Hi, everyone. Welcome. My name is Kelly Schaefer. I am a psychologist and an associate professor at the University of Virginia in the School of Medicine. And I'm very pleased to be sharing today about a cognitive behavioral approach to understanding and managing insomnia. I'll be happy to take any questions at the end, and we can go ahead and get started. I have no conflicts to disclose. And by the end of this presentation, I hope you'll have a clear sense of the diagnostic criteria for insomnia and why those really matter when we think about the cognitive behavioral treatment for this disorder, that you'll be able to explain how chronic insomnia develops and is maintained, be able to describe the primary therapeutic techniques of cognitive behavioral therapy for insomnia, or CBTI, as well as discuss the efficacy and benefits of delivering CBTI fully automated by the internet. So this might sound obvious, but the term insomnia is used in a lot of different ways, from everything from a clinical disorder all the way to something that's a little bit more colloquial. And depending on your definition, there's lots of different prevalence rates. So starting with just meaning insomnia symptoms, like difficulty falling asleep or staying asleep, that's anywhere between 30 to 35% of the adult population will report those at any given time. If we add in daytime impairment, that figure drops down to about 10%. If we mean people who are really dissatisfied with their sleep, again, that's about 10 to 15% of adults. But if we mean someone who meets the clinical diagnostic criteria for insomnia, the prevalence is around 6 to 12% of adults. And it is really important for us to understand those clinical criteria, as the efficacy of CBTI really depends on someone meeting these criteria. So just to make sure we're all on the same page, I'll spend some time going over these. So the first criteria is a predominant complaint of dissatisfaction with sleep quantity or quality associated with one or more of the following symptoms. Difficulty falling asleep, staying asleep, or waking up too early. So you'll notice I've folded a section of that first sentence, the complaint of dissatisfaction. So I like to say insomnia is not a problem if it's not a problem. You have to have that subjective bother as part of the difficulty with sleeping for that to potentially meet for insomnia. And you'll also notice that none of those three difficulties have time quantities. It's just difficulty. So we generally consider about 30 minutes or more to be sort of significant, but again, that's not a hard and fast rule. And someone can have any or all of those particular difficulties. So difficulty falling asleep would be sort of sleep onset or initial insomnia. Difficulty maintaining sleep would be sort of middle insomnia, or difficulty waking up too early would be late or terminal insomnia. And all of those can also be combined. So you can have sort of different combinations of these as well for different kinds of phenotypes of insomnia. Now, the second criteria, again, this is also sort of, it has to be a problem to be a problem. So the sleep disturbance causes clinically significant distress or impairment in any of these sort of realms of daytime functioning. So this sort of always makes me think, we all know that person who only gets about five hours of sleep and they feel great and they're way more productive than the rest of us. That person doesn't have insomnia. It sort of, the difficulties with sleeping have to be distressing or cause daytime impairment. So the next two criteria are around duration. And these criteria become more important when we talk about the theoretical model of chronic insomnia. So the sleep difficulty occurs about three nights per week for at least three months or more. Now, someone can have significant sleep difficulties before the three-month mark. If someone otherwise met those criteria for the, except for this three-month duration, they can be coded as having sort of an acute onset of insomnia. But we also know from the literature that it tends to take people with insomnia an average of 10 years or longer to get to treatment. So it's not really likely to see someone sort of getting into treatment with you so quickly. And if you combine these criteria with the sleep difficulty criteria under A, there's sort of like a handy rule of threes or a mnemonic to help remember some of these duration criteria. So at least 30 minutes of difficulty, three nights per week for three months or more. Now, again, this doesn't include all of the criteria for insomnia, but I find it handy to help me remember these different criteria. And then there are the rule-outs for insomnia. So what kinds of things are not insomnia? So that first criteria, having an adequate opportunity for sleep. So you can think of sort of a new parent waking up every few hours to feed a baby. They might be awake for long periods in the middle of the night, waking up multiple times per night, go on for several months or more, and they might be really tired and having a really hard time at work. But those wake-ups are not in and of themselves insomnia. Now, of course, it's not to say that no new parents have insomnia. What that might look like, though, is that someone wakes up for a feeding, but then can't fall back to sleep for 30 or more minutes. So, again, you can have those things in common. It would just sort of complicate treatment. The second is that insomnia is not better explained or is accounted for by another sleep-wake disorder. So, again, you can think of the example of untreated obstructive sleep apnea. If someone is waking up 15 times a night for two minutes, that's