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"Integrating Behavioral Therapies and Hypnotic Medications in Insomnia Management" Suzanne M. Bertisch (01/05/2022)

January 16, 2022

"Integrating Behavioral Therapies and Hypnotic Medications in Insomnia Management" Suzanne M. Bertisch (01/05/2022)

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  • 00:00Those people from other institutions as well.
  • 00:03It's almost everybody sleep.
  • 00:05Occasionally we'll have somebody come
  • 00:06in who's interested from psychology or
  • 00:08from neurology or from other disciplines,
  • 00:10so it's pretty diverse group.
  • 00:15Alright, so we're just letting people
  • 00:17in so good afternoon everyone and
  • 00:20welcome back to our spring semester
  • 00:22for Yale Sleep Seminar and I will start
  • 00:25with just a couple of announcements.
  • 00:27First, just to remember that these
  • 00:29seminar lectures are available for CME
  • 00:31credit and that to receive credit,
  • 00:33you just need to text the ID for the lecture
  • 00:36to Yale clouds the money by 3:15 PM today.
  • 00:38So information I had to do that
  • 00:40will show up in the chat as well
  • 00:42as the code will show up later.
  • 00:44Recordings of the lectures are
  • 00:46available in approximately 2 weeks
  • 00:48at the site noted in the chat.
  • 00:50CME credit isn't available for
  • 00:51later viewings and then finally,
  • 00:53if you have questions during the talk,
  • 00:55please use the chat.
  • 00:56We will address these at the end and
  • 00:59I'll moderate so now it is my pleasure
  • 01:01to introduce today's lead seminar.
  • 01:03Speaker, Doctor Suzanne, British doctor.
  • 01:06British is an assistant professor
  • 01:07of medicine and Sleep Medicine
  • 01:09at Harvard Medical School and is
  • 01:11clinical director of Behavioral Sleep
  • 01:12Medicine at Brigham and Women's.
  • 01:14Hospital she received her MD from
  • 01:17State University of New York at
  • 01:19Stony Brook and her MPH from Harvard
  • 01:21School of Public Health.
  • 01:22She subsequently completed her
  • 01:24internship and residency in internal
  • 01:26medicine at Beth Israel.
  • 01:28She went on to do a clinical research
  • 01:30fellowship in the Division for
  • 01:31Research and Education in Complementary
  • 01:33and Integrative Medical Therapies
  • 01:35at Harvard Medical School,
  • 01:36and this was followed by a Sleep
  • 01:38Fellowship at Sleep Health Centers
  • 01:40in Brighton,
  • 01:40followed by a clinical Sleep Medicine
  • 01:42Fellowship in the division of
  • 01:44Pulmonary Critical Care and Sleep
  • 01:46Medicine at Beth Israel.
  • 01:47Doctor Burtis has been on the faculty
  • 01:49at Harvard Medical School since
  • 01:512008 and is currently assistant
  • 01:53professor of Medicine.
  • 01:54She now serves as clinical director of
  • 01:57the Behavioral Sleep Medicine Program
  • 01:58at Brigham and Women's Hospital,
  • 02:00so she has been an active member of
  • 02:02the American Academy of Sleep Medicine,
  • 02:04importantly serving as a committee
  • 02:06member on the behavioral Insomnia
  • 02:08Guideline Task Force,
  • 02:09and she's currently chair of the
  • 02:11Young Investigators Research Forum.
  • 02:13She is an active member of the society.
  • 02:15Behavioral Sleep Medicine has served
  • 02:16as chair of the Education Committee.
  • 02:18And is currently on the Board of Directors.
  • 02:21She also serves on the Sleep and
  • 02:23Respiratory Neurobiology web committee
  • 02:25patient education subgroup for the
  • 02:27ATS and is on the membership committee
  • 02:29of the Sleep Research Society.
  • 02:31She's principal investigator or Co.
  • 02:33Investigator on many active and
  • 02:35diverse projects.
  • 02:3622 numerous really to name for this,
  • 02:38but I'll include some mechanisms
  • 02:40underlying the blood pressure
  • 02:42lowering effect of sleep extension,
  • 02:44inflammation and sleep restriction
  • 02:46and recovery.
  • 02:46The development of a sleep health
  • 02:49intervention for football players.
  • 02:50Sleep disruption and neuronal
  • 02:51dysfunction in early Alzheimer's
  • 02:53disease and evidence based peer
  • 02:55support interventions to promote
  • 02:57PAP use among others.
  • 02:58So we are really fortunate to have
  • 03:00Doctor Burtis join us today to
  • 03:02discuss an important and clinically
  • 03:04relevant topic integrating behavioral
  • 03:06therapies and hypnotic medications.
  • 03:08Insomnia management so
  • 03:10welcome doctor. British.
  • 03:12Thanks so much for that warm introduction
  • 03:15Janet and thanks so much for everybody
  • 03:17for taking time out of your busy day.
  • 03:19I know it's a tough time for all of us.
  • 03:21I appreciate you coming along
  • 03:23and hearing me speak today,
  • 03:25and hopefully this talk will
  • 03:28not just be interesting.
  • 03:30Beauty soporific though actually my
  • 03:32goal is to give you actually real tools
  • 03:34that you can bring to your bedside,
  • 03:35and this topic is very close to both
  • 03:37my research and clinical passions.
  • 03:41So I'm just gonna go ahead and get started
  • 03:44and hopefully everybody can can hear me.
  • 03:47Here I do have some conflicts of
  • 03:49interest through some consultants
  • 03:51that have been mitigated,
  • 03:52and when I referred to any
  • 03:54of the medications by name,
  • 03:56I will note any evidence that it
  • 03:58turns to it or off label indications.
  • 04:01So the learning objectives today.
  • 04:03At first we're going to start
  • 04:05by summarizing the guidelines,
  • 04:06supporting the use and timing of
  • 04:08both behavioral and pharmacological
  • 04:09treatments for insomnia,
  • 04:10so this is really sort of like
  • 04:12the level up part of the talk,
  • 04:13so everybody is on the same page and we
  • 04:15know what I'm referring to buy medications.
  • 04:17Which medications where they fall in as
  • 04:20well as behavioral therapies as well?
  • 04:22And then we're going to get into
  • 04:24a discussion of talking about what
  • 04:26is the literature in terms of using
  • 04:29these strategies in terms of choosing
  • 04:30one strategy over the other and
  • 04:32in terms of timing and sequencing,
  • 04:35that will allow you then to develop
  • 04:37and implement, you know,
  • 04:38evidence based treatment plans for
  • 04:40your patients, but also importantly,
  • 04:42trying to connect both what we
  • 04:44know from the evidence based and
  • 04:47into implementation.
  • 04:47As far as how to bring this information
  • 04:50to the bedside and actually implement
  • 04:52real plans of care for your patients in
  • 04:54the clinic in order to really optimize
  • 04:57their insomnia treatment as best as
  • 04:59possible on mitigating side side effects.
