Megan Brooks

June 05, 2013

BALTIMORE, Maryland — A single session of cognitive-behavioral therapy for insomnia (CBT-I) delivered in groups of 20 is proving to be an effective and efficient way to treat patients with chronic insomnia, say researchers at Kaiser Permanente Fontana Medical Center in California.

"Our challenge is not whether cognitive-behavioral therapy is an effective treatment for insomnia, but rather can CBT be delivered cost-effectively so that it is not just effective for an individual but delivered in a method that is effective for a population," Dennis Hwang, MD, medical director of the Sleep Medicine Department, told Medscape Medical News.

"This is important because chronic insomnia is a very common condition that affects up to 30% of the population. And traditional programs that are performed individually or in small groups and require multiple visits limit the volume of patients that can be treated," Dr. Hwang said.

The insomnia program at Kaiser Permanente Fontana is "unique because it is presented in a large group format with only 1 face-to-face session, followed by telephone follow-up calls, thereby improving the efficiency of care," Dr. Hwang said.

The center offers 2 sessions weekly, each lasting 2.5 hours with up to 20 people with chronic insomnia. The program, taught by a physician assistant, addresses sleep hygiene, sleep beliefs, relaxation techniques, sleep restriction, and optimal sleep position.

Their results were presented here at SLEEP 2013: Associated Professional Sleep Societies 27th Annual Meeting.

Improvement in Sleep Time, Reduction in Sleep Meds

Dr. Hwang and colleagues reported that 321 (88%) of 363 adults with insomnia who completed the CBT-I program reported improvement in their insomnia, based on subjective feedback.

Overall sleep time improved an average of 1.5 hours, from 5.0 to 6.5 hours, and time to fall asleep decreased from 51 to 22 minutes. The 134 patients taking sleep medications decreased their use from about 6 to 4 nights per week, and 41 patients (30%) stopped using sleep aids altogether.

Improvements were similar for men and women; shift workers; those with obstructive sleep apnea, fibromyalgia, or restless legs syndrome; and those taking antidepressant medication, the researchers say.

"We wanted to assess objective measures to support the subjectively reported improvements, so we compared medical office encounters and pharmacy refills 1 year after and 1 year before the program," Dr. Hwang explained. "We were able to show a decrease in primary care office encounters (an average decrease of about 1 office visit) after attending the insomnia program."

He said a preliminary assessment of the rate of pharmacy refills "showed a gradual increase leading up to the program and a gradual decrease the year after the program, in particular with sleep and antidepressant medications. Confirmation of this finding is currently ongoing."

Within Kaiser Permanente Southern California, other CBT-I programs are taught by nurse educators in multiple sessions, but the Kaiser Permanente Fontana Medical Center is the only center that uses the single-session format, Dr. Hwang said.

It is also the only center that uses a physician assistant within the sleep medicine department that provides comprehensive management of insomnia, including active medication management and proactive treatment of secondary causes of insomnia, such as depression, restless legs syndrome, and sleep apnea.

"Totally Believable Data"

This study "supports in a real-world clinical setting the effectiveness of a one session CBT and in combination with a group format that is larger than what has been typically studied. Our study is additionally unique in that it assessed impact of the program on primary care office visits as part of a larger assessment of healthcare utilization," Dr. Hwang said.

Asked for comment on these findings, Joyce Walsleben, RN, PhD, associate professor of medicine at New York University School of Medicine in New York and diplomate, American Board of Sleep Medicine, who wasn't involved in the study, called it "totally believable data."

However, she told Medscape Medical News, "who has 2.5 hours to give to the program in one sitting? That seems like a drawback but worth a try for certain clinicians and certain patients."

As reported by Medscape Medical News, a recent study from the United Kingdom showed that group CBT sessions held once a week for 90 minutes for 7 weeks yields significant improvements in sleep measures and quality of life in adults with chronic insomnia.

When it comes to insomnia, "information is the key; doctors and patients just don't understand how simple sleep can be," Dr. Walsleben said.

The authors and Dr. Walsleben have disclosed no relevant financial relationships.

SLEEP 2013: Associated Professional Sleep Societies 27th Annual Meeting. Abstract 0555. Presented June 4, 2013.

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