going to add up to about 30 minutes. But if this really is occurring in the context of OSA, that's not going to be insomnia. Again, someone can have both obstructive sleep apnea and insomnia. If someone still takes about 30 to 40 minutes or longer to fall asleep, they could be comorbid and needing to treat those things together. And then, lastly, of course, sort of checking for substances or other conditions that might explain insomnia and should be treated beforehand. For instance, with substances, it's important to assess caffeine intake and when that's occurring, certain medications that might sort of influence sleep, like steroids and other things. So, I'll walk us through the four-factor model of insomnia. And this is really sort of the foundational rationale of CBTI. So, I find it's really critical to understand as a clinician, and I also find that it's really useful to explain to clients using their own data after an assessment. So, we can sort of start off by imagining there's this insomnia threshold, and everyone starts out with some predisposing factors that make us more or less likely to experience insomnia. Things like female sex, genetic risk factors, and so on. So, this example person's level of pre-mortem factors is about at two, but you can imagine someone who has a really high genetic or family loading, that person might start out much closer to that insomnia threshold, and it might not take a lot to push them over. They might experience insomnia multiple times over the course of their life. So, then something happens that sort of pops that person above the line. So, this might be an acute stressor, a medical issue, or some other change that makes it really difficult to fall asleep or stay asleep, those precipitating factors. And then comes in the trouble. So, the effect of that life event may start to sort of dwindle over time as someone habituates or copes with that stressor, but in the meantime, a person might have picked up some bad habits that are perpetuating the insomnia. So, these can be commonly things like spending a lot of time in bed. So, someone might think, you know, it takes me a really long time to fall asleep. I'm going to go to bed early or hit snooze a couple of times in the morning. And all of a sudden someone's in bed for nine, 10 hours, but they're only sleeping six. Another common perpetuating factor is maladaptive thoughts. So, you know, someone having a lot of stresses and worries, tonight's going to be horrible. I'm, you know, I just can't sleep. Tomorrow, I'm going to feel awful. You know, someone feeling really stressed and all, of course, all of that's going to make it harder to fall asleep. And that also leads to conditioned arousal or to keep with that pee theme, Pavlovian factors. So, remembering Pavlov's dogs, pairing the bell with food. So, they started salivating when they heard the bell, that physiological response to an otherwise neutral stimulus. So, people with insomnia, they spend so much time restless, stressed, frustrated, awake in bed, they begin to pair the bed and bedroom with wakefulness. So, that can help explain why some people will fall asleep on the couch, no problem. But they'll get up, you know, when they get up to bed, it's, you know, they're just wide awake. So, this model also helps demonstrate why that three-month duration is so important in defining chronic insomnia. Because not everyone develops insomnia after a major stressor, right? So, lots of people who go through stressors don't develop insomnia, even if they've had a couple of weeks of sleep difficulty. If they're not building up those perpetuating factors that then go on to develop the conditioned arousal, for these folks, their sleep difficulty just resolves over time. So, CBTI, as a behavioral and psychological treatment, focuses on cutting out those perpetuating factors and beliefs, which in turn helps break down that conditioned arousal to the bed and bedroom over time. So, again, because this model is so important to CBTI, I'll walk through this again with a case example, modeling how I would talk about this model with a client who I've gone through a full assessment with. And this is something that I literally just, I draw freehand on a piece of paper. I'm no artist, but it's pretty easy to do. And I found that clients really have enjoyed having this as sort of a physical token. And it's also really an important part of psychoeducation, a piece to CBTI, which we'll hear more about in just a bit. But for this example, you can sort of imagine I'm working with a 60-year-old woman who started to experience insomnia about five years ago after her husband passed away. So, again, I take that sort of blank piece of paper and say, okay, so we're going to try to understand your insomnia a little better and see how cognitive behavioral therapy for insomnia might help. So, let's imagine there's some sort of imaginary threshold for insomnia. If you're below that line, we might have had, we might have some bad night's sleep here and there, but it's not like what you've experienced most nights per week over the past years, right? So, everyone starts out with certain factors that make them more or less likely to experience insomnia. These are called predisposing factors that exist before you even had insomnia. So, these can be things like gender, age, genetic background, ways we think, and other things, too. For you, women are about twice as likely as men to experience insomnia, and as we age, our sleep changes, and that can make us more likely to experience insomnia as well. Now, we talked about how you first started really experiencing sleep difficulties after your husband passed away. So, that would be