Insomnia keeps people up at night — and frequently leaves them exhausted and unfocused during the day. Many people think of sleeping pills as the first-line remedy. But medications are not a long-term solution.
“Most medications that help with sleep are designed to be used short-term,” said Alan Schwartz, Psy.D., psychologist of Christiana Care Behavioral Health Consultants who sees patients at Foulk Road Family Medicine. “A problem arises when people who take them over long periods of time come to associate taking medications with getting sleep. Interestingly, many people also continue to take the medications even though they do not help sleep.”
Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based, effective method for improving sleep. Christiana Care behavioral health consultants embedded in primary care and neurology practices use CBT-I with patients to improve sleep hygiene, create an environment conducive to rest, and develop helpful behaviors and a helpful mindset about sleep.
While insomnia may be linked to a health issue, such as sleep apnea, it also can be a problem of its own. Studies suggest that 6-10 percent of Americans have insomnia.
“Sleep and problems with sleep are seen across all medical specialties and disciplines,” Dr. Schwartz said. “Sleep is a very delicate process, and particularly when people are feeling stressed or anxious, they often have trouble sleeping.”
Dr. Schwartz collaborates with several colleagues from Christiana Care’s Behavioral Health Consultants, including Kathryn Poppiti, LPCMH, at Lancaster Pike Internal Medicine, and Frank Malinsky, LCSW, at the primary care practice at the HealthCare Center at Christiana, seeing patients specifically referred for CBT-I.
The first step in the process is a sleep assessment that identifies mental health and medical issues that might interfere with sleep. In addition, behaviors that might get in the way of nighttime sleep are identified, such as napping during the day, drinking caffeinated beverages or lack of physical activity.
“Some people have a partner whose snoring impacts sleep,” Malinsky said. “Some have partners who like to sleep with the television on. Some people have pets who wake them up at 4 o’clock in the morning. Or they may be allergic to their pets and that impacts their sleep.”
Reading or watching TV in bed interferes with sleep.
“We want people to associate being in bed solely with sleep and intimacy,“ Malinsky said. “Using the bed for other activities dilutes the powerful association between bed and sleep.”
Medications also can disrupt sleep. For example, Malinsky consulted with one patient’s doctor who switched his medications from a time-released formula to a shorter-acting one that didn’t keep him up at night.
Shilpa Kauta, M.D., is the medical director of the Christiana Care Sleep Disorders Center and a neurologist at Christiana Care Neurology Specialists with expertise in insomnia.
“Given the right behaviors, people can get a good night’s sleep,” Dr. Kauta said. “Medicines tend to wear off. Good sleep habits are enduring.”
She noted having a behavioral health consultant embedded in the practice provides patients with enhanced access to care. In some practices, CBT-I is offered in a group format. At the Internal Medicine Center at Lancaster Pike, Poonum Maru, D.O., and Kathy Poppiti, LPC (BHC), completed a three-session CBT-I group with patients reporting positive results.
“We are seeing far more patients establishing care with behavioral health with our embedded behavioral health consultants than we did when we were only able to provide referrals,” Dr. Kauta said.
Doctors and behavioral health consultants are partnering with the Sleep Disorders Center. Referrals, typically through the primary care physician, are made to the sleep center if a patient is suspected of having apnea or another undiagnosed problem. Many patients who have already had a sleep study or currently use a CPAP device come to CBT-I.
“This partnership allows for a collaborative approach to determining the most appropriate patient-focused treatment plan,” said Melissa Bollinger, MBA, BSN, RN, director of Neurosciences. “The long-term effect of insomnia impacts far more than the individual. Insufficient sleep is a public health concern. A multi-specialty sleep center can help facilitate the highest level of quality care.”
Rising at the same time each morning helps to establish good sleeping habits, said Michele Cavanaugh, APN, the behavioral health consultant in the neurology practice.
“You get up at the same time every day, seven days a week, regardless of how much sleep you got the night before,” she said. “Eventually, there’s a back-fill.”
Dr. Schwartz notes that at times patients are asked to go to sleep later than they typically would in order to get a brief but solid block of sleep. “If they don’t nap during the day, the ‘sleep pressure’ can assist them in getting to sleep at night.”
In addition, addressing people’s beliefs about sleep — the cognitive part of CBT-I — can help in understanding obstacles in thinking and emotions that may be interfering.
Limiting the time in bed when they are not sleeping also is helpful. If you haven’t fallen asleep after 15 minutes, get up and perform a mundane task. Or practice guided imagery or meditation. Don’t check e-mail or watch TV. The blue light from devices is stimulating and interferes with sleep.
“Do something very boring in dim light,” Cavanaugh said. “Clip coupons. File your nails. Write thank you notes. Personally, I fold laundry.”
About 60 percent of the patients she works with have insomnia.
“The people who are willing to try these strategies soon become aware of how much their daytime activities and nighttime environment impact their sleep,” she said. “Learning new behaviors truly makes a difference.”