Implementing Cognitive Behavioral Therapy for Insomnia in Primary Care

1. Session I5-Tapas Saturday, October 29, 2011 Implementing Cognitive Behavioral Therapy for Insomnia in Primary Care Christina O. Nash, M.S. & Jacqueline D. Kloss, Ph.D. Department of Psychology Drexel University, Philadelphia

2. Objectives • Briefly review literature on CBT-I in Primary Care settings • Highlight the additional challenges via a case vignette while delivering CBT-I in light of current research • Identify areas for clinical discussion and pose research questions for future investigation

3. Prevalence of Insomnia in Primary Care • Widely recognized that primary care settings serve as the “front lines” for recognizing and initiating treatment for insomnia • Many individuals with Primary Insomnia seek out help with their general practitioner(Aikens & Rouse, 2005) • 50% of individuals in primary care complain of insomnia, making insomnia one of the most common complaints at general practitioner offices (Schochat, Umphress, Israel, & Ancoli-Israel, 1999; NHLB Working Group on Insomnia) • Among a sample of 1,935 primary care patients, one third met criteria for insomnia, more than 50% reported excessive daytime sleepiness (Alattar, Harringon, Mitchell & Sloane, 2007).

4. Obstacles and Challenges to the Delivery of CBT-I in PC Settings • Assessment and recognition of insomnia; differential diagnosis • Fast-paced setting, yet need for integrated care and collaborative relationships with behavioral health consultants • Managing insomnia given a complex health picture and understanding its comorbidites (e.g., chronic health conditions) • Despite efficacy of CBT and patient preference for non-pharmacological approaches, prescription medications are most commonly administered (Chesson, et al, 1999) and CBT-I is underutilized (Morin, 1999; Espie, 1998) • Health Care Providers are untrained in sleep medicine

5. Additional Challenges of Delivering CBT-I to Underserved Populations • Chronic health concerns in general are even more pronounced in lower SES groups. For example, disparities documented in cancer, diabetes, cardiovascular disease, HIV, psychiatric comorbidities among underserved (Winkelby, Jatulis, Frank & Fortmann, 1992) • Sleep quality is inversely related to income, unemployment, education (Moore, Adler, Williams, Jackson, 2002; Ford and Kamerow, 1989) • Individuals with lower SES as measured by education level were more likely to experience insomnia while controlling for gender, age, and ethnicity (Gellis et al., 2005) and those who have dropped out of high school demonstrated the greatest impairments due to insomnia • Paucity of research on interrelationships between race, ethnicity, SES and insomnia; For example, perhaps poor sleep may account for the relationship between low SES and health disparities (Arber, Bote, & Meadows, 2009; Cauter & Spiegel, 1999) • Shift work more common among low SES, and linked to poorer sleep quality and poorer health outcomes (Cauter & Spiegel, 1999)

6. Research Background to CBT-I Delivery to Underserved in PC Settings • A number of studies have initiated abbreviated CBT implementation in PC settings with success (e.g, Edinger & Sampson, 2003; Goodie et al., 2009; Hyrshko-Mullen et al, 2000; and some with primary care nurses (e.g., Espie et al, 2001; 2007; Germain et al., 2006) • However, to our knowledge, little, if any research has been conducted to examine Sleep Disorders, and specifically insomnia, among underservedcommunity primary care patients • One study, McCrae et al. (2007) a 2-day workshop delivered by service providers (mental health counselor, a provisionally licensed counselor, and social worker) yielded significant improvement in a rural setting with elderly population

7. Translating CBT-I Research to Practice among Underserved Populations • How do we translate and deliver our well-established CBT-I approaches not only within a fast-paced PC setting in an abbreviated modality with care professionals who likely have limited sleep knowledge, but also to populations with complex health histories, impoverished environments, and with limited resources?