what we call a precipitating factor or something that threw you over that insomnia threshold. And over time, we often adjust to that initial stressor. So, you might have begun to get more used to sleeping by yourself and that sort of initial shock starting to fade away, but in starts coming these sneaky perpetuating factors that keep us stuck in insomnia. These can be things that we do or things, the way that we think, that we think are helping us, but they actually can really hurt us in the long run. For you, it sounds like you're getting into bed around 8 p.m. because you want to read and wind down, knowing that it's going to take you a while to fall asleep, and you're getting out of bed in the morning around 6 30. That means that you're in bed for about 10 and a half hours, but by your estimate, you're probably only sleeping about six hours a night. And I also know that you're really frustrated about your sleep. You said, none of my friends have this problem. I don't know what's wrong with me. So, clearly, you're really worried about this, which is really understandable, but I imagine when you're having those frustrated thoughts in bed, that's not making it easier to fall asleep. And that's what brings in the last factor that keeps us stuck in insomnia, which is called Pavlovian factors. Those things that are making it hard for you to fall asleep. So, just really quickly, you might know about Pavlov's dogs. So, Pavlov was a scientist who figured out that he could pair a bell sound while giving food to his dogs, that eventually his dogs would start to salivate just from the tone of the bell, even when food wasn't around. So, the dog's brains paired that bell sound with food, so they had an automatic physical reaction of salivating. And that's not just for dogs. We people can get conditioned too. And for people with insomnia, it's not a bell and salivating, it's their bed and wakefulness. So, being in bed awake for long periods of time and tossing and turning, feeling stressed about trying to get to sleep, you've accidentally paired your brain to feel awake and stressed when you're in bed rather than feeling sleepy and comfy. So, what we're going to do with CBTI is work to cut out those perpetuating, those things that are perpetuating your insomnia, like different things that you're doing and ways that you're thinking about sleep. And eventually that will help retrain your brain to pair your bed with sleep and make it easier for you to fall asleep and stay asleep. So, that's how I would explain this treatment to a client. And now we can talk about how exactly does CBTI target those perpetuating factors. So, think of CBTI as having sort of four major components. The first being education. And that's what we just walked through. It's really helpful for clients to understand the high prevalence rate of insomnia, which is about, again, about 10% of adults. That helps people know that they're not alone. It's also helpful for folks to understand how insomnia develops and maintained and how CBTI as a treatment is going to help address those symptoms. I have sleep hygiene in brackets. So, meta-analytic evidence actually suggests that sleep hygiene really isn't all that effective, but it also doesn't seem harmful. So, during a full assessment, if you notice that someone sort of reports drinking caffeine or working out or eating really late, you could sort of address that. Or if their sleep environment is hot or too light or noisy, again, you can address those things too. People seem to like working on sleep hygiene and it seems face valid. But definitely don't get distracted. The main components of CBTI and the parts that are really needed for it to work are the behavior change strategies and the cognitive change strategies. So, behavior change is what you will work on with most clients first. There are two main components to that being sleep restriction and stimulus control. We'll talk about each of those a bit more in a minute. And then the cognitive change or cognitive restructuring strategies. And why you would start with behavior change first for most clients is by the time that you get to those later cognitive change strategies, actually, you will have had a lot of your work already done for you because people will have these new experiences with sleep through changing their behaviors, which gives them sort of a different, a whole different like approach and beliefs around their sleep as well. And then lastly would be relapse prevention or helping people consolidate the gains that they've experienced through treatment and prepare for future setbacks. Now, there are a lot of really fantastic treatment guides out there. So, Michael Perlis and colleagues have sort of a treatment guide specifically for CBTI. There's a full clinical guide by Charles Moran and Colin Espy among many other reputable guides. And I would really encourage you if you want more information after this brief overview to go through one of those. So, starting with sleep restriction, this strategy uses a systematic sleep deprivation to help consolidate a person's sleep over time. And we do that by matching someone's sleep ability or how much someone is actually sleeping over the course of the night with their sleep opportunity to set a prescribed sleep window. So, again, you can think about that sort of 4P client again. So, someone who gets in bed really early around 8 p.m., they watch some TV and read and rest and relax. They turn the lights off at 10 p.m., but it takes them a while to fall asleep. You know, fall asleep for about two hours, but they wake up, fall asleep, wake up over the course of the night before finally waking up and getting out of bed