  • 05:02So it's mostly you probably already
  • 05:03know in 2016 was really sort of a a
  • 05:06change in the OR the thought process,
  • 05:08and the way we think about treating
  • 05:09insomnia and the American College
  • 05:11of Physicians again,
  • 05:12which I think all of you know,
  • 05:14is a very large,
  • 05:16prominent Society of internal.
  • 05:17Medicine, which again is my background.
  • 05:20I thought they came out with a a
  • 05:22strong recommendation that all adult
  • 05:24patients received cognitive behavioral
  • 05:26therapy for insomnia as the initial
  • 05:28treatment of chronic insomnia,
  • 05:29and this was very different CBT I
  • 05:32as it's referred to as was around
  • 05:35for several decades.
  • 05:36But this was the first guideline to
  • 05:38really make it prominent and put it
  • 05:40to the top and it and really was a
  • 05:43change in the way we conceptualized
  • 05:45treatments,
  • 05:45and we'll talk about the limitations
  • 05:47of the guidelines.
  • 05:48Later in the talk and and then,
  • 05:50this was followed by a recommendation
  • 05:52that patient clinicians use a
  • 05:54shared decision making approach,
  • 05:56and we'll talk more about what
  • 05:58that actually means,
  • 05:59including a discussion that benefits,
  • 06:01harms and costs for medication.
  • 06:03So really demoting medications
  • 06:04to to second line. You know.
  • 06:07Obviously when these treatments,
  • 06:08these treatments are available,
  • 06:09so this was a a guideline that came
  • 06:12out in 2016 as many do also know,
  • 06:14there are several international
  • 06:16guidelines and other guidelines in the.
  • 06:18American Academy of Risk of Sleep
  • 06:21Medicine in the recent years
  • 06:23also recently updated the there,
  • 06:25the the guideline for behavioral
  • 06:28psychological treatments for
  • 06:29insomnia and then a few years ago,
  • 06:31I believe it's 2017 that the
  • 06:34pharmacological treatment for
  • 06:35insomnia guideline came out.
  • 06:37So this is great in that we have a lot
  • 06:40of evidence supporting both cognitive
  • 06:42behavioral therapy for insomnia in
  • 06:45pharmacological therapy for insomnia.
  • 06:47But the way the but these guidelines
  • 06:49don't address and what we face is
  • 06:50clinicians every day in clinic when
  • 06:52we're treating patient is how do we
  • 06:54actually choose which treatment to use,
  • 06:56right?
  • 06:56We have like these these a lot of
  • 06:59tools in our in our that we can use,
  • 07:01but how do we use those and something
  • 07:03I actually don't like about the the
  • 07:05structure to it and something I think
  • 07:07unfortunately we hear a lot about.
  • 07:09Our field is that it's a lot
  • 07:10of one or the other.
  • 07:11You know we're gonna use from the therapies
  • 07:13or you gonna use behavioral strategies.
  • 07:16And really,
  • 07:17every pharmacol therapy that you
  • 07:18give actually has a behavioral
  • 07:20component that will get into in.
  • 07:22It creates this false dichotomy that I think
  • 07:26actually undermines the knowledge base.
  • 07:28The skill of clinicians,
  • 07:29and does it disservice to the patients.
  • 07:32So hopefully we'll sort of learn more
  • 07:34about the more Gray and white of medicine.
  • 07:37And though you know,
  • 07:38unfortunately,
  • 07:39we don't have.
  • 07:40Large comparative effectiveness data,
  • 07:42which is really what we need.
  • 07:43We have some data and then you know,
  • 07:46there's also just clinical
  • 07:47knowledge and skill and sense that
  • 07:50we can actually implement plans
  • 07:52that we've both of these roles.
  • 07:54Unruly.
  • 07:55Try to tailor the care for the
  • 07:57patients as best as possible,
  • 07:58so to start up again.
  • 07:59What do we actually mean by
  • 08:01behavioral therapies and,
  • 08:02and this is actually important,
  • 08:03so there's several different steps
  • 08:06that comprise behavioral and cognitive
  • 08:08behavioral treatments for insomnia,
  • 08:10so.
  • 08:11Again,
  • 08:11since you I think most of your
  • 08:13actually sleep providers,
  • 08:14you already know this,
  • 08:15so I won't spend too much time on it.
  • 08:17But when we think of,
  • 08:18you know psychological behavioral treatments,
  • 08:21know when we sort of came up that guideline,
  • 08:23these are.
  • 08:23These were really the large
  • 08:25groups of categories,
  • 08:26and there's there's many other types of
  • 08:28behavioral therapies we won't get into,
  • 08:30but these are the ones that are
  • 08:31sort of been around the longest
  • 08:33and have the most evidence.
  • 08:34Think the one,
  • 08:35the one that's probably not mine, not.
  • 08:37Here is some of the mindfulness
  • 08:40mindfulness work as well.
  • 08:41But essentially they're sleep hygiene,
  • 08:43which is a cornerstone button.
  • 08:45Own our guideline.
  • 08:46We actually came out and recommend
  • 08:48using sleep hygiene as a monotherapy
  • 08:51and to clarify the use of sleep.
  • 08:52Hygiene is really a focus on sleep practices.
  • 08:54Healthy sleep practices that serve
  • 08:56as like the the barebone minimum
  • 08:58of what people need to do in
  • 09:00order not to perpetuate insomnia,
  • 09:02but it's probably not effective
  • 09:04enough for most pages.
  • 09:05Patient as a mono treatment.
  • 09:07So the real need of the behavioral therapy,
  • 09:09which we'll talk about,
  • 09:11is really sleep restriction.
  • 09:12Therapy where we reduce the time
  • 09:14people spend in bed to increase sleep,
  • 09:16drive into sort of,
  • 09:17we align that with the circadian
  • 09:19timing as best as we can tell.
  • 09:21Clinically,
  • 09:21stimulus control to reduce the arousal,
  • 09:24the environment,
  • 09:25and then aspects of cognitive therapies,
  • 09:27or restructuring maladaptive
  • 09:30beliefs in their impact on insomnia
  • 09:32and then relaxation training,
  • 09:34which I won't talk much about in this talk.
  • 09:36'cause this hasn't actually been studied,
  • 09:37usually as part of the sequential
  • 09:40studies that we'll talk about, but.
  • 09:42But to note that when I refer to
  • 09:45CBT in this talk CBT I is you know
  • 09:48best studies as a multi component
  • 09:50strategy that actually combines
  • 09:52usually these five components
  • 09:54to in packages together in a
  • 09:56comprehensive standardized program.
  • 09:58So when I refer to CBT it'll be the
  • 10:00package of it and I'll just sort of
  • 10:02denote therapies that may be pulled apart.
  • 10:04Some of the monotherapy.
  • 10:05So again this is CBT,
  • 10:07I is the gold standard and these
  • 10:10are the components of it and
  • 10:12and this is what it says in.
  • 10:13In the guidelines,
  • 10:14right?
  • 10:14This is what we're all supposed to be using,
  • 10:16but as you also allowed know that CBT it
  • 10:19knows is really a supply and demand issue.
