Cognitive Behavioral Therapy, Pharmacotherapy for Patients With Insomnia
In this multidisciplinary roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Douglas Kirsch, MD, and Seema Khosla, MD, about interventions for patients with insomnia, including cognitive behavioral therapy, pharmacotherapy, logistics, and challenges in delivery. This is part two of a three-part series on insomnia.
For more insomnia content, visit the Resource Center.
Watch episode one of this three-part series here.
Watch episode three of this three-part series here.
TRANSCRIPTION:
Jaspal Singh, MD, MHA, MHS:
Hello, everybody. I'm Jaspal Singh. On behalf of Consultant360, thank you so much again for joining us today. Today will be episode 2 of our Insomnia Brief series. Here again with us today are our doctors, Doug Kirsch and Dr. Seema Khosla. Dr. Kirsch, can you introduce yourself, please?
Douglas Kirsch, MD:
Yeah, my name is Doug Kirsch. I'm a neurologist and sleep specialist and the medical director of sleep medicine at Atrium Health in Charlotte, North Carolina.
Jaspal Singh, MD, MHA, MHS:
Great. Seema.
Seema Khosla, MD:
My name is Seema Khosla. I'm a pulmonologist, and I practice 100% sleep medicine in a non-academic solo practice environment in Fargo, North Dakota.
Jaspal Singh, MD, MHA, MHS:
Well, it's just great to have you both again. Just to recap for our audience on their first episode, we talked a lot about sort of an insomnia overview, talked about going into a deep dive into the patient's life, into the expectations, into some of the data management, kind of working towards a healthier lifestyle and starting with sleep, but then trying to figure out how that goes into the care of our patients with insomnia.
Both of you did a great job giving us a framework by which to work as clinicians, as people who might be suffering from insomnia or who might have family members who might be suffering from insomnia-type symptoms, but at some point, we have to sort of take a deeper therapeutic intervention, whether it be some type of psychological intervention versus pharmacotherapy. Walk us through sort of at what point you start thinking about things and tell us what are things like cognitive behavioral therapy for insomnia and then also some pharmacotherapy. So, Seema, I'll start with you. Talk to us. What is CBT-I for insomnia? What's all the buzz about this, and how do you go about doing it?
Seema Khosla, MD:
So, I'm probably atypical with CBT-I, so CBT-I is cognitive behavioral therapy for insomnia, and it really is just assessing a little bit of the psychology, setting out appropriate expectations for what is sleep, what is appropriate sleep, and sort of changing and challenging some of our preconceived notions about what normal sleep is. What can I expect from sleep, and what happens if I don't achieve all of the sleep that I need to achieve? Sometimes we address sort of maladaptive coping mechanisms where people who struggle with their sleep will often try to extend their time in bed because they just want to be ready to capture that sleep. The minute the sleep hits them, they want to be ready so they can catch it. And so we kind of explore how that's probably not the best way to approach their sleep. And it's really kind of interesting when you address it one-on-one with people.
You can see that light bulb moment where they say, "Oh, I get it." When you explain how you calculate sleep efficiency, then they kind of understand it. Where I am, it is really hard to find somebody in person who has been trained, as a behavioral sleep medicine specialist. I know Doug has great access where he is, where he has a great referral system and a lot of support. I'm a solo practice person. Our clinic staff is me and my clinic manager, and we have tried to embrace anybody local who has an interest in it. Our go-to person changed to doing inpatient psychiatry now, and so we have had to really embrace app-based CBT-I, and so that has become our go-to.
Jaspal Singh, MD, MHA, MHS:
So the app walks patients through some of these issues like it might do for music, for example, to relax, or it might do for my fitness app, that might tell me how better to do my exercises, for example. Is that kind of what you're getting at?
Seema Khosla, MD:
Well, so we actually use the one that was designed for our veterans, called Insomnia Coach, which is lovely because it's free and it was deployed. They used government dollars to fund it and so they deployed it for free. It's not fancy, but at least it takes them through the basic tenets of CBT-I. So, for us, it's a reasonable first pass, and some people are fine with it, but then it allows us to identify the people that we really do need to look and refer them on to somebody, maybe out of town or somebody via telemedicine, that can help them with this.
Jaspal Singh, MD, MHA, MHS:
Got it. That's great. No, that's a great start. So Doug, Seema tells me that you're in a more resource-rich environment, so I'm going to ask you, what do you do in that space?