around 8 a.m. So, this person's total sleep ability or the total amount of time that they're sleeping in dark blue is about 6 1⁄2 hours. But this person is in bed for 12 hours. So, what I would do with this client is if they can sleep 6 1⁄2 hours, I'll give them about a 6 1⁄2 or 7-hour sleep window. So, if they want to keep their wake-up time at about 8 a.m., that means they're going to bed at 1 a.m. And that's three hours later than they're currently going to bed. So, that gives them three more hours to build up sleep pressure. So, they're going to be really sleepy by the time that they get into bed, and it's much more likely that they're going to fall asleep more quickly and stay asleep longer because that sleep pressure is going to keep them asleep. And we know that consolidated sleep is much more refreshing than just sort of a couple of multiple periods of disjointed sleep. So, even if someone ends up sleeping a little bit less, consolidated sleep is a big win. And this also totally changes someone with insomnia's experience with sleep. So, normally when I tell people, okay, so your new bedtime is 1 a.m., and this person has been getting into bed around 8, you know, the immediate reaction is, oh my gosh, there's no way that I'm going to be able to do that. I'm never going to be able to stay awake. But all of a sudden, you know, you have this person who had been saying, I can't fall asleep, and all of a sudden they're changing to, I'm not going to be able to stay awake. That just totally changes somebody's experience and relationship with sleep, and it helps sort of address some of those sort of just stressors and frustrations with sleep by turning it all on its head. So, it is also really important to emphasize that this sleep consolidation and, you know, filling out that sleep window with sleep, that doesn't happen all at once. So typically someone does start by getting less sleep than they're already getting, and they're gonna feel more tired in the short term. But this is where education is so important, where you really wanna reinforce that feeling sleepy is the point. And just sort of switching those thoughts around to say, just think about how much easier it's going to be for you to fall asleep tonight when you're feeling so sleepy during the day. So it's really important to emphasize that this is very much a short-term pain for long-term gain kind of situation, where people are often really seeing big benefits after about a week or two weeks of going through sleep restriction. So of course you do wanna caution people to be careful with heavy machinery or driving. And I also typically wouldn't recommend setting a sleep window that's shorter than about five hours, but still this is a really powerful part of CBT-I. Moving on to stimulus control, which is the sort of the other major behavioral components of CBT-I. This component aims to address that conditioned arousal or the Pavlovian factors that contribute to chronic insomnia by reconditioning the body to pair the bed with sleep and restfulness. So this component is really about setting and following a handful of rules. And really the sum of these rules is that you should really only be in bed when you need to be. So the bed is for sleep or sex only. So those rules, other rules are really only go to bed when you're feeling sleepy, when you're feeling ready to fall asleep. Get out of bed if you've been awake for about 20 minutes or more. Now this shouldn't be clock watching, but really just an internal sense of I've been awake now for about 15 or 20 minutes, getting up out of bed, going to another room, doing something calm, but staying awake and then going back to bed 15, 20 minutes later and trying to fall asleep again. Waking up and then the last two waking up about the same time every day and no napping again is trying to get your body in sort of that circadian rhythm of expecting sleep at the end of the day. The no napping piece is, I have an asterisk there, for some of our older adults, they might really feel like they need a nap and might need a nap over the course of the day. And that's okay. You can have someone have about a 30 minute nap, but try not to do that later than mid afternoon. And that's just, again, you can reiterate with the client that we're really trying to build up your sleep pressure and napping you're going to spend some of that sleep debt, which we really want to save up and spend later in the evening. So that's something you can sort of describe with your clients as well. So both sleep restriction and stimulus control really rely on the sleep diary. And so as someone sort of keeping track and monitoring their sleep over time. So this is really critical to understand sort of that baseline sleep ability to help set that sleep window, but it also lets your client track how much they're improving over time as well. So setting that sleep window with, you'll take sort of about a week of sleep diaries and average that sleep ability. And you'll want to sort of the rising time minus the bedtime sort of match that with the sleep ability. And when someone's sleep ability about fills up that sleep opportunity. So when someone's sleeping for about 85% or more of the time that they're in bed, you can extend that sleep window by about 15 to 20 minutes at a time, week by week with those sessions. And you'll work your way up to expanding that sleep window until someone feels like their sleep need is met over time. So you sort of adjusting that over the course of the weeks that you're working with someone. If someone's falling below that 85% threshold, you can either keep the sleep window about the same or you can actually decrease it by about 15 minutes so