8. Observations from Community Health Center • Ethnicity/Race: Latino and African-American patients • Over 98% of patients are 200% below the poverty line • Potential for comorbidity • 24.3% of patients met criteria for Major Depressive Disorder (MDD) • 26% met criteria for Generalized Anxiety Disorder (GAD) • 28.5% met criteria for Post-traumatic Stress Disorder (PTSD) • In a study of a sample of 288 patients conducted in 2003, 46% of patients met criteria for a DSM-IV-TR diagnosis, 14% met criteria for 2 diagnoses, and 11% met criteria for 3 diagnoses. • Of 9057 adult patients seen during the last year, 158 were diagnosed with Psychophysiological Insomnia, 2 with Insomnia, Unspecified • Over half of these patients reported symptoms of insomnia during their medical visit • 120 of these patients with diagnosed insomnia are currently prescribed Zolpidem (i.e., Ambien) • Of 9057 patients, 125 were seen by Behavioral Health for screening and/or consultation

9. Observations from the Community Health Center • Language barriers • Literacy • Legal status • Unemployment/Lack of a daytime routine • Patients sleeping in shelters/Homeless • Impoverished sleep environments may lead to poor sleep hygiene (e.g., noise, fear, bed availability, curtains, temperature) • Limited access to sleep education and sleep specialists

10. Case Vignette

11. Treatment Implementation

12. Rosa Sleep Diary Data* *Weekly Averages

13. Insomnia Severity

14. Practices and Pitfalls of CBT-I in the Community Health Center Adapted from Espie’s Stepped Care Model (2009)

15. Future Research and Clinical Considerations • Epidemiological studies on the links between SES and insomnia (e.g., understanding the mechanisms that link insomnia and SES, education, and health); studies on incidence, prevalence, and presentation/manifestation of insomnia • Additional efficacy studies on abbreviated CBT approaches specifically with underserved populations (e.g., in rural settings, at community health centers, varied educational levels); Does one size fit all? • Psychometrically sound screening and assessment measures (e.g., Kroenke et al, 1999; PHQ-9) • How effectively can “in house” care providers deliver CBT-I? Under what conditions? How do we best access BSM specialists and provide adequate supervision and training? • How do we foster collaborative relationships into an integrative care system with the use of behavioral health consultants and/or BSM-trained practitioners? • Consider complex comorbidities (physical and mental health problems) • Enhance decision-making about pharmacotherapy

16. Where do we go from here? • Stepped Care Model (Espie, 2009) • Meta-analyses demonstrated self-help tools (books, internet) to have a small to moderate effect size (Straten & Cuijpers, 2009) • Tele-health, Internet and Telephone Consultations (e.g., Vincent& Lewycky, 2009; Bastien et al, 2004) • Group CBT-I • Implementation of Training Models

17. References • Alattar, M., Harrington, J.J., Mitchell, M.,, & Sloane, P. (2007). Sleep problems in primary care: a North Carolina family practice research network (NC-FP-RN) study. JABFM, 20, 365-374. • Arber, S., Bote, M. & Meadows, R. (2009). Gender and socio-economic patterning of self-reported sleep problems in Britain. Social Science & Medicine, 68, 281-289. • Espie, C.A. (2009). “Stepped care”: a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. SLEEP, 32(12), 1549-1558. • Espie, C.A., Inglis, S.J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general practice. Behaviour Research and Therapy, 39, 45-60. • Ford, D.E., & Kamerow, K.B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. Journal of the American Medical Association, 262, 1479-1484. • Gellis, L. A., Lichstein, K. L., Scarinci, I.C., Durrence, H.H., Taylor, D.J., & Bush, A.J. (2005). Socioeconomic status and insomnia. Journal of Abnormal Psychology, 114(1), 111-118. • Germain, A., Moul, D.E., Franzen, P.L., Miewald, J.M., Reynolds, C.F., Monk, T.H., & Buysse, D.J. (2006). Effects of a brief behavioral treatment for late-life insomnia: preliminary findings. Journal of Clinical Sleep Medicine, 2(4), 403-406. • Goodie, J.L. , Isler, W.C., Hunter, C., & Peterson, A.L. (2009). Using behavioral health consultants to treat insomnia in primary care: a clinical case series. Journal of Clinical Psychology, 65(3), 294-304. • McCrae, C.S., McGovern, R., Lukefahr, R., & Stripling, A.M. (2007). Research evaluating brief behavioral sleep treatments for rural elderly (RESTORE): a preliminary examination of effectiveness. • Moore, J.P., Adler, N.E., Williams, D.R., & Jackson, J.S. (2002). Socioeconomic status and health. The role of sleep. Psychosomatic Medicine, 64, 337-344. • Winkelby, M.A., Jatulis, D.E., Frank, E. & Fortmann, S.P. (1992). Socioeconomic status and health: How education, income, and occupation contribute to risk factors of cardiovascular disease. Journal of Public Health, 82(6), 816-820.