Presidential Column

Now That You Have Prescribed Exercise, How About Sleep?

By Michael W. Otto, Ph.D.

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Let me start this column by recalling a conversation from a number of years ago. The occasion was my first attendance at a sleep training conference. One of the speakers, a sleep expert, came up and warmly greeted me as an outsider to the conference, and then challenged me in a conversation that unfolded something like this:

Michael, you work in a graduate program that champions empirically-supported treatments for a wide range of disorders, and I know you frequently give talks on the benefits of these treatments. But let me ask you, in your program, do you routinely train your graduate-student and post-doctoral clinicians in cognitive-behavior therapy interventions for insomnia? After all, these treatments are brief, powerful, and complete well against pharmacologic alternatives, particularly for longer-term outcomes.

In response, I said, “uhm.” And then I said, “uhm” again, and then I said, “good point, I will get right on it.”

It is absolutely true that cognitive-behavior therapy interventions for insomnia (CBT-I) represent one of the important achievements of clinical psychology. These ultra-brief interventions can be delivered across only a few sessions, and are associated with strong and reliable benefits on overall insomnia severity, sleep efficiency, sleep quality, and maintained sleep after initial sleep onset (van Straten et al., 2017). Notably, these interventions are an especially efficacious alternative to sleep medications, as indicated by both head-to-head trials (e.g., Jacobs et al., 2004) and meta-analytic review (Brasure et al., 2016; van Straten et al., 2017).  The evidence is strong enough that the American College of Physicians recently recommended, in their clinical practice guideline, that all adult patients receive CBT-I as the initial treatment for chronic insomnia (Qaseem et al., 2016). Training in these interventions is made easy by a number of very useful clinician guides (e.g., Edinger & Carney, 2015: Perlis, Jungquist, Smith, & Posner, 2008) as well as in-person training opportunities (e.g., http://www.med.upenn.edu/cbti/). In short, insomnia interventions represent one of those clinical tools that are useful for every clinician’s tool belt.  But why do I bring it up now?

Ongoing research has clarified that, not only is insomnia a risk factor for the development of some disorders (e.g., depression, Perlis et al., 2006), insomnia is linked with greater severity, poorer treatment outcome, and risk for relapse (Li, Lam, Chan, Yu, & Wing, ,2012; Smith, Huang, Manber,  2005; Sunderajan et al., 2010). On the other hand, the good news is that sleep promotion interventions can enhance treatment outcome. Enhancing sleep has direct benefits to mood (Ballesio et al., 2017), and also appears to enhance extinction learning. For example, Zalta and associates (2013) found that the quality of sleep, assessed the night after each exposure-therapy session for social anxiety disorder, was predictive of greater benefit observed at the next session as well as by the endpoint of treatment. Researchers have also found that scheduled sleep after exposure sessions improved the retention and generalization of benefits (Kleim et al., 2014; Pace-Schott, Verga, Bennett, & Spencer, 2012), Why might this be the case?

Sleep has a number of cognition-enhancing effects, aiding the recall of information learned before sleep as well as aiding schema formation for this information (Landmann et al., 2014). Accordingly, sleep after a session can be considered one of a range of memory enhancement strategies for recall of therapeutic learning from sessions (Kredlow, Eichenbaum, & Otto, in press).  Moreover, sleep has additional effects on emotionality. That is, while sleep has the effect of promoting recall, it appears to do so while dampening the emotional evocativeness of these memories (Walker & van der Helm, 2009). In short, sleep can help provide you with clear memories that are less emotionally loaded. Imagine the benefit of this to patients with generalized anxiety disorder or reactive depression, where these individuals often seem jangled by the previous day’s negative emotional content. Sleep restoration has the potential to attenuate this jangling.

So, how do we get more efficacy out of the therapies we offer? One strategy is to stay vigilant to the sleep disruptions reported by our patients, evaluate the presence of other complicating factors (Becker et al., 2006), and to intervene with the efficacious CBT-I when appropriate. These interventions are also useful for helping patients discontinue their sleep medications and to maintain or extend their sleep gains (Bélanger, Belleville, & Morin, 2009).  Also, following sessions where patient has demonstrated important therapeutic learning, clinicians may want to assign their patient a nap or an earlier time to bed to try to lock in these benefits by enhancing memory consolidation.

In conclusion, adequate sleep mirrors some of the benefits of regular exercise on promoting both mood and cognition, and sleep and exercise also share the additional benefit of promoting health and longevity (Bellesi et al., 2017; Cappuccio, D’Elia, Strazzullo, & Miller, 2010).  So let me close this column similarly to the way I opened the last issue of The Clinical Psychologist (Otto, 2017): “did you prescribe sleep this week?”

References

Bélanger, L., Belleville, G., & Morin, C. (2009). Management of hypnotic discontinuation in chronic insomnia. Sleep Medicine Clinics4(4), 583–592.