that you have a little bit more time to build up that sleep pressure. So once you've sort of have those behavioral components underway, later on you'll get to the cognitive restructuring sessions. And those sessions are really about identifying and changing maladaptive sleep beliefs where you're really helping someone sort of reduce their negative thoughts that exacerbate sleep difficulties. So this is where you're really gonna want to walk through that classic thoughts, feeling, behavior, CBT triangle. So for instance, last night, if I was in bed thinking, I'm gonna bomb this presentation tomorrow if I don't get seven hours of sleep. I think anybody having those kinds of thoughts would have sort of anxiety, stress, which of course we know at a physiological level it's gonna make it even more difficult to fall asleep. Then I'm gonna start thinking sort of more stressful thoughts. And so you can see that there's sort of a really negative feedback loop between thoughts, feelings, and behaviors. And I find that this is where setting sort of an early foundation of education about sort of normal, healthy sleep is really critical. So it can help normalize having a few nights bad sleep, everyone has their own sleep needs, and also reinforce to people that there's a lot of things that they can do to improve their sleep and break out of insomnia. It's not inevitable. And so after this phase, a sort of a successful cognitive phase of treatment, you want someone walking away feeling really empowered that they can influence their insomnia and also to reduce beliefs around sleep effort. Like I have to try really hard to sleep. And so if you can sort of get someone to sort of adjust those beliefs and feel really confident that they can, you know, there's things that they can do to help themselves sleep better, those are a good thing. And then lastly, with relapse prevention, this is really just about, again, setting helpful expectations about the future and supporting their agency. So you wanna talk about with someone about, you know, what are your red flags for insomnia coming back versus just having a couple of nights sleep here or there. Again, sort of breaking out that 4P model. Sometimes you're gonna have a stressful event where you're having a couple of nights of bad sleep or a couple of, even a couple of weeks of bad sleep, but what is really gonna, what might it really look like if your insomnia is coming back? And then you'll set with someone a cope-ahead plan. So you really just wanna prepare someone to be their own therapist and ask them sort of what sort of skills are you going to use? Are you gonna break out, you know, maybe print out a couple of blank sleep diaries so that someone can track their sleep, look at what kinds of habits they might be slipping back into. Do they wanna set some new sleep windows for themselves? And then what kind of thoughts do you wanna have? What are the things you wanna tell yourself and what kinds of maladaptive thoughts you wanna look out for? So we know that sort of going through this protocol of CBTI really works. So the latest high quality meta-analysis of 25 studies of CBTI found that there was a 33 higher remission rate for insomnia for CBTI versus control and a 45% higher response rate versus control, meaning the clinically significant reduction in symptoms. And relative to controls, that was about 13 minutes less time to sleep onset and 19 minutes less of total wake after sleep onset. So these are sort of really meaningful changes in sleep that are occurring. So in some, there's sort of moderate evidence for this treatment and it is a first-line treatment for insomnia. It has favorable cost efficacy and research suggests that patients generally prefer this psychological and behavioral treatment to pharmacological treatment for insomnia. Now, if CBTI is so great, then why isn't everybody getting it? So unfortunately, there's just not a lot of really highly specialized behavioral sleep medicine specialists in the US. So there's about one specialist for every 150,000 individuals with insomnia across the US. So there's just not enough availability of this treatment and there's many states that have no specialists and even those that do tend to be in more urban areas and so folks in rural areas are just not able to access this care either. So this is why it's really critical for us to think about how can we increase access to this kind of care, starting most people off with highly scalable, accessible forms of this treatment like self-directed therapy from workbooks or internet-based programs or manualized group therapies and reserving those more intensive, expensive and limited approaches, like one-to-one treatment with a specialist to those who have really complicated cases or haven't succeeded in the lower level treatments. And in good news, these more scalable, accessible forms of CBTI have actually really favorable efficacy when compared to in-person delivery. So again, this meta-analysis by Ettinger and colleagues analyzed study that compared different modalities of delivering CBTI. So these graphs, scatter plots that I'll show you are comparing individual in-person delivery versus at the top group therapy, internet delivery, telephone delivery and self-help delivery. And we actually see comparable outcomes for sleep quality and those relatively comparable outcomes are repeated across other outcomes, including minutes of wake after sleep onset, minutes of sleep latency, number of awakenings in the night and sleep efficiency. So there seems to be a lot of viable ways to increase access to CBTI without diluting its effects. Now, delivering by group certainly increases accessibility and