  • 10:21So this is a slide that I I I got
  • 10:24from Dan Buysse and and this is
  • 10:26actually from several years ago.
  • 10:28But he actually plotted and estimated
  • 10:30how many people had insomnia disorder,
  • 10:32which was a low estimate of
  • 10:34over 12 million people.
  • 10:35And at the time there are 213
  • 10:37registered CBT I providers.
  • 10:40They were certified of BSM which
  • 10:43left about 60,000 patients.
  • 10:44Per provider per year,
  • 10:46so obviously supply far outstripping
  • 10:49demand and then even on a log scale
  • 10:51you can see how severe you know
  • 10:54the the the supply of providers
  • 10:58is so because of that there's been
  • 11:00a real movement in our field to
  • 11:02develop more accessible options,
  • 11:03so something that we we use in
  • 11:05our clinic here at the Brigham
  • 11:07and Faulkner and that we've done
  • 11:09studies on is looking at brief
  • 11:11behavioral treatment of insomnia.
  • 11:12There's several research studies
  • 11:14looking at single component treatments
  • 11:16and then mobile based apps and
  • 11:19online treatments and and some risk,
  • 11:22which is the first digital FDA
  • 11:24approved treatment for insomnia
  • 11:26that is available digitally.
  • 11:27So we're making a lot of progress
  • 11:29in the field.
  • 11:30Again,
  • 11:31there's always implementation barriers,
  • 11:33but CBT is becoming more readily
  • 11:35available for people so that
  • 11:38that's sort of the land.
  • 11:39The important thing to note is that despite.
  • 11:43You know that CBT is a very
  • 11:45effective strategy.
  • 11:46We do know that you know it doesn't work
  • 11:48for every patient it has access issues.
  • 11:51Just as we talked about,
  • 11:53and even the digital strategies.
  • 11:55You know it's not going to be
  • 11:57appropriate for some patients.
  • 11:58There's still a lot of language,
  • 11:59cultural barriers, cost issues.
  • 12:02That's preventing,
  • 12:03you know, broad spread,
  • 12:05use of digital therapies,
  • 12:06and actually data from one of the
  • 12:09large pivotal trials of shut eye,
  • 12:12which is actually the.
  • 12:13The research version of of some risk which
  • 12:16is actually at FDA approved version.
  • 12:18If you look on this side,
  • 12:19this was a this is one of the larger
  • 12:22trials and they followed patients that
  • 12:24went through that eight to nine week.
  • 12:27Should I program which delivers CBT.
  • 12:29I did therapy so actually delivers
  • 12:31almost all of the components.
  • 12:33For those of you who are not familiar to it,
  • 12:35it showed you know this was the
  • 12:37proportion of non responders.
  • 12:39So people who who did not achieve
  • 12:42a certain level of improvement,
  • 12:44that was.
  • 12:44Predefined usually for insomnia we
  • 12:47identify non responders with people
  • 12:49who don't drop at least seven points
  • 12:51on the ISI scale which is a 28
  • 12:53point scale that's commonly used in.
  • 12:56And an outcome trials of both
  • 12:58behavioral and some pharmacological
  • 13:00therapies for insomnia.
  • 13:01So post treatment in the shadow arm,
  • 13:04which you see in in orange or red about.
  • 13:07You know about half of the
  • 13:09half of the patients.
  • 13:11Responded so about half didn't
  • 13:13respond and obviously many were
  • 13:14nonresponders in the control group,
  • 13:17but as they follow people overtime
  • 13:19at six months and one year you
  • 13:21could still see that about 1/3 of
  • 13:24patients to who were in the CBT I arm.
  • 13:27Like still still did not respond
  • 13:29so so despite even if it was
  • 13:32available for everybody,
  • 13:33you know it's not going to be perfect
  • 13:34and every and it was sort of just don't
  • 13:36know this from you know any medicine?
  • 13:38There's always individual
  • 13:39response and variation.
  • 13:40That's that's just how.
  • 13:41It works,
  • 13:42so this is sort of amplifies,
  • 13:43you know, sort of the need that,
  • 13:44despite CBT being effective,
  • 13:47safer than medications.
  • 13:49You know,
  • 13:49we still need other types of therapies
  • 13:52to tackle the problem of insomnia,
  • 13:54so the good the good news is we have
  • 13:56a lot of different medications to try,
  • 13:58and again,
  • 13:58this is not going to be a talk focusing
  • 14:00on on all the different medications
  • 14:02we have 'cause most of the most of
  • 14:04the research looking at you know,
  • 14:06behavioral versus pharmacological
  • 14:07therapy versus combined that
  • 14:08you'll see is really focused on
  • 14:11this first category which is
  • 14:12the benzodiazepine receptor.
  • 14:14Agonist,
  • 14:14so this is actually here.
  • 14:15I'm sort of lumping together the
  • 14:18traditional benzodiazepine's as
  • 14:20well as the non benzodiazepine
  • 14:22benzodiazepine receptor agonist
  • 14:24like zolpidem zopiclone most of
  • 14:26those are FDA approved.
  • 14:27Not all of them,
  • 14:28and then we also have several
  • 14:29other medications like therapy.
  • 14:31I mean that includes several other
  • 14:34FDA approved medications for insomnia
  • 14:36so melatonin agonist FDA one being
  • 14:39rozerem the the newer do lyrics and
  • 14:42receptor antagonist, so this is there.
  • 14:45Super excellent and recently
  • 14:46approved Lemon Brexit fund have fall
  • 14:49under a sedating antidepressants
  • 14:51with Doxepin at low dose Doxepin.
  • 14:55Having FDA approval for insomnia
  • 14:56and then commonly off label use for
  • 14:59Trazodone and then several other
  • 15:01lesser studies or lesser effective
  • 15:03treatments including antipsychotics,
  • 15:05anti convulsants and over the counter
  • 15:08medications which is predominantly non
  • 15:10selective antihistamines so this is sort
  • 15:12of the smattering of of things we can treat.
  • 15:15Patients with insomnia.
  • 15:16So the point being is that we have
  • 15:19a lot of options and I know what
  • 15:21our fellow struggle struggle with.
  • 15:23Swipe at the Brigham we created
  • 15:25actually insomnia clinic to try to
  • 15:27concentrate some treatment of insomnia
  • 15:29in terms of pharmacological therapy,
  • 15:31but also teaching them how to deliver
  • 15:34behavioral treatments of insomnia.
  • 15:35And you know, like many clinicians,
  • 15:37our fellow sometimes struggle like.
  • 15:39How do I?
  • 15:39How do I think about all these choices?
  • 15:41I have both behaviorally,
  • 15:43but also for medications.
  • 15:45And again,
  • 15:46because we lack data, you know,
  • 15:48unlike the JNC 8 guidelines,
  • 15:50where if you have a
  • 15:51patient with hypertension,
  • 15:51you actually kind of have a sense of
  • 15:53how to treat them and what works best.
  • 15:54We really don't have Rd maps
  • 15:56like that in in slave,
  • 15:57so it's important to really have a solid
  • 16:00foundation of how these medications differ,
  • 16:02how they would work once you,
  • 16:03how to select medications.
