Why Face-to-Face CBT-I?

I’ve been pondering what to write for my next blog post, and inspiration struck this week when I attended sleep grand rounds at Emory, where I’m adjunct faculty in the sleep fellowship program. It was a “journal club” morning, which meant the chosen fellow presented on an article and included a background literature search to broaden our knowledge of the topic. This morning’s presentation – an article about the efficacy of an online program for cognitive-behavioral treatment for insomnia. You can see the abstract for the article, which appeared in the JAMA Psychiatry journal here. If you’d prefer the popular press version, you can check out this video from when it made it on to the NBC Nightly News.

I hadn’t originally planned to attend sleep rounds, but when I saw what the article would be, how could I not go and defend my turf? It turns out I didn’t really need to. Even so, I’m glad I went even though the problems in the article – most glaringly the financial involvement of the researchers in the program that was studied and the lack of a comparable treatment condition (e.g., a free CBT-I app), which would have been more useful than the sleep education control  – were discussed thoroughly.

But as I was driving back to my office and then throughout the day, the real value of what I do came to mind…and to my couch. Here are five reasons for why face-to-face CBT-I is always going to be better than the automated online versions:

True tailoring, especially with regard to the sleep restriction portion of treatment. 

Online programs claim to “tailor” the treatment to the user. However, only a certain amount of tailoring can be done via the internet. Even if you send your measurements to a clothing site, it’s likely adjustments will be needed to make the clothes look as good as possible. And don’t even get me started on shoes.

Online CBT-I programs calculate the amount of time a patient should spend in bed based on their reported total sleep time at baseline. One of the other problems of the study was that they used purely self-report measures, not something like polysomnography (gold standard) or even actigraphy (greening bronze standard) for figuring out what a person’s true total sleep time is. Why is this important? Insomniacs have a phenomenon called sleep state misperception, which means their brain is asleep, but they still perceive what’s happening around them and report that time as wake time. Based on a patient’s report of what they’re doing when awake in bed, I and other behavioral sleep medicine specialists will often adjust my sleep restriction recommendations with sleep state misperception in mind.

I have to do what every day???

“I will do anything for sleep, but I won’t do that.”

Let’s be honest. Some of the recommendations of CBT-I are hard. When I’ve seen patients who have failed to improve with online programs such as the one mentioned in the article, it’s often because they’ve been given a treatment recommendation that they felt they absolutely could not follow, and the rest of the program fell apart around it. No matter how cute and interactive a program is, it’s not a clinician who can effectively motivate reluctant patients. We know where to be flexible and have enough experience to modify treatment protocols effectively without diluting their effectiveness. That’s the art of doing CBT-I. For example, sometimes a person’s living situation doesn’t allow them to leave the bedroom if they’re not asleep. The fun part of my job is figuring out creative ways for patients to still get the benefit of treatment recommendations but within their life’s limitations.

What about those sleeping pills?

Many of my patients come to treatment wanting to discontinue hypnotic medications. I work with referring physicians to help patients achieve natural sleep without medication. Due to liability reasons, online programs don’t touch medications. Nor should they. But they’re not addressing patients whose main goal is to get off sleep medications.

There’s something about accountability.

Why is Weight Watchers still going strong in spite of the proliferation of SparkPeople and other food tracking and weight loss sites and apps? You’re much less likely to cheat and more likely to follow through if you know you’re going to be facing the person behind the scale, who’s going to write that number in your little book. It’s different from typing in a number on a website. A characteristic I’ve noticed about patients who didn’t do well with the online CBT-I programs is that handing over a sleep diary makes them more likely to follow recommendations because someone else will see it.

Clinical experience matters.

In a moment of synchronicity, one of my patients said to me today, “I’ve gotten so much farther with you than I did with that online program I tried first.” What was the difference? Clinical experience and finesse – I worked with that person to get them through the problems and snags that felt insurmountable to them but that I’ve seen hundreds of times before. I also highlighted some things on their sleep diary that continue to hamper their ability to sleep to their true potential. Then we discussed the different options for what to do next, and I was able to make recommendations based on my experience and my thorough understanding of this unique patient’s case.

Do I think that the online programs won’t work for anyone? No, I think they’re great for people who are very motivated, are satisfied with the amount of support they can get from the online forums associated with many of these platforms, and who have fairly straightforward cases of insomnia. If you’re the type of person who completes every online course and webinar series you buy or goes through self-help books, does all the exercises regularly, and implements all the recommendations systematically and consistently, then online CBT-I is probably right for you.

Do I believe that face-to-face treatment is better and worth the cost, whether it’s in time or money? Definitely. In the end you’ll end up wasting less time and money than if you’d started with a behavioral sleep medicine specialist to begin with.

As for the sleep fellow who brought the article in… I’m watching you. 😉

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