Douglas Kirsch, MD:
Well, I think the thing is, we have more access. I wouldn't say it's easy to access. So we do have a PhD-level psychologist who is not too far away from my office, who does this type of work, but it is hard to get into here because she is quite busy and she doesn't take insurance. So that sort of limits the availability to other providers, and so you can't just send everybody, it's not a default, just do this. I think, to Seema's point, we would love to have more access to that kind of thing. So I think, really, if you look at the data around this CBT-I, it can be really the first-line therapy for many people with insomnia if you can get them access to that level of care. But before they get there, because this axis is so limited, I actually do some of this work in my office too.
I don't necessarily get into some of the psychology pieces of this, but some of the more practical pieces of this. And so talking to people about sleep compression is actually something we do quite regularly in this office because, at some basic level, if you can get them to buy into the idea that by taking your sleep and spending less time in bed, you can make your sleep more efficient, that is probably the most powerful tool in the CBT-I armamentarium. And so doing that kind of work takes, again, a little bit of time to convince somebody who is not sleeping well that they should spend less time in bed. Seema's very counterintuitive to them.
They're not super excited about the concept most of the time, and it may take a couple of visits to get them to actually follow through on it, but it is really powerful if you can take somebody who thinks, "Hey, I'm sleeping about six hours a night," and actually say, "Okay, you think you're sleeping six hours a night, let's put you in bed for that six hours, make that sleep really good for six hours," see what happens, and then begin to expand it.
And so we do some of that work, and we will do some of the other things that can sometimes be helpful. So for instance, I had a woman today who had some pretty significant insomnia, and she said the only time she's not been able to use medication, which we'll get to in a moment around her sleep, was when she went to Disney World and got 25,000 steps a day. And she said, "I just conked out." And I'm like, "Well, doesn't that tell you something, right?" It's not just about sleep habits, it's about our daytime habits too. And that can be, as we talked about earlier, things like caffeine late in the evening could be... what you're doing in the evening, but it's also about that daytime exercise. If we have a job where we're sitting at our desk eight hours a day 10 hours a day, or 12 hours a day, how well do you think you're going to sleep if you've just been sitting all day? The answer is not nearly as well as if you got 25,000 steps.
Obviously, it's not realistic to do that for most people every day, but it goes to show you the power of exercise and movement on the ability to sleep. I have other people who tell me they sleep better when they do yoga, right? Sure. The same concept is that moving the body in a relaxing state can lead to better sleep. And so there are a number of factors you can do in the office without actually going to that next step, CBT-I. But I will say, when you get somebody to that CBT-I, it is really impressive sometimes how well it can work for that patient, whether they're on medication or not. At that point, really, the goal is to give them control over their sleep a little bit better so that they feel like they can sleep better, and that engenders better sleep.
Seema Khosla, MD:
This may be a little controversial too, but I think sometimes there is this belief that CBT-I should be done in isolation without medications and or medications without CBT-I. But I think it's a little bit like if you walk out the door and you trip over your step and your knee is bleeding, well yeah, you need a bandaid, but at some point, you need to figure out why you're tripping over that step, and so you have to, and there's some data suggesting that by the time somebody with insomnia lands in a sleep clinician's office, they want the drugs, they want something to put them to sleep now. And so they're not as patient, I don't think, they don't want to go through a six-week program to sleep better. They're like, "No, I want something now. I've waited three weeks to get to see you. I want something now."
And so sometimes we'll do is, do a little pharmacotherapy, start them on CBT-I, and what we usually do in our practice, and it may be different because in my neck of the woods, a lot of people are really reluctant to consider medications. And so anytime we start a sleep aid, we always want to have an exit strategy. So yep, here's your sleep aid, but let's also work on all these other things that we can change and improve about your sleep with the goal of getting rid of the sleep aid.
Jaspal Singh, MD, MHA, MHS:
That's interesting. It sounds like very much what the chronic pain population is going through, this whole idea of, initially, they would get all these, the trend was to treat pain super aggressively with drugs, for example, and it's moved to exactly what you're defining as a multimodal strategy, get at the root cause of why things might be happening, why the patient's suffering, in this case, insomnia, try to really get at the deeper drivers of that. Whether what Doug was saying earlier, the daytime activity doesn't just start at night, it's also from the earlier daytime habits, from exercise to caffeine to whatever stressors or other things that are happening to them, then in the evening, and then kind of work on the mental model of what's driving some of this or what can at least help them start that journey towards improvement. In the meantime though, a little bit of pharmacotherapy with an exit strategy with a timed somewhat maybe loosely defined strategy to potentially help them bridge over to until they're kind of more in the therapeutic road. Is that about right?