  • 16:05Again,
  • 16:05I'm not going to go into that in that talk,
  • 16:07that's a separate carmickle therapy tough.
  • 16:10Or you can read our chapter and
  • 16:12Doctor Krieger's new principles
  • 16:13of practice where we discuss that.
  • 16:17But this is just a little land
  • 16:18for the following discussion
  • 16:19about how to think of it.
  • 16:21So again in the guideline I mentioned before,
  • 16:23this may probably won't come as most
  • 16:25of surprised you being asleep audience.
  • 16:27But you know the the ASM task force for
  • 16:30Franco therapy for insomnia came out
  • 16:32in support of a lot of the business
  • 16:35days that can receptor agonist,
  • 16:37Doxepin,
  • 16:38ramelteon suvorexant and then
  • 16:40we get evidence against.
  • 16:42Again,
  • 16:42not surprising,
  • 16:43but I think many people do
  • 16:45get surprised that.
  • 16:46But Trazadone was actually recommended
  • 16:49against by the in this guideline,
  • 16:52and notably because of the really
  • 16:54the limited evidence on efficacy and
  • 16:56the suggestion from the one actually
  • 16:59primary study that was reviewed
  • 17:01that suggested potential harm.
  • 17:03I mean there there are some other studies
  • 17:05on transitone that weren't included,
  • 17:06but really across the board that the
  • 17:08data supporting that transition alone
  • 17:10is efficacious for the treatment
  • 17:12of insomnia is pretty nonexistent,
  • 17:14so just something to keep in mind when
  • 17:16thinking about developing evidence.
  • 17:18Based practices for patients,
  • 17:20we published a study.
  • 17:21It's it's sort of old data now from 2010,
  • 17:24just showing that.
  • 17:25You know,
  • 17:26among prescription medications
  • 17:27used for insomnia,
  • 17:29that the benzodiazepine receptor agonists
  • 17:32are are still the most commonly used,
  • 17:35but Trazodone is that the second
  • 17:37one was commonly used as well,
  • 17:39and when we swim when participants
  • 17:41were specifically asked about,
  • 17:43did you use a sleep medication?
  • 17:45You know, almost 20% of adults?
  • 17:47the United States said that yes,
  • 17:49and this actually included
  • 17:50over the counter medications,
  • 17:51so meaning that you know a lot of
  • 17:54patients are still turning to pharmacol.
  • 17:56Logical strategies for insomnia 2,
  • 17:59so again, it's important to sort of review.
  • 18:02You know some basic points.
  • 18:04About choosing those medications,
  • 18:06having discussions about over
  • 18:08the medication use, you know,
  • 18:10and getting a full assessment
  • 18:11from the patient.
  • 18:12We also noted that over half
  • 18:13of patients using a hypnotic,
  • 18:15we're taking at least one other
  • 18:17sedative medications such as an opioid
  • 18:20or other type of benzodiazepine,
  • 18:21and about 10% of the sample took three
  • 18:25or more commonly sedating medications,
  • 18:28and you'll see this will come up later
  • 18:30in the talk when we talk about Safety
  • 18:32Council regarding safety for medications.
  • 18:34For insomnia,
  • 18:35and this is more recent data that we we
  • 18:38did here that use a different data set,
  • 18:40but showed that you know
  • 18:42over about the past decade,
  • 18:43this is all pre pandemic.
  • 18:46That president prescriptions have been
  • 18:48increasing and this actually held true
  • 18:50across different doses of of trust that
  • 18:52we looked at lower lower dose trazadone.
  • 18:54Very low dose.
  • 18:55Lower dose in this actually was similar
  • 18:58across age groups and also also noted that.
  • 19:02That over the same period of time that
  • 19:04zoptic prescriptions were actually happened.
  • 19:06Deep decreasing.
  • 19:06So if you see on the
  • 19:08bottom since 2011 to 2018,
  • 19:11the ambient stories open
  • 19:13prescriptions have been decreasing,
  • 19:16while trazadone slightly increasing as well.
  • 19:19So again,
  • 19:19there's sort of been a shift.
  • 19:22That have been occurring because of several
  • 19:24risks that we know about benzodiazepine use,
  • 19:26and I'm focusing mostly on these
  • 19:29because there's a lot of evidence this
  • 19:30sort of been in use for the longest.
  • 19:32These are the medications you'll see
  • 19:33pop up and in the trials that I'll
  • 19:35I'll talk about in a few minutes.
  • 19:37But as we all know,
  • 19:39you know it's important benzodiazepine's
  • 19:42are effective for treating insomnia.
  • 19:45But as we also know, the big carry risk too.
  • 19:47So again, this is sort of,
  • 19:49you know, one or the other.
  • 19:50We know the behavioral treatments
  • 19:51aren't perfect for treating insomnia.
  • 19:53But we know medications also have.
  • 19:56They may be efficacious,
  • 19:57but also care risk factors for again,
  • 19:59it just makes our job a little bit harder.
  • 20:02Thinking about what medication we may choose,
  • 20:05what,
  • 20:05what treatment strategy we should
  • 20:07choose for a patient on what
  • 20:09medication strategy is best,
  • 20:10knowing that we may be able
  • 20:11to treat their insomnia.
  • 20:12But we have to be very aware of the
  • 20:14potential risks that we're introducing.
  • 20:16So for benzodiazapines know
  • 20:17there's several studies that show
  • 20:19that it increased risk of motor
  • 20:21vehicle accidents in the elderly.
  • 20:23It's been associated with hip fractures.
  • 20:26It's it causes anterograde amnesia.
  • 20:30There's some suggestion.
  • 20:31There's limited suggestions that
  • 20:32people build a tolerance from it,
  • 20:34but I sort of have found,
  • 20:35at least in my clinic,
  • 20:36that I I often see a tolerance
  • 20:38for patients which
  • 20:39is different from what's in this study.
  • 20:41And as we all know,
  • 20:42there's been recent black box warning for
  • 20:44the use of these medications as well,
  • 20:46so these are these are real issues to
  • 20:49think about when prescribing hypnotic
  • 20:52medication medications. In detail,
  • 20:54so that's really the first part of the talk.
  • 20:56Pushes to kind of get everyone up to speed
  • 20:58on like what is what is the data show?
  • 21:00What is the guidelines say we should use,
  • 21:03but how do we actually think about using
  • 21:05all of these strategies and therapies?
  • 21:09You know to our advantage?
  • 21:10You know when we're actually
  • 21:11at the bedside with patients,
  • 21:13this is really where the rubber
  • 21:14meets the road.
  • 21:15And how do we think through this?
  • 21:18I've been thinking about, you know,
  • 21:19treatment strategies to providing
  • 21:21really standard of care or evidence
  • 21:24based medicine for insomnia treatment.
  • 21:26You know,
  • 21:27the actual evidence is is one part of it,
  • 21:29and this is something that will
  • 21:30come up again later.
  • 21:31In the talk.
  • 21:32You know there's there's what
  • 21:33the science says to do from,
  • 21:35you know clinical trial data.
