Jessica Salwen-Deremer, PhD, on Insomnia in IBD

Dr Salwen-Deremer discusses some findings of her research into insomnia and sleep disturbance in inflammatory bowel disease, and how cognitive behavioral therapy can help.

Jessica Salwen-Deremer, PhD, is an assistant professor of psychiatry and assistant professor of medicine at the Dartmouth-Hitchcock Medical Center and Geisel School of Medicine in Lebanon, New Hampshire.

TRANSCRIPT:

TRANSCRIPT:

Welcome to this podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca  Mashaw. Today I'll be talking with Dr. Jessica Salwen-Deremer, who is an assistant professor of psychiatry and assistant professor of medicine at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire. She specializes in working with patients with inflammatory bowel disease and recently had a paper published regarding chronic insomnia among these patients. Thanks for joining us today.

Dr. Jessica Salwen-Deremer:

Thank you. Happy to be here.

GLN:

You've done a lot of research into fatigue and sleep disruption among patients with IBD. What made you focus on this general topic to begin with?

Dr. Jessica Salwen-Deremer:

Yeah, it's a great question and there's a combination of factors here. One is that we know that folks with IBD are awake during the night more than the average person. And during a severe flare, people wake up with bowel movements and then along comes anxiety, as well, about how will tonight go? Am I going to need to change the sheets? Am I going to be up 6 times? And those situations kind of set people up for development of sleep problems, combined with the fact that insomnia is really treatable from a behavioral perspective. So having this clear problem and a clear treatment, I felt like we really needed to, as a field, kind of bring these two things together.

GLN:

Fatigue seems to be a very consistent issue among people with all different types of autoimmune illness, rheumatoid arthritis, lupus, scleroderma. In your work with patients with IBD, have you identified the factors that you think may cause or exacerbate fatigue in addition to what you just spoke about in terms of the impact of insomnia?

Dr. Jessica Salwen-Deremer:

Right, yeah. So there's all kinds of physiological and biological factors when someone comes in with fatigue. If their disease is well managed, then I imagine that the docs are looking for either doing all kinds of blood work and nutrition workups, that kind of thing. From a behavioral perspective, I'm thinking about things like anxiety, depression, and sleep disorders, all of which can result in fatigue.

GLN:

Your newest research paper specifically relates fatigue to chronic insomnia and the influence of pain in insomnia. What did you set out to investigate about this subject and what did you find?

Dr. Jessica Salwen-Deremer:

I set out to really investigate the cognitive and the behavioral factors that were involved in insomnia in IBD. In the general population, we understand that there's these cognitive, these thought patterns, that influence insomnia. Things like somebody who's watching the clock thinking, "Oh my gosh, I only have 4 more hours left in the night before I have to wake up. Oh no, I only have 3 more hours." It's a really common thing for folks with insomnia.

They're doing this clock watching that then increases arousal and makes it hard to sleep. All those worries about not sleeping, about not performing the next day. But there are some really clear disease-related factors that have to do with sleep in IBD. And so we wanted to know if we could make those same assumptions about what was going on, about how people were thinking or what they were doing.

In our general population, we see that people with insomnia do things like take naps more often. They may have variable bedtimes and wake times. They may do this thing where you have a bad night of sleep and so you get in bed really early just to rest, just to feel like you're catching up. Again, all of those are things that perpetuate insomnia in our general population but we wanted to investigate what happens in IBD.

GLN: And what did you find out?

Dr. Jessica Salwen-Deremer:

We found out that a lot of those same things still exist and a lot of them occur regardless of whether someone has active or inactive disease and across both ulcerative colitis and Crohn's disease. The only area we saw a little bit of a shift was in folks with active Crohn's disease. They're more likely to engage in these kind of pain-related behaviors. Like I took extra pain medication to help me sleep or I was in pain, so I spent several hours resting in bed during the day.

GLN: So is that a sleep-interfering behavior, when you have someone who is in pain and just stays there and tries to work through it rather than doing something else?

Dr. Jessica Salwen-Deremer:

This is really tricky because some of these sleep behaviors feel kind of adaptive. When you have a really severe flare, when you're in a lot of pain, all you want to do is lay down. And actually, I'm not telling patients don't lay down, don't rest. I'm telling them, if you're awake, don't do it in your bed. So lay down on the couch or a chair or somewhere else in your house because otherwise all of that anxiety and arousal and all those bad experiences that are tied up with the pain go live in your bed. And so when you get in bed, those are the things that your brain is associating with it.

GLN:

Interesting. You concluded that cognitive behavioral therapy, rather than some of the traditional sleep hygiene guidelines, are often more helpful for IBD patients with insomnia. Can you tell us a little more about that?

