Resource Development for Insomnia Treatment

Resource Development for Insomnia Treatment

Do you practice CBT for Insomnia? 

Would you like to be involved in a community effort to create a needed resource?

In the field of behavioral sleep medicine (BSM), the sleep diary is an essential and ubiquitous tool. While there has been progress in creating a standard sleep diary form, there has not yet been any advances in providing practitioners with a common and easy to use interface for this standard.

This has left providers stuck with the task of calculating sleep data in inefficient  ways such as by pen and paper or ‘re-inventing the wheel’ by creating their own  means of calculating and tracking the data via MS excel or MS access. Large  amounts of time and creativity are lost as people’s efforts to tackle this problem are not shared with the community.

To address this problem Dr. Scott Rower is leading a team of people in the BSM community to create a simple and accessible user interface based on the standardized consensus sleep diary.  This freely available webpage will allow any provider the ability to calculate their patient’s sleep data in order to inform treatment decision making.

Want to get involved?  Learn more here.

This project is funded through an internal grant at Portland Psychotherapy Clinic, Research & Training Center

5 Excellent Reasons to Treat Insomnia

5 Excellent Reasons to Treat Insomnia

1. Insomnia can cause depression.

A collection of research suggests that untreated insomnia doubles the chance of developing depression, as a causal factor (4 sources – one, two, three, four)

2. Insomnia often does not resolve once the depression is treated or without focused insomnia treatment (source 1; source 2)

3. Untreated insomnia more than doubles the chance of relapse of depression and other mental health diagnoses.  (source 1; source 2)

4. Effective, short-term, focused insomnia treatment exists

Cognitive Therapy for Insomnia (CBT-I) produces significant, sustained relief that is comparable to medications in the short-term & more effective in the long-term (4 meta-analyses – onetwo, three, four).

5. Insomnia represents a significant factor in non-response to treatment (source).

Conclusion

Insomnia is a major factor in clinical response and vulnerability to mental illness.  It does not tend to improve without focused treatment.  Treatment exists & over 30 years of evidence suggests that CBT-I is the most effective. 

Cognitive Behavioral Therapy Superior to Antipsychotics for OCD

Cognitive Behavioral Therapy Superior to Antipsychotics for OCD

A practice I’m seeing more often that concerns me is the addition of antipsychotic medications on top of antidepressants when the antidepressants aren’t working. If someone isn’t showing improvement on an antidepressant alone, a prescriber may add an antipsychotic medication—the idea being it will increase the effectiveness of the antidepressant. The research for this is a little questionable, especially as the side effects for antipsychotics can be pretty bad. I’ve felt strongly enough about this issue that I wrote an editorial about it that the Oregonian published in 2012.

Antipsychotics and obsessive-compulsive disorder

In previous post, I wrote about a study that found that giving an antipsychotic in people with posttraumatic stress disorder (PTSD) provided no additional improvement. A recent study looked at whether adding an antipsychotic medication would be helpful to people with obsessive-compulsive disorder (OCD). Results are extremely clear that the answer is, “No!”

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (EX/RP). (Note: in other posts, I abbreviate exposure and response prevention as “ERP” but use “EX/RP” here to remain consistent with the article.) There is some research that suggests that antidepressant medication can have a small impact on OCD-related problems, but EX/RP remains the gold standard treatment

Another study showing that CBT does the best with OCD

A 2013 study in JAMA Psychiatry examined a group of people with OCD who were already taking an antidepressant but were still experiencing moderate or worse OCD symptoms. These individuals were divided into 3 treatment groups.

  1. Some received psychotherapy—cognitive behavioral therapy with EX/RP.
  2. Some received an antipsychotic—Risperidone.
  3. Some received a placebo (i.e., inactive) pill.

CBT with ERP was much more effective

The results were striking. The researchers found that only 23% of people showed improvement on the antipsychotic; moreover, this result is even less impressive given that 15% showed improvement on the placebo (e.g., sugar pill). In fact, statistical analysis suggests there was no difference between the antipsychotic and the placebo—this means that the antipsychotic and a sugar pill performed about equally.

By contrast, 80% of people who received cognitive behavioral therapy with EX/RP improved.

80% vs. 23% is a big difference, especially since the latter is more of a placebo effect than a response to an active treatment.

One quibble

In the Conclusion section of the abstract, the writers make a subtle statement that really bothered me:

Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered EX/RP before antipsychotics given its superior efficacy and less negative adverse effect profile.” [bolding is mine.]

 

This statement implies that, even though EX/RP is superior to antipsychotics, that antipsychotics are still a viable treatment. This seems a bit disingenuous, however, as the researchers’ own analyses indicate that whatever improvement antipsychotics demonstrated was likely a placebo effect.

If anything, a sugar pill should be offered before an antipsychotic since they are equally effective, and the former has fewer side effects.

Concluding thoughts

Although I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to be of much help for someone with OCD, the superiority of ERP over medication for OCD isn’t new information.

There’s already a solid base of research that suggests the EX/RP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study makes it pretty clear that antipsychotics should not be considered for people with OCD.

UPCOMING TRAINING EVENTS

January 31, 2020, 8:30 am – 4:30 pm · Portland, OR · Details

This workshop is intended to be part 1 of a two day workshop, but can also be taken on its own. This workshop is useful for therapists who want an update on the current clinically applicable research on how shame functions, including an overview of how and when shame tends to be adaptive versus maladaptive. This day has two primary goals: 1. To provide an overview of research on shame and self-criticism that can guide clinical practice and 2. To allow therapists to experience the model from the inside-out so as to develop greater personal self-compassion and a deeper intuitive understanding of compassion-based intervention strategies. Read more

February 1, 2020, 8:30 am – 4:30 pm · Portland, OR · Details

This workshop is intended to be part 2 of a two day workshop, but can also be taken on its own. If you already have a thorough understanding of the functions of shame and a good understanding of Acceptance and Commitment Therapy, then it is you will probably be OK taking just the second day of this workshop. The workshop proceeds to discuss how ACT processes can be focused on addressing chronic and pervasive shame-based difficulties, with a particular focus on flexible perspective taking. Demonstrations of how to use perspective taking and compassion-fostering strategies with clients will be provided and attendees will also practice in small groups. An overview of chair work in the context of ACT will be provided. Read more

February 29, 2020, 9:00 am – 12:15 pm · Portland, OR · Details

Exposure is one of most the effective treatments for anxiety, trauma, and obsessive compulsive and related disorders (e.g., OCD, PTSD, panic disorder). A transdiagnostic intervention, exposure involves the repeated and systematic engagement with avoided stimuli that cause anxiety. Unfortunately, exposure remains underutilized by clinicians (e.g., Scherr, Herbert, & Forman, 2015), mostly due to misunderstandings of how exposure works and perceived difficulty of using it with clients. This half-day workshop will address these gaps by drawing from research on enhancing clinician understanding of and ways to overcome barriers to delivering exposure therapy (Farrell et al., 2016). Using didactics, role-play, and experiential exercises, participants will learn flexible application of exposure for a variety of clinical targets. Read more

April 17 and 18, 2020, 9:15 am – 5:00 pm · Portland, OR · Details

Do you ever “get stuck” as a therapist? Do some of your clients press your “hot buttons”? Do you ever find yourself struggling and thinking about “what do I do next” or feeling anxious, scared or stressed in therapy? In this workshop we will work on clarifying your therapist values and defining what is “difficult” about “difficult” clients. Through discussions, demonstrations and roleplays we will then work on these difficult clients and look at the processes from a compassionate ACT perspective. Read more