do half arsed CBTi.

 

[tr]

I've tried referring people to CBTi Coach and had very little success. It seems like the protocol is unpleasant and counterintuitive enough that most people won't do it without a live human being prodding them. I have pretty good success doing CBTi myself (I learned in residency with supervision) but I often don't have the available time to offer it to all my patients who actually need it.

I think it might be something that would actually be worth doing a training for if you are in a place where it is hard to access. It's actually pretty straightforward and also very time-limited compared to most other forms of therapy. I learned a six-week protocol but I've seen some places offer abbreviated two-week protocols (not sure they are quite as effective though). In practice I don't end up sticking strictly to the six week timespan, but most people do see quite a lot of improvement in about that period of time.

I actually feel like one of the most efficacious components of sleep hygiene is left out of almost all of the handouts that are easily discoverable on the internet. This is attention to the importance of light/dark exposure for the maintenance of circadian eurhythmia. Almost all of us in the developed world have some level of day/night cue inversion caused by staying indoors all day (and thus limiting or eliminating our exposure to sunlight) and then spending our evenings in front of a screen (which emits blue light that mimics the wavelengths of daylight and effectively suppresses melatonin). Many patients have never heard this before and often they report very significant improvements in sleep quality/duration just by paying attention to getting 15-30 minutes of outdoor time during the day and reducing or eliminating blue light exposure after sunset.

 

[FlowRate]

I think it might be something that would actually be worth doing a training for if you are in a place where it is hard to access. It's actually pretty straightforward and also very time-limited compared to most other forms of therapy. I learned a six-week protocol but I've seen some places offer abbreviated two-week protocols (not sure they are quite as effective though). In practice I don't end up sticking strictly to the six week timespan, but most people do see quite a lot of improvement in about that period of time.

I actually feel like one of the most efficacious components of sleep hygiene is left out of almost all of the handouts that are easily discoverable on the internet. This is attention to the importance of light/dark exposure for the maintenance of circadian eurhythmia. Almost all of us in the developed world have some level of day/night cue inversion caused by staying indoors all day (and thus limiting or eliminating our exposure to sunlight) and then spending our evenings in front of a screen (which emits blue light that mimics the wavelengths of daylight and effectively suppresses melatonin). Many patients have never heard this before and often they report very significant improvements in sleep quality/duration just by paying attention to getting 15-30 minutes of outdoor time during the day and reducing or eliminating blue light exposure after sunset.

Great points. I've unfortunately also not had great experience referring people to apps although with my patients it's usually that they don't even actually engage with the app in the first place, despite all the various ways I've tried to sell it. (We use MyStrength--also free through our insurance--which has really well done psychoed videos to go along with the more baseline content.)

Regarding protocol, just as another data point, we have a team that do CBT-i in group form and it's a 4-week protocol. When patients engage, it is very effective. Many patients don't want to make time for 4 daytime appointments. I don't know what it is about patients with insomnia but many of them complain about it, expect a med to fix everything, and put little effort into correcting the problem despite it being a huge focus of their general distress. (Not to over-generalize, but seems a VERY consistent trend--this is, after all, why many sleep med physicians refuse to see insomnia patients.)

About blue light, that's a great suggestion I had forgotten about as well. Plus a lot of computers/phones support an amber light / no blue light mode that you can put on a timer. (Historically ninite was an app you could download but windows and android do this natively now.)

 

[WisNeuro]

Great points. I've unfortunately also not had great experience referring people to apps although with my patients it's usually that they don't even actually engage with the app in the first place, despite all the various ways I've tried to sell it. (We use MyStrength--also free through our insurance--which has really well done psychoed videos to go along with the more baseline content.)

Regarding protocol, just as another data point, we have a team that do CBT-i in group form and it's a 4-week protocol. When patients engage, it is very effective. Many patients don't want to make time for 4 daytime appointments. I don't know what it is about patients with insomnia but many of them complain about it, expect a med to fix everything, and put little effort into correcting the problem despite it being a huge focus of their general distress. (Not to over-generalize, but seems a VERY consistent trend--this is, after all, why many sleep med physicians refuse to see insomnia patients.)

