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Cognitive behavioral therapy for insomnia, depression mental illness disorder - .

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CBT is based on a cognitive model of the relationship among cognition, emotion, and behavior. For depressed older adults, RCTs have found CBT is superior to treatment as usual, wait-list control, and talking as controlThompson et al12 compared 102 depressed patients age >60 who were treated with CBT alone, desipramine alone, or a combination of the 2. As patients get older, cognitive impairment with comorbid depression can make treatment challenging. However, some research suggests that CBT for GAD may not be as effective for older adults as it is for younger adults. Adding memory and learning aids to CBT for anxious older patients may improve the response rateInsomnia. Older patients tend to complete CBT assignments, and are interested in applying the learned strategiesClinical experience indicates that older adults in relatively good health with no significant cognitive decline are good candidates for CBT. There are no absolute contraindications for CBT, but the greater the cognitive impairment, the less the patient will benefit from CBT (Table 2). CBT for older adults should focus on the meaning of losses and transitions in the patient’s lifeChanges in cognition. The websites of the Academy of Cognitive Therapy, American Psychological Association, and Association for Behavioral and Cognitive Therapies can help clinicians who do not offer CBT to locate a qualified therapist for their patients (Related Resources).
In another RCT focused on 25-64 year olds, Jacobs and colleagues found that CBT outperformed PCT (drug: Zolpidem) and placebo and was as effective as CBT+PCT combined therapy in sleep efficiency (percentage of time devoted to sleep that the subject is actually sleeping) and sleep onset latency (how long after intention to sleep the subject actually fell asleep). Even with that limitation, since CBT will cost me very little and can be self-administered (and effectively so, according to another RCT), I consider it worth the effort for me. Anyway, would love your views on the research paper, and good luck with overcoming your insomnia! Insomnia is usually classified as transient (short term), intermittent (on and off), and chronic (constant).
Insomnia is a disorder characterized by chronic sleep disturbance associated with daytime disability or distress, such as memory impairment and fatigue, that occurs despite adequate opportunity for sleep. In this Clinical Information Supplement, Thomas Roth, PhD, describes the nature of insomnia and its pathophysiology. Insomnia is a symptom-based diagnosis.3 Patients with insomnia experience one or more sleep-related complaints, including difficulty falling asleep, difficulty staying asleep, early-morning awakenings, and sleep that is nonrestorative or not adequately restorative (Slide 1). The disparity between the prevalence in the general population and that in the clinical population may be explained by the risk factors associated with insomnia.
Although 30% of patients with a medical disorder have insomnia, one must consider the fact that 70% do not.
While most people experience a decline in body temperature at night, this is not as consistently seen among insomniacs. The sleep systems in patients with insomnia are relatively normal, but the individuals are hyperaroused, as reflected in catecholamines, brain metabolism, and body metabolism. Several epidemiologic studies1-7 have used cross-sectional analysis or longitudinal data to compare people with insomnia to normal sleepers in an effort to determine the specific impairments and alterations in quality of life associated with insomnia. Findings from cross-sectional studies show a strong correlation between insomnia and impairment. An enlightening study by Katz and McHorney2 compared the SF-36 findings in a group of patients with severe insomnia to those in a group of patients with major depression and a group of patients with congestive heart failure. Longitudinal data demonstrate that people with insomnia experience increased absenteeism and decreased productivity in their work roles. There are limitations to our knowledge of how treatments for insomnia affect the impairments and risks associated with the disorder.8 Examinations of some measures of daytime function have produced negative findings. At the National Institutes of Health (NIH) State-of-the-Science Consensus Conference on insomnia, held in June 2005 in Washington, DC, the Federal government addressed insomnia and its associated problems for the first time in >20 years.
Other forms of behavioral treatment may be administered in the clinician’s office, however. Sleep restriction and stimulus control are other behavioral treatments for sleep disorders.
Patients with insomnia should engage in relaxing activities as part of their sleep preparation ritual. Over the years, patients have used a variety of products, alone or in concert with behavioral changes and modifications, to induce sleep (Slide 4). Laudanum, a combination of opium and alcohol, has been around for over 100 years, and was used extensively during the American Civil War, when it was available at every corner grocery store. The selective melatonin receptor agonist ramelteon is a recent addition to the sleep-agent armamentarium and is also approved by the FDA for the treatment of insomnia. Currently, the nonbenzodiazepines and ramelteon are the newest pharmacologic treatments for insomnia patients. Q: Most clinicians, particularly psychiatrists, are trained to think about insomnia as a symptom of another disorder.
