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

How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC