Given the demonstrated efficacy of cognitive behavioral therapy for insomnia, recent research has focused on how to disseminate it to the many people in the population who suffer from insomnia. One method that we've evaluated is whether or not we can deliver treatment over the phone to individuals who suffer from insomnia. In a recently published paper, we evaluated 30 individuals and assigned them to either receive up to eight sessions of cognitive behavioral therapy for insomnia over the phone, or to an information pamphlet control. Individuals all had education modules that they received by mail and then received all sessions over the phone. Here you're looking at the effects on sleep efficiency, that is considered to be a measure of solidness of sleep at pre-treatment, post treatment, and three month follow-up. You can see a baseline in red, both the active cognitive behavioral therapy for insomnia phone group and the control IPC condition, or information pamphlet control did not differ. But at post-treatment, there is substantial improvement in the cognitive behavioral therapy for insomnia phone condition in terms of sleep efficiency, and a more modest improvement in the IPC condition. At three month follow-up, there was no significant gains in the IPC condition, a small diminution of sleep efficiency in the CBTI-Phone condition, but still, they'd maintained their gains relative to baseline. So it seems like at least initially we have pilot data to suggest that this treatment not only has to be delivered in office, in person, but can be at least administered over the telephone. Other studies have looked at whether we can distill the treatment from six or eight individual sessions down to a fewer number, by concentrating on only a few of the treatment components. This large scale study, published in older adults, about 80 adults, who had chronic insomnia looked at whether or not two sessions of just a brief behavioral treatment for insomnia, which included only the behavioral components of this multi-component treatment was better than an information control pamphlet over one month of treatment. The graph shows the percent of individuals who achieved remission to their insomnia, had a treatment response, a partial response, or no response at the end of one month. You could see relative to the information control group that those who got the brief behavioral treatment for insomnia were significantly more likely to achieve remission to their insomnia as well as response to their insomnia. This suggests that this cognitive behavioral treatment for insomnia may be distilled down into a fewer number of sessions, and still have the same desired effects. These decimation trials are ongoing in a variety of different modalities as well different ways of delivering the treatment are being assessed. I should note that non pharmacology treatment for insomnia includes cognitive behavioral therapy for insomnia as a first line treatment, but there are other non-medication treatments for insomnia that are being evaluated. For example, this relatively recent study looked at the effects of mindfulness-based stress reduction and its effects on insomnia compared to a pharmacol therapy treatment. You're looking at the general effects of baseline and post treatment for the mindfulness-based stress reduction group compared to a pharmacol therapy group on the Insomnia Severity Index, the Pittsburgh Sleep Quality Index, and two sleep diary measures of sleep efficiency and total sleep time. And you can see by looking at the table that the improvements in sleep were similar between the mindfulness-based stress reduction group and the pharmacol therapy group. So it's suggested there may be non-pharmacological treatments in addition to cognitive behavioral therapy for insomnia that may be beneficial for individuals who have insomnia. These other forms of treatment certainly require further evaluation and careful consideration. Cognitive behavioral therapy for insomnia as the first line non-medication treatment for insomnia is not without its limitations. For example, we have a really limited understanding of how it works, which treatment components are most important, but really how it works, what does it target? It's really unclear if it targets the insomnia pathophysiology for individuals or whether it targets something else. Finally there continue to be relatively limited data on the effects on endpoints other then sleep endpoints whether they be subjective or objective endpoints, such as mood endpoints, other health endpoints that’s might be of importance. And finally there are a whole host of treatment delivery issues that require further consideration and examination. So for example which treatment components are most effective, what's the optimal treatment frequency and modality, should cognitive behavioral treatment for insomnia be delivered with or without medication, and if so, how should that be sequenced? Although the treatment seems relatively safe, very few, if any, randomized controlled trials have really evaluated safety as an outcome of cognitive behavioral therapy for insomnia trials. Adherence is well known to be a challenge for cognitive behavioral therapy for insomnia and ways to improve adherence need to be further explored. And finally the expertise needed for treatment delivery. Many of these treatment trials have included highly trained sleep psychologists, but there's increasing evidence that individuals don't need that level of training in order to effectively deliver cognitive behavioral therapy for insomnia. So let me summarize this section on non-medication and nonpharmacological treatments for insomnia. Cognitive behavioral therapy for insomnia has been shown to be efficacious in the short-term and long-term, and seems to have minimal adverse effects. Although as I just mentioned, I think adverse effects need further consideration. The treatment effects may not be immediate. In fact, we tell many patients that treatment effects may take a little bit of time before they start to emerge. And this can have effects on people's adherence and willingness to stick with treatment. There are a variety of treatment implementation issues I mentioned previously, that can sometimes present potential barriers, and certainly require further study for further elucidation. And finally, we really understand, have limited understanding of the mechanisms of action that are responsible for any kind of treatment response.