  • 21:36But then there's also,
  • 21:37you know,
  • 21:38you know what we're learning is
  • 21:40equally as important or really the
  • 21:42behavioral science aspects of it.
  • 21:44What's acceptable to patients,
  • 21:46what's appropriate for patients?
  • 21:48Will the patients actually?
  • 21:49Use it,
  • 21:49is it something that's feasible
  • 21:51for them and will they?
  • 21:52Will they stick with the work?
  • 21:55So in thinking about choosing,
  • 21:57you know medic roughly like
  • 21:59medications or behave cognitive
  • 22:01behavioral therapy for insomnia.
  • 22:02Unfortunately, there's there's not a
  • 22:04lot of studies that I've compared them,
  • 22:06and I'm going to sort of go through.
  • 22:09You know what we do know from from the
  • 22:11evidence based and then tide in together to,
  • 22:13you know, apply that to patients.
  • 22:15So really, you know, Charles Marin really
  • 22:18is spearheaded a like much of this work.
  • 22:22And there's, you know,
  • 22:23some early studies that are helpful in
  • 22:25thinking about you know which do we choose?
  • 22:28Is this CBT?
  • 22:29I better to get all of these looked at CBT
  • 22:31on this slide versus medications and all of
  • 22:34these studies looked at have benzodiazepines.
  • 22:36Something that works in the
  • 22:37benzo benzodiazepine receptor.
  • 22:41And I think and and so the first
  • 22:43study was by, you know,
  • 22:45led by Charles and in 1999.
  • 22:49And these four studies that I present here,
  • 22:51as you can see here, all small.
  • 22:52So the first is the marine
  • 22:54study and you know,
  • 22:56there are 18 patients with CBT,
  • 22:58I-20 with temazepam and then they
  • 23:00also looked at combined placebo and
  • 23:03then in 2006 there was actually
  • 23:05similar studies that compared.
  • 23:07You know CBT I versus either singular
  • 23:11Med options combine and versus placebo.
  • 23:13And once you can see what they all have
  • 23:16in common is they're not very big.
  • 23:19They're pretty small studies.
  • 23:21And what they also had in common is
  • 23:23that they they all showed a similar
  • 23:26benefit short term between CBT I and
  • 23:28ZOPICLONE and I think this is these
  • 23:30are really important studies for for
  • 23:33behavioral Sleep Medicine people to
  • 23:35show you know that these techniques
  • 23:37work as well as they seem to work as
  • 23:39well as these medications which is important.
  • 23:42But you know these are these
  • 23:44are pretty small studies,
  • 23:45a couple of other things that the
  • 23:48studies observed is that CBT I seemed.
  • 23:50Got to have a longer benefit long
  • 23:52term from 6 to 24 months I will
  • 23:55have to say you know,
  • 23:56someone who's actually reviewed
  • 23:57these studies and they're in there
  • 23:59are a lot of dropouts in studies,
  • 24:01and I don't and I don't.
  • 24:02I don't think this is conclusive,
  • 24:04and the reason why I bring it
  • 24:05up is because this is, I think,
  • 24:06one of the myths that sort of gets
  • 24:08perpetuated and you'll see in later
  • 24:10later studies you know may not provide
  • 24:12the same evidence of support of this.
  • 24:15So I think it's just like it's important to
  • 24:17dispel these messages as our data evolves.
  • 24:20And actually these studies.
  • 24:21Also showed that combining CV2
  • 24:23with medications may have a slight
  • 24:25advantage over single therapy.
  • 24:27Short term, and again,
  • 24:28this is also usually different
  • 24:30from what people say, right?
  • 24:31We usually hear about that
  • 24:33false dichotomy of meds or CBT,
  • 24:35and I've had patients turned down to CBT.
  • 24:37I because they were on the medication,
  • 24:39so I think it's important to to know
  • 24:41these studies and actually know
  • 24:42what they they show in terms of
  • 24:44the benefits and seemingly
  • 24:46equal benefits short term,
  • 24:47but also know what they didn't show
  • 24:49and that you you know you can.
  • 24:50You can still use these medications.
  • 24:52Together and you know,
  • 24:52and then we think about
  • 24:53how to use them together,
  • 24:55so these so these were important
  • 24:56early studies to really put,
  • 24:58I think CBT in the map show that they you
  • 25:01know whereas effective medication short term.
  • 25:04And then, and you know what the
  • 25:07take home message being that either
  • 25:09CBT or one of the benzodiazepine
  • 25:12receptor medications are are actually
  • 25:14reasonable first line approaches.
  • 25:17You know from what we can
  • 25:18tell from this evidence,
  • 25:20then Doctor Marin actually
  • 25:22had a another sort of.
  • 25:25Practice informing studied in
  • 25:272009 and this was a little bit
  • 25:30of a more complicated trial.
  • 25:32Was a smart design which means
  • 25:34that they actually randomize people
  • 25:35multiple times in this study.
  • 25:37So in this study and I'll go through
  • 25:38it in more detail the next side.
  • 25:40But essentially they initially randomized
  • 25:42people and they had about 160 people total,
  • 25:45so half of the people were randomized to CBT.
  • 25:48I and the other half were randomized
  • 25:50to combine treatment, so CBT,
  • 25:52I plus soulpad M and then after six.
  • 25:56Freaks people were re randomized again to
  • 25:59either the treat to either to either though,
  • 26:03and I'll actually go through it on
  • 26:05the next side, 'cause it's easier,
  • 26:07but this this was the study.
  • 26:09So whoops, yes. So here's 160 people.
  • 26:13So 80 were randomized to CBT I
  • 26:16and then they underwent a a second
  • 26:19randomization where they were
  • 26:21re randomized to extended CBT.
  • 26:24I so the CBT I then extended CPT I.
  • 26:27Or CBT are no treatment and those
  • 26:31who received CBT I, plus zolpidem.
  • 26:34Were re randomized to extended CBT.
  • 26:37I so combined followed by CBT I.
  • 26:41Or extending or extending the
  • 26:43combination so those were the
  • 26:45four possibilities and these are.
  • 26:47As you can imagine, are complex trials,
  • 26:49and you can note that you know
  • 26:51towards the end there's there's
  • 26:52fewer people in each subset,
  • 26:53but regardless,
  • 26:54this is really an important larger
  • 26:56study that actually I think has
  • 26:58some important gives us a lot
  • 27:00of information about this common
  • 27:02clinical problem that we see.
  • 27:04So this this is a this figure is
  • 27:06actually showing the proportion
  • 27:08of treatment responders,
  • 27:09so again these are people who achieved.
  • 27:11At least a seven or eight point
  • 27:13reduction of the Insomnia Severity
  • 27:15Index is their outcome,
  • 27:16and these are presented proportion of
  • 27:19patients by the filing initial randomization.
  • 27:23I'm sorry about that.
