Cognitive-behavioral therapy for insomnia (CBT-I) may not be a well-known approach for the treatment of the sleep disorder, but that may soon change as research advances the understanding of its benefits and effectiveness.
The science of sleep is a relatively new field and there remains much to explore. It was fairly recent, in 1953, when experts first identified that there are two distinctly different types of sleep – dream sleep and non-dream sleep, which is also known asREM sleep.
Experts are only now beginning to ask scientific questions and dig deep to advance the knowledge of behavioral sleep medicine.
Helping pave the way is a team of researchers and alumni at Virginia Commonwealth University, many of which have led some of the pioneering work in sleep research and contributed to the development of new avenues for treatment.
“It is amazing how much knowledge we have gained of the complex human body and how to take care of it. But, here we have sleep – something we spend a third of our lives pursuing that is as essential as air and water – yet we’re so far behind understanding sleep problems,” said Bruce Rybarczyk, Ph.D., clinical psychologist and leading sleep expert in the VCU College of Humanities and Sciences. Through the VCU Center for Psychological Services and Development and his private practice, he and his students treat patients with chronic insomnia with CBT-I.
“People are in desperate need of help. We need more knowledge and education, more experts in the field, and the help of primary care professionals to make the referrals,” he said.
According to Rybarczyk, the development of behavioral sleep medicine as a specialty has only taken place in the past 10 years. Nationally, there are approximately 300 certified or trained clinicians in behavioral sleep medicine and the need for more professionals in the specialty is dire. The VCU professor is one of only two Richmond-area sleep behavioral sleep medicine specialists.
In the 1990s, several sleep experts across the country, including one VCU faculty member and one VCU alumni, made significant strides in the development of CBT-I, a drug-free approach to the treatment of insomnia. The treatment, which involves extensive talk therapy has several treatment components, including an initial reduction in sleep to increase sleep drive and retrain normal sleep.
CBT-I also serves as a method for eliminating time spent in bed while awake to weaken the association between being in bed and having anxiety about not falling asleep. Before patients begin the intervention, they gain an in-depth education about the sleep system – something Rybarczyk refers to as the “owner’s manual for sleep.”
CBT-I research – in the beginning
Much of the early CBT-I-related research focused on chronic insomnia in the population at large. At that time, researchers believed that insomnia present within another medical disorder or psychiatric disorder was entirely different than when insomnia was present in the general population.
“We thought that the patients already contending with a primary medical disorder would not benefit from CBT because we had to resolve the triggering problem – be it night terrors of PTSD, or pain in arthritis, or chemotherapy side effects for cancer patients,” Rybarczyk said.
“But chronic insomnia starts with a trigger but then worsens and perpetuates by the same mechanisms involved in all insomnias, essentially a disconnection of the natural sleep system.”
Rybarczyk’s early work, prior to joining VCU, had examined how sleep was impacted in patients with arthritis, heart disease and lung disease. He tested the impact of CBT on patients with these primary medical conditions, observing that this group of patients was able to correct their sleep at the same rate of the general public who had no other medical or psychiatric issues.
“The foundation of a chronic sleep problem is going to be related to behavioral factors rather than what triggered it in the first place. In fact, patients had been telling us this for years. Basically, the sleep did not work even on their best days when they had no significant symptoms of pain, depression, coughing or other symptoms that were thought to be the cause of their insomnia,” he said.
For example, Rybarczyk recalled a patient who had said, “I sleep badly even on nights I don’t have pain.”
“We know sleep is essential to improving the health of these patients in particular, no matter what their initial trigger may have been. They need it to heal, to function, have a better quality of life,” he said.
Those initial findings sparked Rybarczyk’s current VCU research program with his VCU doctoral students. The research examines how CBT may benefit other populations that experience high levels of chronic insomnia including veterans with post-traumatic stress disorder (PTSD) and individuals with a psychiatric condition such as depression.
This fall, the team published findings from two intervention studies featured in a special issue of the Journal of Clinical Psychology.
Caring for veterans with PTSD
In one intervention study, published in the October print issue of the Journal of Clinical Psychology, Skye Margolies, Ph.D., a graduate student in the clinical psychology doctoral program at VCU who is mentored by Rybarczyk, examined the impact of four sessions of CBT-I on a group of 40 combat veterans with PTSD at the Hunter McGuire Veterans Administration Hospital in Richmond. This group of veterans had served in the recent conflicts in Afghanistan and/or Iraq and experienced high levels of both PTSD and insomnia. The treatment offered by Margolies included four sessions of CBT-I and an optional supplementary treatment for nightmares called imagery rehearsal therapy. The project was funded by a grant from the U.S. Department of Veteran Affairs.