delivery by telephone or video reduces travel barriers, but I wanna draw your attention and speak for a moment specifically about delivering CBTI fully automated by the internet or as a digital therapeutic, which I'll define further in a minute. So some talk about this issue as a distinction between consumable interventions, meaning those that are limited and once used, they can't be used by someone else like an hour of a therapist's time versus non-consumable interventions that are infinitely scalable like digital health interventions. And one quote that I really like about this, this distinction is by Munoz and colleagues. So to reduce health disparities, we need interventions that can be used again and again without losing their therapeutic power and that can reach people even if their local systems don't have that care available to them. And the fact of this kind of modality is also critically important to address these issues globally. And so this concept is really important because delivering care fully automated by the internet is essentially infinitely scalable. So if we consider an intervention's ultimate impact is its reach multiplied by its efficacy, digital CBTI has incredibly high potential impact because we know that fully automated CBTI delivered by the internet is highly efficacious. There's large effect sizes on insomnia severity and medium effect sizes on sleep efficiency, sleep onset latency, wake after sleep onset and sleep quality. And it's worth noting that these graphs and figures are from a meta-analysis in 2017. So this is even seven years behind on many new studies published with programs that continue to be more and more sophisticated, personalized and efficacious. So just so we're all on the same page, the FDA defines digital health technologies as those that use computing platforms, connectivity, software and sensors for healthcare and related uses. And the specific goal really is to make healthcare more personalized and accessible for patients. So when we talk about sort of EM health, internet interventions, those are sort of more specifically defined as they tend to be behavioral treatments that are highly structured. They're at least somewhat self-guided, or as I've mentioned, sort of those fully self-guided or fully automated programs. They've tend to be based off of effective face-to-face treatments like CBTI. They're interactive and they're personalized or tailored based on input from the user. So there are also programs like Somrist or Sleepio that have been approved by the FDA. And these are called prescription digital therapeutics, which are software as drugs that treat serious diseases with high unmet medical need like insomnia. And there's a ton of benefits to digital therapeutics or EM health interventions. We know that the cost of internet interventions is almost certainly less than office visits because it's, again, you're not needing to compensate a highly trained professional for their time. It increases access to care because you're not limited to where a clinician is or their timing either. So that's a major pro is for convenience that these interventions can be available anytime or anywhere you have a connection to an internet connection and it can accommodate your own schedule. A really nice benefit of these is that they're private. So there's not a lot of stigma around insomnia per se, but for other conditions where there might be more stigma involved, fully automated programs are really discreet. No one needs to know that you're accessing care. Again, they're highly scalable. They can be quickly scaled by technology to really exponentially accommodate more patients. Again, not limited by the number of clinicians or clinician hours that we have available. And of course, we've talked about proven results. So we know these programs can be highly efficacious and many have gone through many trials as well. So you might be wondering what one of these programs might look like. So I'll show you one example, and this is called SHUDI or Sleep Healthy Using the Internet, which is a fully automated internet delivered CBTI program. And this is the predecessor of the Prescription Digital Therapeutic Somrist, the license for which is owned by Knox Medical. So SHUDI has been tested in more than 25 clinical trials across the world, and it's accessed by internet browser on a computer, tablet, or smartphone. And I'm gonna show you a couple of snapshots now. So someone logs in through a password-protected login built on a HIPAA-compliant, highly secure backend system. When someone logs in, they'll see their dashboard. So you can see in the middle there that this treatment is delivered through six weekly cores or lessons. So again, that's that sort of face-to-face ancestry, you might say, of CBTI coming through where sort of someone gets their next core one week after they've completed the core before. We talked about those diaries, and so individuals complete sleep diaries in this treatment, and they are provided with graphical feedback to see how their sleep changes over time, which is always a really fun aspect of the program that people like. And this data is also used to set a prescribed sleep window that's really tailored to them over the course of their program as well. Pardon me. Our core content is really designed to be highly engaging with different interactivities, videos, patient stories, games, and there's also automated emails that helps keep people engaged with this program over time. And we consolidate the learning with sort of end-of-course summaries as well as personal assessments to see how people are changing over time as well. Now, SHODi is just one of many different digital