  • 27:26So over here,
  • 27:27for those two are randomized first
  • 27:29to CBT I so with the first six weeks
  • 27:32of treatment about 60% of patients
  • 27:35responded and this is actually
  • 27:37similar to those that had CBT or
  • 27:39so put them so that the combination
  • 27:42therapy these looked about the
  • 27:44same so you know so see so the the
  • 27:47medication didn't make CBT any worse,
  • 27:48which is sort of the myth that we hear about.
  • 27:51And then when we looked at extended
  • 27:53treatment for the CBT group.
  • 27:54So those in the darker Gray had.
  • 27:57See an extra extended to CBT for
  • 28:00six months versus those with none.
  • 28:03You know it looks like
  • 28:04those with CBT extended.
  • 28:05Did a little bit better but there
  • 28:08were not substantial differences in
  • 28:10long term and those that perceive the
  • 28:13combined treatment initially those
  • 28:15that continue to receive the the
  • 28:18combination there be again seem to
  • 28:20to do to do better and but those who
  • 28:23seem to do the best for those who got
  • 28:25the extend who started the combination.
  • 28:27Therapy was continued for CBT.
  • 28:29I over a period of time again these
  • 28:32start getting out to to smaller
  • 28:34groups and this is similar results
  • 28:36we're seeing with Remitters.
  • 28:37So this is actually the proportion
  • 28:39of patients who by definition
  • 28:41no longer had insomnia.
  • 28:42So there ISI total scores are under 7,
  • 28:45so you can see you know both groups in
  • 28:48the short term did fairly fairly well.
  • 28:50Not much change in the extended CBT group.
  • 28:54Whether they got treatment or no treatment,
  • 28:56but those who received the
  • 28:57initial combination.
  • 28:58Therapy actually seem to do better in
  • 29:01the long term with either extending
  • 29:04this cognitive behavioral therapy.
  • 29:06Or the the medication component so you know,
  • 29:10sort of the take home message that
  • 29:11I see from from these cities?
  • 29:13Is that CBT alone has durable effects.
  • 29:16Though combining and then tapering with
  • 29:18medication seems to have the greatest impact.
  • 29:20So that's sort of getting out here.
  • 29:23Again,
  • 29:23these get it to the smaller groups so
  • 29:26it's again hard to be more conclusive
  • 29:28than all that what that shows.
  • 29:30But this was really one of the first
  • 29:31cities to actually look at this.
  • 29:32The combination of medications
  • 29:35versus CBT CBT.
  • 29:36I alone another interpretation,
  • 29:39you know,
  • 29:40sort of making it as a clinically as
  • 29:42simple as a morsel is that despite
  • 29:44again the myth that you can't
  • 29:45do CBT with medications,
  • 29:47it actually clearly shows that zolpidem
  • 29:49does not impair the response to CBT.
  • 29:51I and actually may.
  • 29:53Augment augment the long term
  • 29:55effects of the medication,
  • 29:56and so again you know there.
  • 29:58There's always a time and
  • 29:59a place for medications,
  • 30:00but this doesn't provide evidence
  • 30:02that the the medication doesn't make
  • 30:04make the response to CBT any worse,
  • 30:06and actually may make it better.
  • 30:08So again,
  • 30:09this was followed up by Charleston,
  • 30:10another study where he has to a
  • 30:13related but different questions.
  • 30:15So the first day was looking at
  • 30:17CBTI versus CBT with medications
  • 30:19as the primary comparison,
  • 30:21and in the more recent study
  • 30:23that was published,
  • 30:24I forget which gym and
  • 30:26network Jim Psychiatry.
  • 30:27In 2020 he actually had the question
  • 30:29of not just one versus the other,
  • 30:32but actually what is.
  • 30:33What do we know about the sequencing
  • 30:35of of medications and CBT?
  • 30:38I so this is another you know for this field,
  • 30:40larger study of over 200 people
  • 30:44and this was you know,
  • 30:45middle aged adults and have
  • 30:46no you know more than
  • 30:47a third had a comorbid psychiatric disorder.
  • 30:50So so very clinically relevant
  • 30:52in terms of the population that
  • 30:54we commonly see with insomnia.
  • 30:56So this again is another complicated smart
  • 30:59design study with a 2 step randomization so.
  • 31:02As the main comparison, they randomized
  • 31:05people to either behavioral therapy.
  • 31:07So this is not CBT.
  • 31:08I this is just behavioral therapy,
  • 31:10mostly stimulus control and sleep
  • 31:12restriction, versus azole epidemic.
  • 31:14Again, I think was like 5 to 1010 milligrams
  • 31:17at the time and then as a second step.
  • 31:20If you receive behavioral therapy
  • 31:23as your first line and continue to
  • 31:25have symptoms so those that were
  • 31:27remission were not re randomized
  • 31:29'cause they no longer had symptoms,
  • 31:31you were re randomized to
  • 31:33medication or cognitive therapy.
  • 31:35So those that had behavioral therapies
  • 31:38were were bumped and didn't respond,
  • 31:40were bumped up to either medication
  • 31:42or cognitive therapy to figure out,
  • 31:44you know,
  • 31:44if you don't respond to behavioral therapy,
  • 31:46what is what's best next?
  • 31:49And similarly,
  • 31:50if you started with the medication
  • 31:52and didn't respond,
  • 31:53your re randomized to behavioral therapy
  • 31:55as a second line or switching from
  • 31:58Zoll Paden to Trazodone medication.
  • 32:01So a complex study will go through the
  • 32:04results and you can see once you start
  • 32:06getting to these these groups down here,
  • 32:08the numbers do get do,
  • 32:09get smaller,
  • 32:10and when they actually power the studies
  • 32:12they actually powered up the order
  • 32:13up here just to keep that in mind.
  • 32:15So this is still the primary
  • 32:17compare comparison up here and
  • 32:18this starts giving us some.
  • 32:20Information about the ordering,
  • 32:21which are really, you know,
  • 32:23they're designed to really answer,
  • 32:24like clinically important,
  • 32:26important questions that we have.
  • 32:29So what did they find in this figure
  • 32:32shows the response and remission rates,
  • 32:34so those are the two different blue
  • 32:36colors for the Firstline strategy.
  • 32:37So again,
  • 32:38this is after the first randomization
  • 32:40of looking at behavioral therapy.
  • 32:42Insulted and and you could see that
  • 32:45the the impact was actually similar in
  • 32:47terms of response rate across groups.
  • 32:49The behavioral therapy.
  • 32:51Had you know, higher remission rate.
  • 32:53But again,
  • 32:55patients did well essentially
  • 32:57have about the same.
  • 32:59The proportion of patients with
  • 33:01improvement were similar across groups.
  • 33:03In the second line of treatment again.
  • 33:08Looking broadly, you could see,
  • 33:10so this is these are these two groups here?
  • 33:12Those who were first randomized
  • 33:15to behavioral treatment and these
  • 33:17who received zolpidem first,
  • 33:19so you could see that those overall those
  • 33:22who receive behavioral therapy first,
  • 33:24no matter what their second line is.
  • 33:27I'm actually continue actually
  • 33:29improves more than those who had
  • 33:32zolpidem as first line response.
  • 33:35So when when patients?
  • 33:38Oh sorry,
  • 33:38this sort of got.