Mood and behavior are viewed as determined by a person’s perception and interpretation of events, which manifest as a stream of automatically generated thoughts (Figure).3 These automatic thoughts have their origins in an underlying network of beliefs or schema. A combination of medication and CBT worked best for severely depressed patients; CBT alone or a combination of CBT and medication worked best for moderately depressed patients.
In a study of CBT for GAD in older adults, Stanley et al19 reported smaller effect sizes compared with CBT for younger adults. Studies have found CBT to be an effective means of treating insomnia in geriatric patients. Similarly, severe depression and anxiety might make it difficult for patients to participate meaningfully, although CBT may be incorporated gradually as patients improve with medication.
Laidlaw et al30 developed a model to help clinicians develop a more appropriate conceptualization of older patients that focuses on significant events and related cognitions associated with physical health, changes in role investments, and interactions with younger generations. Changes in cognitive functioning with aging are not universal and there’s considerable variability, but it’s important to make appropriate adaptations when needed. For patients with substantial cognitive decline, cognitive restructuring might not be as effective as behavioral strategies—activity scheduling, graded task assignment, graded exposure, and rehearsals.
The subjective measures (sleep diaries) are not considered inferior in this type of work because self assessment of sleep (concern about insufficient sleep) is one of the key psychological drivers of insomnia. Incidentally, I overcame my own insomnia with CBT, which is what inspired me to develop Sleepio…so hang in there! It is used successfully with or without the addition of prescription medications which in the past, were often the only prescribed therapy option. Patient and doctor then work together to establish new sleep solutions that may include medication, light therapy and a new and effective plan to break old habits and create better sleep hygiene that may include a change in diet and exercise if needed. Roth is director of the Sleep Disorders and Research Center at Henry Ford Health System in Detroit, and clinical professor of psychiatry at the University of Michigan School of Medicine in Ann Arbor.
Krystal is director of the Sleep Research and Insomnia Program at Duke University School of Medicine in North Carolina.
Some of the greatest risk factors for insomnia are age and psychiatric disorders (Slide 3).
On the other hand, it is very clear that shift work contributes to insomnia by causing changes in circadian rhythm.
It is important for clinicians to understand that while insomnia interacts with other medical disorders, it is not necessarily caused by them. Several studies in the medical literature demonstrate that insomnia increases the risk of depression by a factor of 5. Hyperarousal overrides these normal sleep systems and causes insomnia, which then interacts with the comorbid medical and psychiatric disorders. While impairment and decreased quality of life are included among the criteria for the diagnosis of insomnia, the nature and degree of these impairments are difficult to ascertain. In another type of study, patients with insomnia receive insomnia-specific therapies and are followed to determine how their function and quality of life improve.
Compared to normal sleepers, people who meet insomnia criteria have impaired quality of life.
The striking results indicated that people with insomnia had more impairment in areas of vitality, general health, and physical ability to function than those with congestive heart failure and those with major depression. Breslau and colleagues5 looked at a group of patients who met insomnia criteria at baseline and a group of people without insomnia.
In a study by Suka and colleagues,6 4,794 male workers from one company in Japan were diagnosed with insomnia at initial evaluation and followed for 4 years. As there is a tendency not to publish negative findings, it is not known how often studies fail to find therapeutic effects. In four of these studies, people completed morning self-ratings that indicated their alertness or ability to function had significantly improved after insomnia treatment.
Two of the major chronic insomnia treatment endorsements came out of that conference: First, cognitive-behavioral therapy (CBT) for insomnia is effective and should be utilized. The role of CBT in insomnia is to challenge the dysfunctional beliefs and misconceptions about sleep held by a person with insomnia (Slide 2).2 One of the cornerstones of CBT for insomnia is to stop the patient from focusing too much on the time.

Other CBT techniques that require less training and are thus more easily delivered include relaxation training, in which patients are taught to reduce their physiologic and cognitive arousal at bedtime. Patients with insomnia should exercise in the morning or, at the very latest, by early afternoon. They should begin these activities early in the evening so that they are set for sleep at bedtime.