About blue light, that's a great suggestion I had forgotten about as well. Plus a lot of computers/phones support an amber light / no blue light mode that you can put on a timer. (Historically ninite was an app you could download but windows and android do this natively now.)

I would agree with this. I used to do CBT-I way back in the day at this point. When patients bought in, high chance of appreciable improvements. But just way too many people who will not even put 50% effort into this. Granted it's not "easy," but if you are telling me that sleep is the number one complaint you have, it affects multiple areas of your life, and it's been a problem for many years, why can't you engage in 6-8 standard appointments and a week of uncomfortable night and tired days for what has a high chance of long-term gain?

Same patients, been on sleep meds for 10-20 years, still reporting absolute crap sleep. "But, I can't stop taking ambien/xanax/etc, it's the only way I can sleep." Mfer, you literally just told me that you still only sleep 3-5 hours a night, which is where you were before going on the meds.

 

[Stagg737]

Better yield would be sleep hygiene discussions. Sleep hygiene doesn't great for people with things like REM related parasomnias, or primary insomnia with already good sleep practices, but there are plenty of people for which their sleep hygiene is mostly contributory. Things like high amounts of caffeine close to bed, watching TV/tablet/phone right until bedtime, etc. More bang for your buck there.

My anecdatal experience tends to actually line up better with the literature data in that most of my patients, even ones who we've ruled out other disorders in, benefit minimally from sleep hygiene education. I do notice an exception that patients who cut back on afternoon/evening caffeine do sometimes report significant improvements, but other aspects of it rarely seem to provide much benefit. The problem with sleep hygiene is actually making sure patients are practicing the recommendations as instructed as I have plenty of patients claim they're strictly following good sleep hygiene guidelines but still can't sleep.

I've tried referring people to CBTi Coach and had very little success. It seems like the protocol is unpleasant and counterintuitive enough that most people won't do it without a live human being prodding them. I have pretty good success doing CBTi myself (I learned in residency with supervision) but I often don't have the available time to offer it to all my patients who actually need it.

I've had mixed results with CBTi Coach. Most of the time there's little to no benefit, but I have had a few patients who said it "cured" them. Since it's free and fairly easy, I always provide a brief explanation of it as a resource when I'm directly treating insomnia. I also asked about it at APA a few years ago after listening to a sleep specialist talk and they confirmed there is some data for it and it's worth providing as a resources for patients who can't do formal CBTi. My experience seems to line up with his statements pretty well.

This is attention to the importance of light/dark exposure for the maintenance of circadian eurhythmia. Almost all of us in the developed world have some level of day/night cue inversion caused by staying indoors all day (and thus limiting or eliminating our exposure to sunlight) and then spending our evenings in front of a screen (which emits blue light that mimics the wavelengths of daylight and effectively suppresses melatonin). Many patients have never heard this before and often they report very significant improvements in sleep quality/duration just by paying attention to getting 15-30 minutes of outdoor time during the day and reducing or eliminating blue light exposure after sunset.

I also talk about this with patients a lot. I'm not a huge fan of the podcast as a whole, but the Huberman Lab Podcast's first 3-4 episodes are about sleep and one of them talks a lot about the neurobiology of light and our circadian and biological rhythms which is fantastic. I've actually found that for some people who can't get direct sunlight exposure in the morning recommending use of a light therapy lamp in the morning has helped them significantly with regulating their sleep. I don't regularly recommend it for insomnia, but for patients with depression and insomnia I've found it to be quite helpful for some.