Douglas Kirsch, MD:
I think that's true. I think that you would love to always have an exit strategy. I think it's not always realistic. I think the pain patient population is an excellent comparator because not every pain patient is going to be able to get off pain pills, and there are going to be some patients whom using medication in the long term is probably going to be the only method of success for whatever reason. And maybe it's pain, right? Pain is a perfectly problematic issue in sleep. If you're in pain, you don't sleep well. So I think that the goal is always when I talk to patients about that the goal is always to have them be able to control their sleep to the point where they don't need any medication, or that if they know that they're going to have a problem sleeping, they have the medication to use at that time rather than have to use it every night.
Those are the goals, but they may not be realistic for every patient. And I think it's important to say that we're going to do our best to get you there, but that may not be where we can get everybody.
Seema Khosla, MD:
And I feel like that's okay. Just like with our chronic pain people, it's not a matter of, "Oh, these medications are evil and they have no use." These medications are utilized in a responsible manner, and if you need it, you need it and that's okay. It doesn't mean, it's not a personal failing if you can't get off your sleep aid. It's not a moral failing if you need pain medication.
Douglas Kirsch, MD:
Although I think what people see though, is a lot of pressure to get people off sleeping pills, particularly in the elderly population, and so I don't know about you, Seema, but we have been sent and have continued to be sent a lot of patients who are in an older population who are on sleep aids, and sort of the idea that nobody who is over the age of 65 should be on a sleeping pill because it's a risk for falls or risk for side effects. And so I think that's where a lot of that messaging comes from, is that sleep pills are bad for you. And I think in the end, that may be true in some cases, for sure, that there are certain medications that are probably not great to use in the long run. There are certain medications that, as people get to a point at which they are less stable on their feet, that may not be a good choice for them. But I think the challenge is that not sleeping also has side effects.
And so when you're talking about pharmacotherapy with a patient, you're trying to find the right medication for the right patient. And that's not always an easy thing, but it is trying to walk a fine line sometimes between a medication that is going to be effective but maybe have some side effects versus medication that may take some time to be effective or may not be as effective but may have fewer side effects for that patient.
Seema Khosla, MD:
Well, and even you're suggesting, even recognizing that same patient who did fine on medication now five years later, maybe that was okay for them, and maybe it's not okay for them anymore. And so there's that continuous risk-benefit analysis and asking them, and I think recognizing that they may not want to let go of that sleep aid and they may be a little bit resistant to switching to something else, but sort of partnering with them to explain, "This is a concern, we can always try this." We recognize that sleep is important and there's the risk of not sleeping too, and we just have to figure out what is in our best interests.
Jaspal Singh, MD, MHA, MHS:
Got it. No, this is great, and it sounds like I've got time constraints, we're not going to talk about the individual drug choices. I'm sure a lot of our audience is going to potentially want to have an idea of what medications you all prefer, but that's going to be a very complicated discussion. And I think the idea though, which I'm taking out of this is a very nuanced approach, right? That's going to be a nuanced approach with not just the medications combination of some type of cognitive behavioral intervention, we'll say, right? The idea of driving into deeper issues then there's also probably lifestyle issues in general for health that all have the interplay. And yet, your patients are oftentimes coming to you. I think, Seema, you mentioned the point of by the time they get to you, they've suffered with this for a while, or something related to that for a while, and there's been stuff brewing in the background, and they're maybe symptomatically quite troubled, and they want immediate intervention.
So just as a guideline, how soon or how often would you see a new patient regularly in terms of cadence? If you mind giving our audience members some ideas of what's a typical sort of pathway for you all?
Douglas Kirsch, MD:
I think that, obviously, your cadence for seeing patients is going to vary depending on how crowded your clinic is. So availability is always an issue. And so, at least my goal is always to say, if I'm going to start somebody on medication or do behavioral therapy or both, the goal is to have them back in six to eight weeks to see where they're at with the things that we've laid out. And honestly, some of the time, I'll actually make sure that they don't get pushed up because sometimes if you're doing a test and my staff sees that they want to review the test, I'm like, "No, no," they have to spend six or eight weeks working on these things that I laid out because if they come back in three weeks, they won't have had enough time to do these things. And so unless they're having a side effect, obviously you expect them to reach out to you on a medication, but I think it's reasonable to say, "Hey, take six weeks, try this medication. Here's a plan. If this isn't working, do this and lay it out so that there's structure."
And I will say, as a physician, I am constantly leaving a list of things that I want to do for that patient so that somebody's covering for me when I'm out. It's like, "Hey, try this medication. If this isn't working, go up to this dose, and if that's not working, the next two medications I might try are this and that.