Clinicians may look very hard for an underlying psychiatric disorder or for an associated medical problem—even an acute stressor.
Roth: The National Institutes of Health (NIH) realized that insomnia is not a symptom, but rather a chronic disorder. Krystal: When treatment is started, one does not know how long a patient will have insomnia.
Krystal: For some people, you can institute these behavioral changes right away, but their sleep does not improve for several weeks. Since then, research and application of CBT with older adults has expanded to include other psychiatric disorders and researchers have suggested changes to increase the efficacy of CBT for these patients. It emphasizes the need to explore beliefs about aging viewed through each patient’s socio-cultural lens and examine cognitions in the context of the time period in which the individual has lived.
For example, depressed patients could view their retirement as a loss of self worth as they become less productive.
Patients may experience a decline in cognitive speed, working memory, selective attention, and fluid intelligence.
Because older adults often have strengthened dysfunctional beliefs over a long time, modifying them takes longer, which is why the tapering process usually takes longer for older patients than for younger patients.
A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late-life depression.
Cognitive therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults.
Clinical effectiveness of individual cognitive behavioral therapy for depressed older people in primary care: a randomized controlled trial. Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: a meta-analysis. Cognitive-behavioral therapy for depression in Parkinson’s disease: a randomized, controlled trial.
One session cognitive behavioural therapy for elderly patients with chronic obstructive pulmonary disease. A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counseling for anxiety symptoms in older adults.
Cognitive-behavioural therapy for late-life anxiety disorders: a systematic review and meta-analysis. A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder.
Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder: two pilot investigations.
Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults.
But I have seen many that urge consumers to talk to their doctors about Lunesta (Eszopiclone) or Ambien (Zolpidem) or Restoril (Temazepam) or other insomnia drug.
But they are more costly for payers and more lucrative for pharmaceutical manufacturers, generating revenue that supports expensive ad campaigns. The bars represent the number of minutes subjects were awake after sleep commenced (sleep onset), according self reports (sleep diaries).* Notice that for all follow-up intervals CBT outperformed all other approaches. Maybe fewer Americans should pop pills and more should ask their doctors about CBT for insomnia.
If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Any one of these latter symptoms must be present with the sleep-related complaint, and must occur despite adequate opportunity for sleep. Familial aggregation is a risk factor, suggesting that there is a genetic basis for this disorder.
The majority of patients with medical disorders such as rheumatoid arthritis or neuropathic pain do not have insomnia. Patients with a history of depression are also at a greater risk of relapse if they have insomnia. Derivation of Research Diagnostic Criteria for Insomnia: Report of an American Academy of Sleep Medicine Workgroup. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005.
Eszopiclone co-administered with fluoxetine in patients with insomnia coexisting with major depressive disorder.
Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects. One important question is whether insomnia causes alterations in physiology or behavior that might lead to longer-term adverse consequence. A 1997 retrospective analysis by Simon and VonKorff3 compared a database of ~2,000 primary care patients with insomnia to controls. The incidence of hypertension increased in those who had difficulty initiating sleep or staying asleep compared with those who did not meet have insomnia. The relationship between insomnia and health-related quality of life in patients with chronic illness. Nightly treatment of primary insomnia with eszopiclone for six months: Effect on sleep, quality of life and work limitations. Patients are best treated with the nonpharmacologic behavioral interventions outlined above, such as CBT and relaxation training.
Ever since the 2005 NIH State-of-the-Science Consensus Conference on insomnia, all drugs approved by the Food and Drug Administration have been indicated for the long-term therapy of insomnia.
And after a patient starts pharmacologic treatment, one will not know if the patient still does have insomnia.
One should start out with just cognitive-behavioral therapy, especially the behavioral approaches. And there are some people whose anxiety is such that it is difficult to change their behavior.
The therapeutic process consists of helping the patient become aware of his or her internal stream of thoughts when distressed, and to identify and modify the dysfunctional thoughts. Insomnia patients may improve after 6 to 8 CBT-I sessions and patients with anxiety or depression may need to undergo 15 to 20 CBT sessions. He says he has been taking an extra 10 mg when he “needs the extra boost.” He asks for an early refill and increased dosage. It’s worth noting that a limitation related to the study of CBT is that a placebo is not possible, as it is for drugs.