“Many of these patients have nightmares and night terrors – and most have some form of insomnia because they have conditioned arousal around sleep time, and it is hard to break that cycle. They are ideal candidates for CBT-I,” Rybarczyk said.
The team observed significant improvements in self-reported and objectively measured sleep, as well as a reduction in PTSD symptom severity. Additionally, the group had fewer PTSD-related nighttime symptoms and fewer depressive symptoms, compared to the waitlist control group.
In a related, yet to be published study, the team has also examined CBT-I in group treatment with veterans from all eras of service, including those from the Vietnam era who suffered PTSD.
“Though sleep also improved substantially, the benefits were not significant for PTSD symptoms, possibly because they had been suffering from the disorder for such a long period of time that those symptoms were not as malleable,” Rybarczyk said.
“But with the second group – the young veterans – who haven’t suffered years upon years with PTSD, their symptoms may be reversible,” he said.
Benefits of CBT-I for depression
In another intervention study, also published in the October print issue of the Journal of Clinical Psychology, Nile Wagley, Ph.D., a graduate student in the counseling psychology doctoral programs at VCU who was mentored by Rybarczyk, examined 20 patients with comorbid psychiatric conditions that included depression symptoms, and also symptoms of insomnia at the VCU Outpatient Psychiatric Clinic. This group underwent two sessions of CBT for insomnia, one was in person and the other was conducted via telephone. The team reported that CBT-I was found to be effective in improving sleep and reducing depressive symptoms. Eight weeks following the start of treatment, 38 percent of participants were able to achieve normal sleep relative to none in the control group.
In addition to Rybarczyk, other VCU faculty contributors to these studies include Steven Danish, Ph.D., professor of psychology; David Leszczyszyn, M.D., Ph.D., director of the VCU Sleep Center and associate professor of neurology in the VCU School of Medicine; Scott Vrana, Ph.D., professor of clinical psychology, Ph.D.; and William Nay, Ph.D., assistant professor of psychiatry in the VCU School of Medicine.
Stepped care: Accessible and low-cost CBT for cancer and pain patients
Since it has been difficult to make CBT available to the millions of Americans who could potentially benefit, Rybarczyk and his colleagues are interested in developing and testing abbreviated and low-cost treatment models. Furthermore, some groups of patients would be more likely to attempt treatment if it were offered in an easily accessible format. Cancer patients have been identified as one such group.
According to Rybarczyk, approximately 20 percent of people with cancer have significant insomnia, likely due to side effects of chemotherapy, as well as the stress and anxiety associated with the diagnosis and treatment.
A study being conducted by Amma Agyemang, a VCU graduate student, and Rybarczyk will test two treatments that are highly convenient. This group of patients will be offered treatment through an online insomnia program called SHUTi, or two sessions of therapist-delivered treatment. SHUTi was developed by Rybarczyk’s colleague, Lee Ritterband, Ph.D., a professor from the University of Virginia, who develops Internet interventions for health care. The two sessions of treatment will include: a training session that patients will complete around the time they come talk to their oncologist and a phone session. Patients will maintain a sleep diary to track their experiences and progress to share with their therapist.
“If their sleep could be enhanced during such a demanding period – the fight of their life – then it could potentially help with recovery, coping, energy level, self-care, mood and healing,” said Rybarczyk.
“Our goal here is to see if cancer patients will follow through with if the treatment is made convenient enough – even in the midst of experiencing the most demanding period of cancer treatment,” he said.
Additionally, in an effort to increase dissemination of CBT-I in the community for under-served populations, Rybarczyk and colleagues are applying for a grant to test a “stepped care” approach to delivering CBT in safety net primary care clinics. This will involve using varied levels of treatment intensity and different methods of delivery, including the online insomnia program, SHUTi. Under-served populations are at even greater risk for secondary health consequences from insomnia, due to higher levels of co-morbid conditions such as diabetes, depression and chronic pain, so they may be even more likely to obtain health benefits from improved sleep. This stepped care approach will be tested in several primary care offices in the Richmond and Norfolk area.
Lastly, Margolies and Rybarczyk, together with Christine Cameron, affiliate professor in the Department of Psychology, have also begun work on a treatment manual that will provide extensive guidelines of CBT-I to clinicians.
“These studies contribute to growing evidence that CBT for insomnia is a treatment that should be offered to a wide patient population,” Rybarczyk said. “This is a very important advancement in understanding the treatment of insomnia. Our goal with the book is to disseminate the treatment to a much wider range of health professionals and their patients.”
By Sathya Achia Abraham
University Public Affairs, VCU Across the Spectrum (www.spectrum.vcu.edu)