Friday, June 26, 2009

Insomnia: Meds Vs Therapy: Therapy wins. Again. Tell your Physician. JAMA May 20 2009.

Charles M. Morin; Annie Vallières; Bernard Guay; Hans Ivers; Josée Savard; Chantal Mérette; Célyne Bastien; Lucie Baillargeon.Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent InsomniaA Randomized Controlled Trial.JAMA. 2009;301:2005-2015. May 20, 2009.

This study has great news. If you can call the repetition of a well-recognized result "news." We have known for decandes that cognitive-behavioral therapy works for sleep. The new part is knocking down yet another late-comer (carrying along its side-effect baggage with it): Ambien.

If you have insomnia problems, and you go in to see your physician - prinary care, gynecologist, whomever - they are generally more likely to prescribe a med versus informing you that you ought to seek a therapist who is trained in helping people address sleep problems, and do some psychotherapy for your sleep problems.

However, that is the wrong answer.

Why?

As this recent study shows, talk therapy has equivalent results to sleep meds in the short term;plus when the short-term treatment is done, you are left with skills and strategies you can use anytime, anywhere, whether your meds run out or not;You are not limited to the warning to only use the intervention for two weeks or less;you avoid the side effects of sleep medications - in this article, Ambien is tested - sleep meds including Ambien lead to sleep-walking behaviors in some - sleep-eating, sleep-driving, sleep-s ex which can be both good and bad in your relationship, but not for you because you don't remember; etc.;Nearly all of the sleep medications have risk of dependence if used for longer than the approved short terms;For some, the psychotherapeutic intervention for sleep can be done by self-help, or with "bibliotherapy" - just get a therapist to guide you through the book, versus providing the entire treatment - this can greatly reduce counselign sessions, lowering time and cost;etc.

Why does the doc not guide you to the treamtent that has equivalent results but a greatly reduced side effect issue?

Several reasons.
Problems come from the physician side, but also the psychotherapist side.
Physicians generally do not hold sufficent respect for psychotherapy, and so do not maintain decent relationships with local psychotherapists. Psychotherapists do not systematically reach out to their local medical community and build relationships to overcome these barriers. And psychotherapists tend to fail to provide feedback to the physician, so the physician gets no info on whether you, or other patients, benefited or not - so the physician ends up losing the opportunity to discover a valuable resource, and gets a negative view of psychotherapists as isolative and non-communicative.

Physicians have all the means they need to address these problems when they occur - physicians can ask you, the patient with sleep problems, about your sleep treatment, and can ask you to sign a piece of paper giving the physician and psychotherapist permission to share your private information, and encourage you to encourage your psychotherapist to provide updates. Including in this, you can ask your psychotherapist to discuss some things and not discuss others. So, if you have disucssed private information with your psychotherapist, in the course of the treatment for sleep, just tell the talk therapist to not mention that, but just to discuss sleep.

In fact, you can write this on the piece of paper giving permission for these two to communicate - there will be a blank where you enter what info and a blank for what purposes - for info just put "info specific to psychological treamtent for sleep," and for purposes, put "coordination of clinical care, and update clinical providers on clinical progress."

Like this, the talk therapist and physician are free to discuss the sleep treatment. The physician needs to keep up to date in order to consider whether some medical problem -such as chronic pain as part of some medical comdition, some hormonal problem, sleep apnea, etc., is accounting for poor sleep. Plus, the physician needs to know if the psychotherapist is a good provider, or if they are merely sitting there in the chair, collecting $100/hour, and repeatedly asking "how does that make you feel" -- That is not cognitive-behavioral therapy for sleep - that is someone who is not properly delivering empirically recognized psychotherapy for sleep problems but is just acting like it. Your physician needs to know who the good talk therapists are in your geographic area.

Along with all of this, your physican is regularly visited by a salesperson whose job is to plant an easy decision in the mind of your physician for various problems - as here, the salesperson informs your physician that when someone mentions sleep problems, the physician should automatically think "Ambien."

That salesperson will NOT be carrying copies of the decades of studies showing that talk therapy works for sleep problems. The salesperson WILL have a handout summarizing, with simple pictures, the result of some biased study that was designed to give the med the edge over a placebo, or some watered-down psychotherapy. And the salesperson will act like this new info, due to its newness, puts the old info out of the picture - as if it updates it, like Windows Vista updates Windows XP, making it irrelevant. This is how Microsoft works, but clinical care is just not like this. If talk therapy worked in the 1970s, and the 1980s, and the 1990s, and in the 2000s, there is no med study that will make those results irrelevant. Old = trusted, proven, and dependable, not retired and obsolete.

Sad to say, but this is what you are up against if you start at your physican when starting your journey in seeking sleep help. However, You, or your family member, have every right to insist that the process go in the correct direction: 1. that your physician help you locate a decent psychotherapist, and 2. at the same time help rule out any likely medical reasons for poor sleep, such as pain, or sleep apnea and 3. your physician stay up-to-date with your psychotherapist.

As I have said, psychotherapists somehow need to develop the networks with physicans to improve communication.

Patients have a role, too.

In the field of psychotherapy, some therapists believe that patients who get a good benefit have an obligation to share the news when they can - since therapists are ethically prevented from shouting the most recent success fro mthe rooftops, it is up to the patients. This would include sharing this news with your physician. Along with the salesperson, patients with psychotherapy success stories could give the info that physicians do not quite get from research studies such as this JAMA study.

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