Pain conditions and depression are commonly associated with insomnia, either as secondary or comorbid conditions.
Finally, the sleep difficulty must occur at least three times per week for at least 1 month. The night after a tornado, for example, a town population may have a sleep disturbance prevalence as high as 70% to 80%. The clinical subpopulation that does have insomnia is composed of patients with a predisposition for it. The more medical conditions they have, the greater the number of precipitants, and the greater their likelihood of developing insomnia. Other medical disorders commonly associated with insomnia include arthritis and other chronic pain syndromes, congestive heart failure, cerebral vascular disease, chronic pulmonary disease, Parkinson’s disease, dementia, gastroesophageal reflux, and renal failure (Slide 6). As is the case with treating other comorbid conditions, treatment of insomnia diminishes illness severity and improves response to antidepressant treatment. Nofzinger and colleagues8 demonstrated increased brain metabolism in the arousal centers in the brain, indicating that insomnia does not result from broken sleep systems but from over-engaged arousal systems (Slide 7). Lushington and colleagues12 demonstrated that those with insomnia experience an increase in body temperature, and Stepanski and colleagues13 indicated that insomniacs also experience increased heart rate—both at night and during the day.
In a study involving 261 insomnia patients and 101 controls, Zammit and colleagues1 employed the 36-item Short Form (SF-36) Health Survey, a well-validated epidemiologic measure of quality of life.
After that interval, there was a much greater incidence of major depression, anxiety, and alcohol and drug dependence problems in those who had insomnia. Usually, hypnotics should be prescribed only if good sleep hygiene principles and cognitive interventions are not sufficient to allow patients to get a good night’s sleep.

People without any insomnia at all were asked whether they have difficulty sleeping when they experience stress.
We use the cognitive interventions first, and then we use pharmacotherapeutic agents for awakening or increased alertness, and to help with sleep.
However, before one decides that a patient has insomnia, one should make sure that the patient has adequate opportunity to sleep. We published data showing that starting a sleep agent with behavioral therapy, with buy-in from the patient, can improve in sleep right away.
Fordyce Professor, Director, Geriatric Psychiatry, Department of Neurology and Psychiatry, Saint Louis University School of Medicine, St. Behavioral techniques are used to bring about functional changes in behavior, regulate emotion, and help the cognitive restructuring process. About 30% of adults report some symptoms of insomnia and 10% meet all the criteria for the condition.
The studies say so, and some say it’s more effective than pharmacological therapy (PCT).
In addition, a greater incidence of anxiety, alcohol and drug dependence, and cardiovascular disease is found in people with insomnia. Lieberman III, MD, MPH, provides an overview of therapeutics utilized in patients with insomnia, including behavioral therapies and pharmacologic options. However, the 30% sleep disturbance prevalence does not account for the population suffering from insomnia. Age is the greatest risk factor for insomnia; however, the reason elderly people experience increased risk of insomnia is not due to a breakdown of their sleep systems. However, the fact that the incidence of insomnia is not 100% among patients who have three or four medical disorders indicates that medical disorders themselves are not responsible for causing insomnia. Virtually every medical disorder can be associated with insomnia because most medical disorders require an arousal response. Fava and colleagues7 demonstrated that patients with comorbid insomnia and depression experience a quicker, more effective antidepressant response when treated with a sleep agent and antidepressant combination than when treated with either a sleep agent or antidepressant alone. The results demonstrated that people with insomnia differ from normal sleepers in their vitality, their emotional role, their health, and their physical role.
The results showed that insomnia was correlated with global impairments in patients’ ability to live their lives (Slide 3).
Consequently, in some areas, there is a shortage of cognitive-behavioral therapists and an inability to access them because of insurance policies.
A 4-watt nightlight, for example, might provide light sufficient to prevent injury without interfering with a patient’s ability to go back to sleep.
It turns out that those people who have more disturbed sleep in stressful circumstances, in age- and sex-matched controls, have an ~11-fold increased risk of developing insomnia in the future. However, comorbid insomnia is very different from secondary insomnia, in which a condition or disorder is the primary cause of insomnia.
