Cognitive Behavioral Therapy, Telehealth Among Recent Advances in Treatment of Chronic Insomnia

In this video, Michael Vitiello, PhD, professor of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, discusses his recent virtual presentation at Neurology Week, titled “Recent Research Advances in Treatment of Chronic Insomnia,” which covered significant treatment methods for chronic insomnia, a recent emphasis on cognitive behavioral therapy and telehealth, and what is on the horizon in this field of research.

Read the Transcript:

Michael Vitiello, PhD: Hello, I'm Dr. Michael Vitiello. I'm at the University of Washington in Seattle, and I'm a professor of Psychiatry and Behavioral Sciences.

I'm going to talk to you today, I'll give you a brief recap of the presentation I gave, which is looking at recent advances in our understanding of treatment of insomnia, particularly chronic insomnia.

Let me give you the take-home message first. We have very effective treatments for chronic insomnia, specifically something called cognitive behavioral therapy, which I'll talk a little more about in a bit. A lot of the research has been exploring the ability to deliver it more effectively.

My take-home message for you is, we have this effective treatment, and if you're working with people that have chronic insomnia, the most appropriate thing for you to do as a practitioner is not learn to do the treatment, but learn to refer to the most appropriate source of reputable treatment.

That's typically a sleep center, sometimes cognitive psychologists or nurse practitioners in the area with the records in expertise and more and more, as I'm going to explain, this method of treatment has been delivered very effective digitally, and I've done some work which I'm going to finish with talking about telephone delivery and its advantages.

With that in mind, let me recap the talk. Effectively, chronic insomnia is very common in the population. It has significant morbidity, and it's related to significant mortality. Someone with chronic insomnia has a significant problem that deserves treatment, and we indeed have very efficacious treatments for it.

Specifically, the treatment that's recommended, and this was a breakthrough in behavioral treatments for insomnia. In 2016, the American College of Physicians recommended that the gold standard treatment for all chronic insomnia was cognitive behavioral therapy. Not drug therapy, but behavioral therapy.

Cognitive behavioral therapy is a multi-modal approach. It's a multi-component treatment. It effectively employs education, monitoring of the sleep problem with a sleep log, delivery of two major interventions, one that targets falling asleep, which is something called stimulus control therapy, one that targets maintaining sleep, which is called sleep restriction therapy or time-in-bed therapy. Then, it can also include such things as relaxation therapy and some cognitive approaches like cognitive reframing. There may be some other things that people do occasionally, but those are the major components.

I don't have time to really describe them in detail. We could do a two-hour seminar on treatments.

There have been multiple studies that have supported the efficacy of cognitive behavioral therapy for chronic insomnia both for uncomplicated insomnia, that is existing without any other co-morbid illnesses. Indeed, in the phase of co-morbid illnesses, which is of particular importance because most chronic insomnia, especially as one gets older, typically occurs co-morbid with other illnesses.

There have been multiple meta-analysis that have shown that cognitive therapy works very well from the get-go. It's typically delivered over a six-week period or so, six to eight weeks with about six treatments. It also then works long term and the follow-up studies have been out to two years.

This is a very consistent finding, typically works about two-thirds of the people that are being treated. It works in the face of most co-morbid illnesses that one experiences.

Interestingly, there's a lot of data to suggest that it may influence or improve some of the co-morbid illnesses, particularly the psychiatric illnesses like anxiety and depression, but also some medical illnesses like pain conditions and similar things like that.

There's a vast amount of research that supports the efficacy of cognitive behavioral therapy. It's really not about can we show that this works, it clearly works. Now, the work has been focusing on getting it scalable, getting it set up in such a way that can be delivered to the most people the most efficiently.

There's a lot of work that's been done using telehealth, using various digital modalities be that computer or smartphone-driven and also, as I'm going to conclude, using the standard landline or a non-smartphone, just a verbal life communication. The demonstrations of digital cognitive behavioral therapy have been remarkably efficacious.

It's not quite as good as you would imagine as in-person therapy or one-to-one interactive therapy, but it still gets a lot of bang for the buck. There is probably and the most recent meta-analysis shows equivalence even though if you look at the absolute numbers of improvement, they're a little bit lower for digitally delivered cognitive behavioral therapy.

My own work in the last few years has focused on working with older adults with osteoarthritis who have both pain and chronic insomnia. The idea being if we fix the chronic insomnia, can we also address the pain problem because treating pain in any population, but in particular older adults, is difficult. We don't have a lot of good options.

We certainly don't have any good pharmacological options, and behavioral treatments that focus specifically on pain are not that efficacious. Typically, you see effect sizes of about 0.2.

We've looked at treating the sleep disorder in these people, the chronic insomnia, to see if not only can we improve the sleep of these people, but what about other aspects, other conditions that are common with sleep and pain. Fatigue for example, depression, those types of things.

We've done a cognitive behavioral therapy that we deliver by telephone, standard landline, and we recently completed a state-wide here in Washington randomized controlled trial. This was funded by the NIA and recently published the outcomes in Gen Internal Medicine.

What we found was that telephone-delivered cognitive behavioral therapy, consisting of 6 treatments of about 20 minutes each over an eight-week period versus an attention control where we only give education but not how to do anything, was very efficacious in improving sleep.

In fact, at post-treatment of everyone in the treatment group who all had significant insomnia at the beginning, about 60 percent of the sample showed remission, post-treatment. I will tell you to that of that 60 percent, almost all of them remain remitted at one year follow-up. About 56 percent of the sample remained remitted.

That compares to control remission rates of down in the low 20s. It's at least double the control rate, so it's quite impactful. The other interesting things about that are that we not only showed improvements in sleep, but we showed improvement in fatigue, depression, and pain at post-treatment.

The fatigue effect health at 12 months. Still don't understand quite why the pain effect and the depression effect didn't work, but may have been a matter of sample size or the nature of the sample.

Again, further work is going to be done for this, but the bottom line is we've shown that telephone-delivered cognitive behavioral therapy can be most effective long-term benefit for sleep and indeed may improve co-morbid illnesses and co-morbid conditions.

There's some advantages to telephone-delivered cognitive behavioral therapy over digital. One of them is not expense, obviously. Digital is very inexpensive and highly scalable and is available to the patient 24/7. Telephone-based therapies have their place. First of all, they allow for real-time interaction with an actual person on the other end.

That can develop a therapeutic alliance, which can be very helpful in doing these kinds of interventions.

Also, there's flexibility there because you have a live person, not a cam program at the other end and that gives you much more flexibility in terms of working with the individual and their situation and problem-solving things that they may experience in their real lives, to try and implement the changes that are necessary in cognitive behavioral therapy to improve sleep.

We're very pleased that telephone therapy is this effective. It gives us another modality, and although I didn't talk about this in the context of the presentation, down the line I can see that to have a step care approach to treating chronic insomnia where everybody might start with digital and if it doesn't work, move to telephone.

Then, possibly in the really hard cases, you move to some type of in-person treatment either group or individual. Again, the take-home message is chronic insomnia is common in the population, particularly in older adults. It typically occurs with co-morbid illnesses and is worthy of treatment in its own rights because we can improve it and relieve a lot of the burden that's associated with it.

Down the line, may even impact the co-morbid illnesses. I thank you for your attention, and I'll say goodbye.