Dr. Jessica Salwen-Deremer:

Sleep hygiene, those things that you typically think of, like you mentioned, having your room cool, dark, and quiet, managing caffeine, nicotine, alcohol, how they influence your sleep schedule, having no screens in bed. Those are standard sleep hygiene recommendations and they are insufficient for insomnia treatment. In fact, researchers sometimes use a sleep hygiene condition of the control condition in a clinical trial because it looks good, looks like you're doing something, but we know it doesn't work very well.

GLN: So how does CBT then work into helping get through this insomnia issue?

Dr. Jessica Salwen-Deremer:

we directly target some of those cognitive and behavioral factors. So we will do things like, have patients have regular bedtimes and wake times, even if they've had a horrible night of sleep. So if 6:00 is the earliest you have to wake up every morning, we tell patients to wake up at 6:00 every day, even if they were up 6 times last night, even if it's the weekend, even if, even if, even if. And we get those bedtimes and wake times really regular.

We also do something called stimulus control, where we're having folks not do things except sleep and sex in their bed. So the screens get kicked out, the TV watching, the resting, the hanging out before bedtime, the laying there because your alarm hasn't gone off yet. All of that is supposed to happen not in bed and then we work on some of those beliefs, as well. So when you're laying in bed with a head full of worries or stress because you haven't unwound from the day or because you haven't actually had any space in your day to look at or think about or address those thoughts, they show up at night. So we help patients learn other strategies of managing their arousal and managing their worries to take them out of the bed.

GLN: Another key conclusion of your research is that patients want to talk about fatigue and sleep disruptions with their physicians and they're interested in receiving treatment that will help them get through this. Does that mean that their physician should be taking more of an initiative to bring the subject up with the patient or are patients at all hesitant to bring it up themselves? Do doctors need to probe a little bit more on this?

Dr. Jessica Salwen-Deremer:

Yeah, I think they do. And for me, I think that the mechanism, on average, is less that patients don't feel like they should bring it up but more like they're not sure it has anything to do with IBD or they assume that they should be tired. They assume that this is just part of the disease and doesn't have a treatment that they could do.

So I know these clinical visits are usually so packed.  But I insomnia is more prevalent than all those other things that patients and doctors are starting to talk about, like worry, your mood. Not that they're not all important but this is more likely to be showing up in more patients.

GLN: And worry and mood issues could be contributing to the insomnia, as well, right?

Dr. Jessica Salwen-Deremer:

Yes. They go both ways. And if somebody has both depression and insomnia, we know that insomnia treatment actually works just as well on the depression as depression treatment does. So it's a 2 birds, 1 stone, situation there.

GLN: So what else would you advise practicing clinicians to do to help patients with IBD work through issues with sleep to get better sleep and hopefully to reduce fatigue?

Dr. Jessica Salwen-Deremer:

I think bringing it up even in a very simple format, like, "Have you had any problems with sleep or fatigue lately?" Making that part of a standard check-in that you do with patients is a really important first step. But I know that people don't like to ask questions when they don't have a place to send the patient who says, yes. You get that helplessness in that case.

And so, in this article and in others that I've written, we talk about where providers can send their patients. there are online programs, apps, all kinds of things that providers can do to send patients to. So they don't have to feel like, "Gosh, I asked this question and now I don't know what to do with the answer." We also have some kind of basic guidelines on what providers might recommend if patients are saying that they are having sleep problems.

GLN: And what are some of those guidelines?

Dr. Jessica Salwen-Deremer:

same schedule every day is an easy one to fit into a clinical encounter. I think patients understand it. I think often patients have heard it and maybe not wanted to do it. So that, try to go to bed at the same time, try to wake up at the same time, even when you've had a bad night of sleep can be an easy one to have people start engaging in. And the other would be telling people when they're feeling really fatigued, when they're feeling pain, to put that rest on the couch instead of in bed.

GLN: So take it to another location so that the association isn't there between going to bed and being restless and having pain.

Dr. Jessica Salwen-Deremer:

Exactly right. Exactly.

GLN: Well, this is really interesting and I know that you're continuing to delve into this subject, so I hope we'll talk again about it soon.

Dr. Jessica Salwen-Deremer:

Sounds great. Thank you for having me.

Reference:

Salwen-Deremer JK, Godzik CM, Jagielski CH, Siegel CA, Smith MT. Patients with IBD want to talk about sleep and treatments for insomnia with their gastroenterologist. Dig Dis Sci. 2023. Published online ahead of print February 25, 2023. doi: 10.1007/s10620-023-07883-8 

For more information on sleep related questions and responses see: https://academic.oup.com/crohnscolitis360/article/2/3/otaa052/5862396 [academic.oup.com]