The decision of the NIH indicates that there is a role for chronic therapy, but for whom and under what circumstances depend very much on the patient, just as in determining treatment for patients with depressive disorders. And as long as there is a plan to taper that medication over the course of three weeks, before the full benefit of behavioral therapy kicks in, you still seem to get full benefit of the behavioral therapy. To accommodate for a decline in fluid intelligence, presenting new information in the context of previous experiences will help promote learning. Clinicians must consider whether chronic treatment of insomnia can prevent the relapse of depression or other like conditions. In all of the different subscales of the survey, quality of life was diminished in the patients with insomnia (Slide 1). Finally, there are no studies that have had a primary focus on morbidity; a study of the effects of insomnia therapy on morbidities must examine a group of people who have an identified set of morbidities, and then follow them in a method powered to detect those effects. Treatment seems to improve the deficits people with insomnia experience, including those in quality of life, social role, and work performance. The bed should not be used for television watching, dog grooming, stamp collecting, or any other activity executed in hopes of eventually falling asleep.
They know that in cases like patients with recurrent episodes of depression, lifelong pharmacologic therapy is required, so I think they are more easily convinced to use chronic treatments for insomnia. Several trials have shown that wake-enhancing compounds, such as modafinil, can be helpful for people trying to stay awake during nightshifts. Some interesting data suggest that if you continue insomnia medication long term, the behavioral therapy benefits do not seem to manifest, perhaps because there is no motivation to change behavior. Recordings of important information and conclusions from cognitive restructuring that patients can listen to between sessions could serve as helpful reminders that will help patients progress.
Insomnia patients experience increased metabolic rate, body temperature, and heart rate, and elevated levels of norepinephrine and catecholamines. Finally, the prevalence of insomnia varies among medical practices in the clinical population.
However, most studies are powered to determine whether therapies include sleep and are not powered to find the effects on non-sleep outcomes.
Effects of treatment on risks for medical and psychiatric disorders have not yet been sufficiently studied. I think the more interesting question is how much of that hyperarousal is due to the insomnia, rather than the cause of insomnia.
We do not have as much longitudinal data for chronic treatment of insomnia as we do for depressive disorders.
Second, the temptations not to maintain a regular sleep schedule are greater for shift workers, because, for example, they can attend their children’s t-ball games in the middle of the afternoon. Phone prompts or alarms can remind patients to carry out certain therapeutic measures, such as breathing exercises.
Pharmacologic options for the treatment of insomnia include benzodiazepine hypnotics, a selective melatonin receptor agonist, and sedating antidepressants. For example, insomnia prevalence in geriatric medicine differs from that in athletic medicine.
Clinicians may be trained to infer that a patient’s depression causes their insomnia.
Some patients respond to a limited course of therapy; after a while the insomnia is ostensibly cured and the therapy can be withdrawn.
Caretakers can attend sessions to become familiar with strategies performed during CBT and act as a co-therapist at home; however, their inclusion must be done with the consent of both parties and only if it’s viewed as necessary for the patient’s progress. However, insomnia may be best treated with cognitive-behavioral therapy and instruction in good sleep hygiene, either alone or in concert with pharmacologic agents.
However, across all medical specialties and all medical clinics, ~50% of patients meet diagnostic criteria for insomnia (Slide 2). However, if insomnia is caused by depression, treating depression should, and does, alleviate sleep disruptions. Chronic therapy has always been an option clinically, but it is now also an option in terms of regulations, both as indicated on medication labels and in terms of clinical guidelines. Studies on the effects of insomnia treatment use variable methodologies or do not publish negative results, and there are currently no studies of treatment focusing on morbidity. There is equally a large body of data indicating that those who suffer from insomnia also experience cognitive hyperarousal, indicating the pathophysiology is not simply biological. Further research is necessary to better understand the effects of insomnia therapies on medical and psychiatric disorders. Krystal presented data from Breslau and colleagues,2 which shows that in the majority of cases, insomnia precedes the depression.
The use of light can be helpful in moving their internal clocks, though this may not be the best choice for shift workers with family or social obligations on weekends. There are also data that would suggest that if you treat depression, then the more refractory symptom is insomnia.
But the notion that we need to use some medications chronically, in patients who have severe recurring conditions, is not foreign. Hence, although it is clear that insomnia often is comorbid, this does not preclude the treatment of insomnia as its own distinct condition.
This is appropriate so long as we can make the association between that insomnia and some of the other conditions that these clinicians treat.

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