Bellesi, M., de Vivo, L., Chini, M., Gilli, F., Tononi, G., Cirelli, C.  (2017). Sleep loss promotes astrocytic phagocytosis and microglial activation in mouse cerebral cortex.  Journal of Neuroscience, 37, 5263-5273.

Ballesio, A., Aquino, M. R. J. V., Feige, B., Johann, A. F., Kyle SD, Spiegelhalder, K.,Lombardo, C., Rücker, G., Riemann, D., Baglioni, C. (2017). The effectiveness of behavioural and cognitive behavioural therapies for insomnia on depressive and fatigue symptoms: A systematic review and network meta-analysis. Sleep Medicine Reviews, [Epub ahead of print]

Becker, P.M. (2006). Insomnia: prevalence, impact, pathogenesis, differential diagnosis,and evaluation. Psychiatric Clinics of North America, 29, 855-70

Brasure, M., Fuchs, E., MacDonald, R., Nelson, V. A., Koffel, E., Olson, C. M., Khawaja, I. S., Diem, S., Carlyle, M., Wilt, T. J., Ouellette, J., Butler, M., Kane, R. L. (2016). Psychological and behavioral interventions for managing insomnia disorder: an evidence report for a clinical practice guideline by the American College of Physicians. Annals of Internal Medicine, 165,113-124.

Cappuccio, F. P., D’Elia, L., Strazzullo, P., & Miller, M. A. (2010). Sleep duration and all-cause mortality: A systematic review and meta-analysis of prospective studies. Sleep33(5), 585–592.

Edinger, J. D. & Carney, C. E. (2015). Overcoming Insomnia: A Cognitive Behavioral Therapy Approach (2nd Edition). Oxford University Press: New York.Fortier-Brochu, E.,& Morin, C. M. (2014). Cognitive impairment in individuals with insomnia – Clinical significance and correlates. Sleep,37,1787-1798.

Jacobs, G. D., Pace-Schott, E. F., Stickgold, R., & Otto, M. W. (2004).  Cognitive-behavioral therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison.  Archives of Internal Medicine, 27, 1888-1896.

Kleim, B., Wilhelm, F. H., Temp, L., Margraf, J., Wiederhold, B. K., & Rasch, B. (2014). Sleep enhances exposure therapy. Psychological Medicine, 44, 1511–1519.

Kredlow, M. A., Eichenbaum, H., Otto, M. W. (in press). Memory creation and modification: Enhancing the treatment of psychological disorders.  American Psychologist.

Landmann, N., Kuhn, M., Piosczyk, H., Feige, B., Baglioni, C., Spiegel- halder, K., . . . Nissen, C. (2014). The reorganisation of memory during sleep. Sleep Medicine Reviews, 18, 531–541.

Li, S. X., Lam, S. P., Chan, J. W. Y., Yu, M. W. M., & Wing, Y.-K. (2012). Residual sleep disturbances in patients remitted from major depressive disorder: A 4-year naturalistic follow-up study. Sleep35(8), 1153–1161.

Otto, M. W. (2017). President’s column: Did you prescribe exercise this week? The Clinical Psychologist, 70(3), 1-4.

Pace-Schott, E. F., Verga, P. W., Bennett, T. S., & Spencer, R. M. (2012). Sleep promotes consolidation and generalization of extinction learning in simulated exposure therapy for spider fear. Journal of Psychiatric Research, 46, 1036–1044.

Perlis, M. L., Jungquist, C., Smith, M. T., Posner, D. (2008) Cognitive behavioral treatment of insomnia: A session-by-session guide (2nd Edition). Springer: New York.

Perlis, M. L., Smith, L. J., Lyness, J. M., Matteson, S. R., Pigeon, W. R., Jungquist, C. R., & Tu, X. (2006). Insomnia as a risk factor for onset of depression in the elderly. Behavioral Sleep Medicine, 4(Suppl 2), 104–113.

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., Denberg, T. D.; Clinical Guidelines Committee of the American College of Physicians. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 125-133.

Smith, M. T., Huang, M. I., Manber, R. (2005). Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25, 559-592.

Sunderaja, P., Gaynes, B. N., Wisniewski, S. R., Miyahara, S., Fava, M., Akingbala, F.,DeVeaugh-Geiss, J., Rush, A. J., Trivedi, M.H. (2010). Insomnia in patients with depression: A STAR*D report. CNS Spectrums, 15,394-404.

van Straten, A., van der Zweerde, T., Kleiboer, A., Cuijpers, P., Morin C. M., Lancee, J. (2017). Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. Sleep Medicine Reviews. [Epub ahead of print]

Walker, M. P. & van der Helm, E. (2009). Overnight therapy? The role of sleep in emotional brain processing. Psychological Bulletin, 135(5), 731-748.

Zalta, A. K., Dowd, S., Rosenfield, D., Smits, J. A., Otto, M. W., Simon, N. M., . . . & Pollack, M. H. (2013). Sleep quality predicts treatment outcome in CBT for social anxiety disorder. Depression and Anxiety, 30, 1114–1120.