CBTI programs that are available and that you can search and look through, just making sure that you evaluate the evidence base for any program before you would recommend it to patients. So definitely continue to watch this space as digital CBTI becomes increasingly available, both for prescribers as a digital therapeutic, but also just generally more available as different online programs. So obviously this is a really critically important way to increase availability to effective care to treat the prevalent disorder of insomnia around the world. So before I wrap up, I wanted to just save a really important point for last. So there's a known independent and strong link between insomnia and suicidal ideation, behavior, and death. And this is not accounted for by the link between insomnia and other mental health disorders like depression, it really affects everyone with insomnia. There's about a two to three fold higher incidence of suicide among those with insomnia versus those without sleep difficulties, pardon me. But if we effectively treat insomnia, that reduces the risk. And so that's another really important reason why we need to make effective treatments like CBTI as widely available as possible. So I just wanted to make sure, I'm sure everyone on this call is very aware of our newest national lifeline here in the US, but all the same, it's just worth remembering and just making sure that you provide anyone that you work with insomnia with this life-saving information. So the 988 Suicide and Crisis Lifeline works just like calling 911. With a trained crisis counselor, the service is free for everyone. It's confidential, available 24 seven. You can call the number from any phone, text the number from a cell phone or chat online as well. So again, please make sure to provide this information to those you work with. So in wrapping up just a few main points. So insomnia as a diagnosis has multiple inclusion and exclusion criteria that are really important to do a thorough assessment with your client and make sure that they're really meeting for insomnia before moving forward with CBTI. Remember, it's only a problem if it's a problem. And that rule of three is to help define the 30 minutes, three nights or more a week for three months or more. And that those criteria are really important when we think about that 4P model of insomnia with insomnia being a function of pre-morbid, precipitating, perpetuating and Pavlovian factors. With those Pavlovian factors being the conditioned arousal that develops over time and really entrenches insomnia to be a chronic problem. And CBTI targets perpetuating and therefore Pavlovian factors through education, those behavior change strategies of sleep restriction and stimulus control and the cognitive restructuring strategy as well. And then delivering CBTI fully automated by the internet is effective and scalable. So I'll stop here and welcome questions as well as just a brief reminder for your next lecture up after the lunch break. But thank you again. Well, anyone who has any questions, please feel free to pop those in the chat. Sometimes I'm asked whether someone has, you know, how insomnia, CBT-I treatment can be used with folks with other medical conditions. And we'd say that CBT-I is really effective in the context of other comorbid conditions as well. We know that, so a lot of my work is in the realm of cancer, and we know that insomnia is a really common, very prevalent survivorship issue for folks who have gone through cancer treatment with both sort of psychological and physiological etiologies to that. And we know that CBT-I is a really effective treatment for cancer survivors as well. So a question that came in in the chat is, are there particular digital CBT-I programs that I recommend, and will insurance ever cover digital CBT-I treatments? So I'll say that there are both Somrist and Sleepy-O have been FDA approved. And both of those programs, I would say, are definitely, to my knowledge, the most rigorously tested digital CBT-I programs, and of course have been sort of rigorously reviewed by the FDA. I'm a little bit more familiar with Somrist, and I'm not 100%, I'm not super familiar with Sleepy-O's pathway. But I think the goal is ultimately to have these covered by insurance. I don't think they're currently covered by insurance, but I do think that both sort of companies that own those licenses would ideally like to see them be covered to make them more accessible. I'm not sure for both of those programs, I'm not sure what their current availability is. I know that at least Somrist, it's being worked on to get it available to prescribers, but there have been some changes in the licensing recently. But hopefully it'll be more available soon. So another question, do I know what the cost for digital CBTI is generally? So that's a really good question, and I don't think, so I don't know about Sleepio, and I think Somrist, again, is not currently publicly available, and I think they're working through that cost modeling now, so unfortunately, I don't have that answer, and I apologize. Is there any study looking at CBTI alone versus CBTI plus sleep medication? The answer is yes, so there is an ongoing, although I think recently wrapped up study funded by PCORI, or the Patient-Centered Outcomes Research Institute here in the US, and that study was comparing the SHDI program, which I showed you, with, against sleep medication or SHDI plus sleep medication. I know that they're working through the results of that right now, and so definitely keep your eye to that space to see those results, hopefully will be coming out in the next couple of months. I'm definitely encouraged to