Seema Khosla, MD:
And I think that's helpful for the patient to hear too. We always talk about, "Well, this is our first plan, and then if that doesn't work, we're going to try this, and this is our contingency, and this is sort of delineating it," because then they are like, "Okay, I feel everything's not hinging upon this one medication." There are other things that I can do. And then you can see them sort of visibly relaxed. They're like, "Okay, okay, we got this."
Jaspal Singh, MD, MHA, MHS:
No, that's great. So just to wrap up for the audience and both of you correct me if I meant something. So the idea of, when you get to the point where you want insomnia now, you need to intervene, there's something deeper going on. One, you're going to still work on the stuff that's deeper. It's going to constantly work on that, whether it be daytime activity, whether it be lifestyle issues, all the stuff has to happen. Start the cognitive behavioral therapy intervention route at some point, depending on the resources you have. If you want someone who wants to do an app, for example, you might want to try this. What was it called?
Douglas Kirsch, MD:
Insomnia Coach.
Seema Khosla, MD:
Insomnia Coach.
Jaspal Singh, MD, MHA, MHS:
Insomnia Coach, which is a free app, that's a good start. For example, if you want to refer to a professional psychologist, if you have the resources and the patient, the resources, that might be a great option for patients. That's probably the most time-tested, or, I should say, board, right answer for the board certification, cognitive behavioral therapy for insomnia. But in the meantime, do the things that you can along those routes. In the meantime, for medications, a nuanced approach with close clinical follow-up, trying to get that patient sort of on that path to recovery and then just kind of walk them through that. And I like the idea of what you mentioned, Doug, is sort of, and I think Seema validated that, was the idea of getting step B, and step C outlined for the patient, started making the plan out, and then sharing that with the patient to get them the buy-in. Does that sound about right?
Douglas Kirsch, MD:
I think so. I think the one thing that we didn't touch on that I think is really important when you're talking about behavioral treatment for insomnia is light, and there's been a lot of noise about blue light and about other kinds of light. But what I will say is, it's not blue light specific as much as it is, I think, recognition that we as humans are getting a lot of light at times we shouldn't. And the sun goes down and we don't go to bed, and that's because we have electric lights, and 50-inch or 80-inch TVs and computers, and iPads. And the number of people I talked to who have maybe three different, they have their phone and their tablet, and their computer next to them, and they're doing all these things at nighttime.
It is important as you start thinking about sleep to recognize that light has an impact, and when you get light in the evening, it makes you less likely to want to go to bed. When you don't get light in the morning, it makes it harder for your body to recognize it's time to get up. And so all the other things you mentioned, Jaspal, which I think are all correct, it's important to talk to people behaviorally about the amount of light they get and when they get it because that really drives the body clock to do things correctly.
Jaspal Singh, MD, MHA, MHS:
Thank you for that reminder. That was a great reminder about the importance. I think you're also hinting at the adverse effects of artificial light, which is through our devices. And I think you kind of hinted at the advantageous aspects of sunlight. Am I seeing that right? Or...
Douglas Kirsch, MD:
There was a great study that was done out in Colorado where they took people out of their usual environment, put them on a campground in Colorado, in the mountains, and took away all their electronics. And what you saw was their body clock shift by an hour backward very quickly. And that change is radical in terms of what it means for somebody's ability to go to sleep. And so anybody who's gone into nature and taken themselves out knows that they tend to go to bed earlier, and you tend to get up earlier. And why is that? Well, because it mimics what activities are available, right? The sun.
And so I think people need to understand the impact of natural light in the morning and cutting down on the artificial light in the evening as best you can, increasing the natural light in the morning, particularly for people who are supposed to be up in the morning. That's different if you're a shift worker or working nights, or that kind of thing. But for an average individual, that is kind of the goal for people. And so we try to get people out moving, get the walk-in first thing in the morning because that is going to drive their body clock to get the sunlight and the activity levels to be up. It's not always easy to get them up and rolling, but that would help.
Jaspal Singh, MD, MHA, MHS:
No, that's great. Seema, any other thoughts to add?
Seema Khosla, MD:
No, I hadn't heard about that camping study, but I completely believe it. When we go camping, that sun comes up really early, it wakes me up, I buy it.
Jaspal Singh, MD, MHA, MHS:
No, that sounds great. That sounds fantastic. So, I think that closing on that light therapy is a nice sort of ending, sort of what things we can do to potentially intervene for our patients. So on behalf of Consultant360, it's a great episode, and I want to thank you for doing this episode with us and for our audience. Again, this is Jaspal Singh on behalf of Consultant360, I want to thank Dr. Seema Khosla and Doug Kirsch for talking to us about Insomnia Part 2, which is the intervention episode. Thank you.