  • 33:43So the the behavioral the the
  • 33:47behavioral therapy nonresponders
  • 33:49did better when when offered you
  • 33:51know another option for second line,
  • 33:53so either medications or cognitive therapy.
  • 33:56Those who receive medication first line.
  • 33:59If the medications didn't work for them,
  • 34:01behavioral therapy was less helpful.
  • 34:03So again, you know this may be similar
  • 34:06to you know you know whether or not
  • 34:09this this is sort of supports the the
  • 34:11ACP guideline of offering cognitive
  • 34:14therapy first is more more helpful,
  • 34:16and I'm not sure really it.
  • 34:17It completely supports that,
  • 34:19but it's it gives you more options if
  • 34:21you have a patient who does a behavioral
  • 34:24therapy first switching them too.
  • 34:26Pharmacological therapy in this case,
  • 34:28so pedem versus adding cognitive therapy.
  • 34:31They seem to improve.
  • 34:32If they didn't respond initially,
  • 34:34whereas if they're on Zhopa damn
  • 34:36initially starting behavioral therapy
  • 34:38or switching them for trazadone didn't
  • 34:40quite have much of an effect as sort
  • 34:43of the the bottom line for this study.
  • 34:45Interestingly, so,
  • 34:46So what I just showed you here is
  • 34:48actually the post assessment period,
  • 34:50and you can see there's you know,
  • 34:51separation of these groups,
  • 34:52so up here is behavioral therapy,
  • 34:54first line,
  • 34:55so this is response rate remission rates.
  • 34:57But then as they followed people
  • 34:59throughout the study.
  • 35:00Again, overtime the groups look the same,
  • 35:03and so you know nihilist would say,
  • 35:04well, it doesn't matter.
  • 35:05You can use any of the combinations,
  • 35:07but I think if someone seeing
  • 35:09patients and thinking about you know
  • 35:11you want your patients to improve
  • 35:12us quickly as possible, you know.
  • 35:15It seems that.
  • 35:17You know the you know the knowing who
  • 35:20actually what your second line options
  • 35:23would be off to get get go may be
  • 35:26helpful but again you know it really.
  • 35:29You could.
  • 35:30People respond equally well
  • 35:31initially to either behavioral
  • 35:33therapy or result the dense.
  • 35:34So again I think it just
  • 35:36it doesn't really steer us,
  • 35:37particularly necessarily One
  • 35:38Direction or the other is sort of,
  • 35:41I think,
  • 35:42supports a diversity of approaches
  • 35:45based on the evidence and and
  • 35:46hopefully we'll have more studies.
  • 35:48But these these head-to-head
  • 35:50comparisons and I think different
  • 35:52combinations of medications and
  • 35:54behavioral strategies as well.
  • 35:56So then moving into sort
  • 35:57of what does this all mean?
  • 35:58So that that's really,
  • 35:59you know, not a lot of evidence,
  • 36:01but that's the data looking at
  • 36:03combinations and and comparing
  • 36:04directly of behavioral medications to
  • 36:07pharmacotherapy medications for insomnia.
  • 36:09And it, you know, it's not.
  • 36:10I think it is clear that comparison
  • 36:13as people sometimes make it out to be.
  • 36:15But you know,
  • 36:16I think what what matters is then when
  • 36:18we bring this information to patients.
  • 36:19And I think this is where you know ACP,
  • 36:21you know,
  • 36:22sort of hit the nail on the
  • 36:23head of like you know,
  • 36:24it really is a shared decision
  • 36:27making process.
  • 36:28And for those of you who are not familiar,
  • 36:29sort of there,
  • 36:30there's a whole field of
  • 36:31shared decision making,
  • 36:32and you know it's defined as
  • 36:34an interactive process between
  • 36:35patient and or their family
  • 36:37members and clinicians.
  • 36:38And the goal is to engage patients
  • 36:41and decision making provide
  • 36:42patients with accurate information
  • 36:44about options and outcomes,
  • 36:46and then tailor the treatment plans
  • 36:48to patients goal and preferences.
  • 36:51So even though I tend to have a bias,
  • 36:53I thought as I you know, I.
  • 36:54I sort of almost tell all my patients,
  • 36:56I want them to do some behavioral therapy.
  • 36:58Just because I think it's effective
  • 37:00and I think it's safer, you know it's.
  • 37:02I know it's not going to work
  • 37:03for all my patients and you know,
  • 37:05every time I see a patient with insomnia,
  • 37:07we the first conversation we have
  • 37:10is the shared decision making
  • 37:11like you know what are,
  • 37:13what are the benefits of
  • 37:15medications or behavioral therapies?
  • 37:17Let's think through the process.
  • 37:20What would work best for you?
  • 37:21What are you interested in and you know
  • 37:22I can guide some of the conversation.
  • 37:24You know 'cause I I bring some
  • 37:25of that to the table, but again,
  • 37:27it's individualized for every patient.
  • 37:30And these are the three components,
  • 37:31so it's shared decision making essentially
  • 37:34combines medical evidence where it's clear,
  • 37:36accurate and unbiased.
  • 37:37Medical evidence about what are
  • 37:39the alternatives to treatment,
  • 37:41including no intervention.
  • 37:42So again,
  • 37:43when treating insomnia,
  • 37:44we can try behavioral strategies.
  • 37:46We can try pharmacological strategies.
  • 37:48We can try new treatment.
  • 37:52And this action and this meets
  • 37:53together with you,
  • 37:54know your your skills and knowledge
  • 37:56and all that training you have
  • 37:58as a clinician in communicating.
  • 37:59You know what the options are to treatment.
  • 38:02What is the evidence?
  • 38:04Taking that information and tailoring
  • 38:06tailoring it to your specific patient,
  • 38:08their beliefs,
  • 38:10attitudes and medical needs,
  • 38:12and engaging with the patients who
  • 38:14and trying to help them think through
  • 38:16what are their personal values and goals,
  • 38:18what are their preferences and
  • 38:20and this is a real skill to to do,
  • 38:22but this is really the crux I think
  • 38:25of how we take this medication,
  • 38:27how how we take this information
  • 38:29actually bring it to to the bedside.
  • 38:31So in summary,
  • 38:31you know these are the the the the
  • 38:34central steppes of shared decision making.
  • 38:36So you have to seek your
  • 38:38patients participation,
  • 38:39help the patients explore their options,
  • 38:41assess their values and preferences,
  • 38:43and sometimes it's clear and
  • 38:44upfront and sometimes it's not.
  • 38:46And then actually you know,
  • 38:47formulate that treatment plan
  • 38:49based on these decisions you have.
  • 38:52Assess how the patient is feeling about
  • 38:54them so you know the you know based,
  • 38:56so your role just to summarize is
  • 38:58providing information on benefits
  • 39:00and risks talking to the patients
  • 39:03about their preferences and then
  • 39:05also not just telling them.
  • 39:07What to do?
  • 39:08But actually how to do it so the
  • 39:11implementation there?
  • 39:12There's some small literature.