see that as well. We know that CBTI also, one of the outcomes of CBTI is that folks tend to have less medicated nights over time as well, so as much as sort of starting off CBTI with a sleep medication might help someone sort of make progress faster, especially if they have really severe or entrenched insomnia, that folks over time are able to sort of wean off of those medications and find that they're able to sleep even without those medications over time. That was one of those findings from the Edinger 2021 meta-analysis covers, covers those results. All right, how do you work with resistance to sleep restriction and no napping? For example, college students before exams, this is a really good question. I would say this is a really common one. Sleep restriction, I'm sure even when I describe it, it sounds horrible, and I know that it sounds horrible. I have a lot of clients who are just like, no way, no way am I going to be able to do that. I really try to frame it as, are you willing to give this a try for a week? I would say that there are times that are better for this than others. I probably wouldn't start sleep restriction with someone in their week of exams that really it's a week or two weeks of pain. But again, I tell clients about two weeks because usually it's just about one, and so I like to set the bar and people will be pleasantly surprised that they're starting to feel a lot better sooner. I would really try to start this strategy with people in a week or two week period where they're more able to give this a try. But then with the resistance as well, I think a lot of people who are coming in with insomnia are just so desperate that even as much as the sleep restriction technique sounds really terrible, I think a lot of people who come in are at their wit's end and they're willing to give something a try, even that sounds a little crazy. I'll try to get people's buy-in to just give it, let's say, we're going to give this a try for one week. Are you willing to spend one week of your life with the benefits could be huge. Are you willing to give this a try for one week and we can even reevaluate next week based on how things go this week. So I do try to make it, this is a short-term process that it's going to be a really difficult week or two weeks, but it's a powerful, it's one of the most powerful treatments that we have for insomnia. And if you're desperate enough to have made it into my office, then you're probably pretty desperate. And it's worth giving it a shot. I have also worked with family caregivers. And so family caregivers who are providing sort of unpaid medical, emotional, practical support to someone with sort of medical illness. And I'd say insomnia is a really common problem among family caregivers as well. And you have to be a little creative for folks who are waking up in the middle of the night for reasons other than insomnia. So family caregivers, those new parents as well, you know that they're going to be waking up in the middle of the night. And sleep restriction is just, you know, sometimes there are cases where you just really can't do sleep restriction and you just do the best that you can. You can talk more about sleep compression. So even if you can change your bedtime, if you can go to bed a little bit later, that's a good thing. And really, again, just walking through that 4P model and explaining why that time in bed is not helping them feel more rested, that it's actually hurting them and making it harder for them to fall asleep and stay asleep. So it can be tricky. Motivational interviewing is definitely a good skill set to break out when you're talking with someone with sleep restriction. And I presented sleep restriction and stimulus control as sort of two sort of separate behavioral techniques. They are sort of considered independent techniques, but you often, the CBTI manuals often sort of present these strategies concurrently. So you can think about the stimulus control rule of trying to wake up about the same time every day. When you think about the sleep restriction and setting your sleep window by backing up from a wake time, you can see how these two strategies are really worked together. And so they're often presented really in the same vein. It's not that you're working on one in one session and another in another session. So when you present that sleep window, you also sort of bring in the stimulus control concepts of, you know, you might, if you get to 1 a.m. and you're still really amped up and not ready to sleep, you know, wait 15 or 20 minutes before going to sleep and seeing if you're a little bit more sleepy. Now, as people are going through sleep restriction, they're probably gonna be pretty sleepy by that time, but just to bring that in as well. And you can also talk about if you are awake for about, again, 20 minutes or more, not looking at the clock or watching the clock, but just sort of your internal sense, then do get up, go do something, not too stimulating, ideally in another room. Although I've also practiced in New York City where it's, you know, not everybody has another room to go to. If you can just sit in a chair rather than sit in your bed, that works as well. So you'll really do all of that behavioral work together. And again, just as a reminder to everyone, I know our hosts put this in the chat as well, but we have another great talk up next for you at 1.30 following the lunch break. We'll have a few minutes more if there are any additional questions. Thank you.

Cognitive Behavioral Therapy for Insomnia

CBTI

insomnia

sleep restriction

stimulus control

digital health interventions

Kelly Schaefer

University of Virginia

insomnia treatment