A few years ago, while I was updating a lecture for medical students on the subject of “General Anaesthesia”, I discovered a “tool” that could be very beneficial (and profitable) for both patients and anaesthesiologists alike.
At that time, out of the desire to provide students with current information and discoveries in the field, I took an online course sponsored by the University of Michigan Medical School called “Sleep: Neurobiology, Medicine, and Society”.
I was pleasantly surprised to find out that the people who were leading this course were in one way or another involved with Anaesthesiology: Ralph Lydic and Helen Baghdoyan were both Professors Emeritus in Anaesthesiology and George Mashour, MD, PhD, who was teaching the “anaesthesia segment” of the course was also an Anaesthesiologist.
Included in the syllabus was a module on “Cognitive Behavioral Therapy for Insomnia” or CBT-I for short. This is the tool which I would like to talk about, showing you some arguments for why it can be a powerful if unusual addition to the anaesthesiologist’s “tool bag”.
So what is CBT-I and why should we consider it?
Let’s start with the facts. Insomnia affects more than 12% of the world population. Although this statistic is based on a set of rigid diagnostic criteria, the reality is that the number of people who suffer from undiagnosed sleep problems is much higher.
Traditionally, the ones “officially assigned” to deal with this problem have been psychiatrists and neurologists. However, the usual course of treatment has almost always been pharmacological – a “sledgehammer” approach with side-effects and only short-term results.
During the past decades, CBT-I has surfaced as a promising non-pharmacological alternative to solving this problem. Hundreds of studies and tens of meta-analyses have proven its efficiency in treatment, especially in chronic cases of insomnia. It has been shown to be a superior alternative to the usual route of using sleep-inducing drugs.1-4
But what does the CBT-I treatment actually involve?
The first step consists of identifying and evaluating the factors that contribute to a patient’s sleep disturbances. This is done through surveys and a sleep journal that the patient is tasked to keep for a couple of weeks in order to identify patterns of thought, behaviours, and stressors that contribute to his pathology. As has been found, the most common root causes for sleep disturbance lie in the psychosomatic component – the patient’s thoughts, beliefs, or perceptions related to sleep, which keep him in a state of hyperarousal.
Once the cause has been identified and assessed, “defusing” it is done through a combination of techniques pertaining to stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy.1,3All these steps can be easily taught to medical professionals who do not possess specialist, sleep-related knowledge.1Anaesthesiologists arguably have an “in-built advantage” over other fields thanks to their intimate knowledge of the mechanisms shared by general anaesthesia and sleep, especially the ones concerning the homeostatic sleep drive.
At present, modern insomnia treatment guidelines (i.e., American Academy of Sleep Medicine2008, National Institutes of Health2014, American College of Physicians2016) recommend CBT-I as the first-line of treatment, especially for chronic insomnia.3,4
The benefits over pharmacological solutions are many: sustainable results that can be maintained on a long-term basis, no side effects, lower long-term treatment costs, domino-like positive effects on comorbid pathologies, and so on. Another possible benefit of treating insomnia is that it can reduce anaesthetic requirements and pain experience, as a study in the Journal of Clinical Anesthesiologyhas shown that patients with sleep problems often need higher dosage for effective procedure.5
Even though the effectiveness of CBT-I has been thoroughly proven, in many countries it’s still at an infancy stage as far as implementation on a large scale goes. In 2012, the U.S. federal government funded a Veterans Health Administration training program with a long-term goal of preparing 1000 CBT-I specialists. Since then, the demand for this kind of practitioner has grown; however the supply has not. This presents a profitable opportunity for those who are interested in exploring this field further.1
CBT-I can be taught to physicians and subsequently delivered to patients entirely through the Internet (this variant is called ICBT-I). This eliminates obstacles like geographical location or interfering with a physician’s regular office hours – allowing one to create his own schedule and preference on where and when to deliver it.2,6The relaxed nature of this treatment can also be a welcome addition and even an extra income source for the physician who wants to decrease his involvement in clinical routine work but still wishes to be involved in the medical field.
As Prof. Gurman mentioned in a recent issue of the ESA Newsletter, the later stages of a physician’s career most often turn to education and teaching. ICBT-I can be either an addition to that or even a primary alternative as it provides the physician with the ability to positively impact the patient’s well-being without the hectic rhythm and intensity that is characterized by the beginning and intermediate stages of one’s profession.
Lastly, as a kind of testimonial to the validity of ICBT-I, I’d like to write a few words about my own experience with it. Although done on a small, individual scale, I can personally attest to the efficiency of ICBT-I provided by an anaesthesiologist. Besides the results that do not differ from the ones described in the literature, the possibility of delivering CBT-I in small groups (in my case from 5 to 7 patients) through the internet makes it an “easy-to-integrate” component to regular activities.
Hopefully, this article has given the reader an idea on what CBT-I is, its possible application, as well as a further direction for investigation. Although it can be seen as an unconventional tool for our profession, it represents a burgeoning field with considerable promise. As it is with every medical progress and discovery, we cannot afford to ignore it, for in doing so, we would not only bar ourselves from its fruit, but also our patients and their wellbeing.
- Manber R, et al. J Clin Sleep Med2012;8(2):209-18.
- Zachariaea R, et al. Sleep Med Rev2016;30:1–10.
- Schutte-Rodin S, et al. J Clin Sleep Med2008;4(5):487-504.
- Qaseem A, et al. Ann Intern Med2016;165:125-33. doi:10.7326/M15-2175
- Erden V, et al.J Clin Anesth2016: 34:367-72, doi: 10.1016/j.jclinane.2016.05.020
- Blom K, et al. Behav Res Ther2015;70:47-55. doi: 10.1016/j.brat.2015.05.002
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