  • 39:13Janet Chung actually published a study and
  • 39:16thinking about patient decision making.
  • 39:18You know for insomnia,
  • 39:19I'm not going to go through it here,
  • 39:21but you know,
  • 39:21she sort of lays out a similar
  • 39:23pathway in a recent publication
  • 39:25in Behavioral Sleep Medicine.
  • 39:26For this as well.
  • 39:29And then also just to keep in mind
  • 39:31that you know keep that the patient
  • 39:32in preferences are are not in a
  • 39:34vacuum in the patients much more
  • 39:36than than the person in clinic and
  • 39:38their preferences and their ability
  • 39:40to actually implement their plan
  • 39:41are actually going to be influenced
  • 39:43by not just the knowledge that
  • 39:46you're giving them in clinic,
  • 39:47which is up here and skills, but also.
  • 39:51Their their motivation for treatment
  • 39:54for different treatment options,
  • 39:56their goals for treatment,
  • 39:58their beliefs about the treatments
  • 40:00and consequences of the treatments,
  • 40:02emotions, how they think they're
  • 40:04going to respond to a treatment
  • 40:06as well as opportunity.
  • 40:07So again, you know you could have
  • 40:09a patient who absolutely wants to
  • 40:10do cognitive behavioral therapy,
  • 40:11but if they can't access,
  • 40:13you know someone who provide that
  • 40:16insurance coverage language barriers.
  • 40:18That's just going to, you know,
  • 40:20impeach or implementation of the plan.
  • 40:23Relatedly, it's important to know you
  • 40:25know what's acceptable for the patients too,
  • 40:28and we hear a lot of this in in
  • 40:29in insomnia clinic to, you know,
  • 40:31medications don't work for me.
  • 40:33Behavioral treatments going
  • 40:34to be too difficult.
  • 40:35My my meds are working,
  • 40:37so it's just important to
  • 40:38to emphasize what it what.
  • 40:39Is that patient actually bringing to
  • 40:41the table when you're making these
  • 40:43decisions and party Rule 2 is to
  • 40:45help guide the patients and what is
  • 40:47actually feasible and appropriate for them.
  • 40:49So you know there's some of the obvious
  • 40:51things you know costs language barriers.
  • 40:53Can but things that may not be as obvious
  • 40:55like what are their competing priorities?
  • 40:58Do they actually have time to
  • 40:59like attend 6 to 8 sessions for
  • 41:01cognitive behavioral therapy?
  • 41:03What are their comorbidities?
  • 41:04And you know how is that going
  • 41:05to influence you?
  • 41:06Know, do you choose behavioral therapies?
  • 41:08Do you choose medications?
  • 41:09What medications are you actually going
  • 41:11to choose based on that comorbidity?
  • 41:12'cause it may vary substantially.
  • 41:14Your medication selection based
  • 41:16on those factors,
  • 41:17and then I think it's also important
  • 41:19to keep in mind as a practitioner,
  • 41:21what are your time and costs.
  • 41:23You know, I I do.
  • 41:24Behavioral treatments in my my practice.
  • 41:27I do brief behavioral treatments,
  • 41:28but you know,
  • 41:28I can't do it for all of the
  • 41:30patients 'cause I simply don't have.
  • 41:32You know enough clinic slobs
  • 41:33and enough follow-up slobs and
  • 41:35enough support to be able to do it
  • 41:37all the time for each patient.
  • 41:38So I sort of have to select which
  • 41:40patients I'm actually able to do it
  • 41:42in and then you know refer to CBT.
  • 41:44Those patients that that I don't feel
  • 41:45like I can work with and I think it's
  • 41:48important to have that honest conversation.
  • 41:50So again,
  • 41:50this is just a slide showing
  • 41:52that even in the best laid plans,
  • 41:53you know the actual implementation
  • 41:55of these plans is always gonna
  • 41:58vary and and be more challenging
  • 42:00and unexpected that you think.
  • 42:02One thing we do to sort of,
  • 42:04you know, counteract some of the
  • 42:06the preferences or beliefs and and
  • 42:09and sometimes distorted beliefs
  • 42:11that patients have about any of
  • 42:14these treatments for insomnia.
  • 42:15Is to is to, you know,
  • 42:17change their expectations,
  • 42:18even if it's settled for not and
  • 42:20you know every patient with insomnia
  • 42:22needs to be taught about realistic
  • 42:25expectations and and you know.
  • 42:26And we always discuss no.
  • 42:28Just start with the basic that you know.
  • 42:30Sleep is an involuntary biological process
  • 42:33they can't will themselves to sleep.
  • 42:35The sleep medications don't work by
  • 42:38making sleep a more voluntary process,
  • 42:40you know that they're not that
  • 42:42great for knocking people out that
  • 42:43they're actually good with giving
  • 42:45people a little bit of a push.
  • 42:46So you need to have that.
  • 42:47Homeostatic sleep drive and just
  • 42:49let the medications push them into
  • 42:51sleep and patients also need to have
  • 42:53realistic expectations about how well
  • 42:55the sleep medications are going to work.
  • 42:59But also you know what,
  • 43:00what do we expect from the medications
  • 43:02in terms of their response,
  • 43:04you know,
  • 43:04and and often tell patients you
  • 43:06know they're not.
  • 43:06They're not going to be able to
  • 43:07be on like the Olympic sleep team.
  • 43:09They're not going to be elite sleepers.
  • 43:11Our goal is to getting them.
  • 43:12You know enough sleep so that they're
  • 43:14actually able to function during the
  • 43:16day and feel like they have improved
  • 43:18mood and concentration and memory and
  • 43:20not let their sleep disturbance you
  • 43:21know be be a focus or cause problems
  • 43:24and how they're feeling during the day.
  • 43:27In terms of leaving in so against,
  • 43:29these are even patients were
  • 43:31prescribing medications and we're
  • 43:32weaving in some of these behavioral
  • 43:35principles about expectations,
  • 43:36and it's also equally important when
  • 43:38you're prescribing medications to actually
  • 43:40go through the patient instructions.
  • 43:42'cause taking out a medication
  • 43:45is actually a daily behavior,
  • 43:47and often they they're very
  • 43:49motivated to take the medications.
  • 43:50But what we find in sleep clinic
  • 43:52and what they've actually shown in
  • 43:54studies that people often don't
  • 43:55take the medications the right way.
  • 43:57Either 'cause they have unrealistic
  • 43:59expectations about how the medications
  • 44:02work haven't explained some of
  • 44:03the safety issues we see.
  • 44:05Patients often dose long acting
  • 44:07medications in the middle of the night,
  • 44:09and so you need to be really clear
  • 44:12on what medication they're taking,
  • 44:13what time they're supposed to take,
  • 44:15the medications,
  • 44:16and about you know details of the
  • 44:19medication in terms of you know,
  • 44:21should they take over food or avoid out.
  • 44:24Patient for how long they're gonna
  • 44:26be on the medication on so these
  • 44:28are all really important.
  • 44:29You know,
  • 44:30behavioral principles towards implementing
  • 44:32a pharmacological and insomnia.