 

[WisNeuro]

My anecdatal experience tends to actually line up better with the literature data in that most of my patients, even ones who we've ruled out other disorders in, benefit minimally from sleep hygiene education. I do notice an exception that patients who cut back on afternoon/evening caffeine do sometimes report significant improvements, but other aspects of it rarely seem to provide much benefit. The problem with sleep hygiene is actually making sure patients are practicing the recommendations as instructed as I have plenty of patients claim they're strictly following good sleep hygiene guidelines but still can't sleep.

In my experience, it's usually because the higher yield sleep hygiene issues are the least likely to be done. Things like exercise and diet. Time of caffeine consumption is also a higher yield piece, but so much easier to make a change.

 

[clausewitz2]

I would agree with this. I used to do CBT-I way back in the day at this point. When patients bought in, high chance of appreciable improvements. But just way too many people who will not even put 50% effort into this. Granted it's not "easy," but if you are telling me that sleep is the number one complaint you have, it affects multiple areas of your life, and it's been a problem for many years, why can't you engage in 6-8 standard appointments and a week of uncomfortable night and tired days for what has a high chance of long-term gain?

Same patients, been on sleep meds for 10-20 years, still reporting absolute crap sleep. "But, I can't stop taking ambien/xanax/etc, it's the only way I can sleep." Mfer, you literally just told me that you still only sleep 3-5 hours a night, which is where you were before going on the meds.

Until someone is willing to do at least a week's worth of sleep logging for me in a way that is not obviously hastily copy-pasted a few minutes prior to our appointment, the only thing I am going to discuss with primary insomnia people re: sleep is identifying the obstacles to completing the sleep diary and determining how they can be more successful in completing those sleep logs in the future. It is a very basic seriousness test.

EDIT: The big-deal academic sleep expert I trained with would just immediately send people back to the front desk to reschedule their appointments if they turned up without sleep logs. It's good to be king.

 

[Candidate2017]

Ain't no one got time for CBT-i, sleep logs, sleep hygiene, or pesky CPAPs. If my PCP can give me a shot for my weight, why can't you gimme a damn pill for my sleep! I can't believe I waited a month for this appointment just for you to talk to me for an hour, and you want to charge me a $25 co-pay and not give me Restoril or Ambien!

 

[clausewitz2]

Ain't no one got time for CBT-i, sleep logs, sleep hygiene, or pesky CPAPs. If my PCP can give me a shot for my weight, why can't you gimme a damn pill for my sleep! I can't believe I waited a month for this appointment just for you to talk to me for an hour, and you want to charge me a $25 co-pay and not give me Restoril or Ambien!

One signal benefit of working in OCD-land is that you end up working with a lot of extremely conscientious, perfectionistic people who go hard they agree to do something structured. You do then run into the problem of "no, actually, please don't include the seven extra categories of data that weren't on the sleep log but you thought was important and added on when you created your own customized webform for recording this."

 

[sloh]

One signal benefit of working in OCD-land is that you end up working with a lot of extremely conscientious, perfectionistic people who go hard they agree to do something structured. You do then run into the problem of "no, actually, please don't include the seven extra categories of data that weren't on the sleep log but you thought was important and added on when you created your own customized webform for recording this."

Haha OCD-land seems like the type that would easily succumb to orthosomnia.

https://deploymentpsych.org/blog/staff-perspective-why-we-don’t-recommend-wearable-sleep-trackers-assessment-and-treatment

 

[Celexa]

In addition to psycho education about light, I started asking patients about temperature. A shocking number of people turn out to sleep in overly warm rooms. I live in part of the country where (for now) most of the time it is cheaper to keep a room cool except for at the height of the summer. I can't say it's had a dramatic effect but it's pretty low hanging fruit to at least try.

 

[clausewitz2]

Haha OCD-land seems like the type that would easily succumb to orthosomnia.

https://deploymentpsych.org/blog/staff-perspective-why-we-don’t-recommend-wearable-sleep-trackers-assessment-and-treatment

Yes I have this conversation a lot as well. Dysfunctional beliefs about sleep definitely an issue in this population.