2016 PAS Conference Presentation

1. Cognitive Behavioral Therapy for Insomnia

2. Pharmacy Association of Saskatchewan
2016 Annual Conference
April 30 , 2016
AJ Rémillard and K. Jensen

3.  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

4.  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.

6.  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

7.  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

8.  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)

9.  sleep hygiene and bedroom environment
 stimulus control therapy
 sleep restriction therapy**
 cognitive restructuring
 relaxation techniques

10.  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

11.  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

12.  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

13.  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

14.  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

15.  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.”

16.  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

18.  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

19. 1. patient a candidate for CBT-I?
2. describe the program
3. 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

22.  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/d
ocuments/members/GeriRxFiles-Tapering-EXCERPT-
TwoPages.pdf
◦ Empower:
 http://archinte.jamanetwork.com/article.aspx?articleid
=1860498

23. 1. summarize information on sleep logs
◦ mismatch between TIB (time in bed) and TST (total
sleep time)
2. introduce behavioural model of insomnia
3. explain sleep restriction and stimulus
control
4. set sleep prescription based on TST
5. discuss strategies to stay awake before
bedtime, during time out of bed during the
night

24.  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

25. 1. review sleep log information at the
beginning of each session
2. assess treatment gains and compliance
3. determine if upward /downward titration is
warranted
4. introduce cognitive therapy, relaxation
techniques as needed
5. review sleep hygiene

26.  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

27.  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)

28. 1. 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

29.  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

30.  assess results from pilot
o patient outcomes
o pharmacist satisfaction
o 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 Health
o proposal to 3rd party payers
 CBT for other indications?
◦ weight loss
◦ chronic Pain
◦ other conditions