Blog Post

Pharmacological versus psychological treatment for insomnia

Clare Munro • 3 January 2020

Guest post by Clare Munro

Introducing Clare Munro...

STEM Scotland are delighted and honoured to present a blog post by Clare Munro, on insomnia and its treatment. This was originally posted on Clare’s own blog page (see https://clarespsychology.home.blog/2019/11/25/pharmacological-versus-psychological-treatment-for-insomnia/ ) and Clare very kindly agreed that we could re-post it here. Thank you Clare!

A talented Psychology graduate, Clare is now developing her expertise via a Masters in Clinical Health Psychology, and aims to pursue a career in Clinical Psychology. Clare’s research as an undergraduate and now Masters candidate is focused on the psychology of sleep, an extremely topical field. Please read and enjoy!

*****


Pharmacological v psychological treatment for insomnia

In my last blog post, I looked at the relationship between insomnia and depression and just how important it is to target insomnia as this may be the leading cause of depression. I have decided to devote a blog post to treating insomnia as I feel this is very useful information for people to be aware of!

As we all know, when we are suffering from health problems – whether it be a mental health disorder or a physical health problem, we are likely to try medication first to treat the problem. For a lot of physical and mental health conditions, medication is very effective. However, for some conditions, psychological treatment can be a much more effective alternative to taking medication (Fleming and MacMahon, 2015; Linde et al, 2015). This applies directly to insomnia (among many others).


Treatment approaches to insomnia

As I have already mentioned in my previous blog (on the link between insomnia and depression), insomnia is a mental health condition classified in the DSM-5 to be when an individual experiences poor sleep more than 3 nights a week, for a period of three months or more. In addition, this condition also has night-time symptoms such as; difficulty getting to sleep, nightly awakenings and day-time symptoms consisting of fatigue, impaired concentration and attention etc (DSM-5).


Problems with the pharmacological approach to treating insomnia

Short-term sleep problems, to a certain extent, can be helped through taking sleeping pills. If you are dealing with something stressful or something unexpected happens to you and you do not normally struggle with your sleep, taking sleeping pills on a short-term basis is acceptable. However, research indicates taking sleeping pills to treat insomnia is not effective. As we already know, insomnia is characterised by sleep problems which occur for more than 3 nights a week for 3 months or more. However, sleeping pills should not be prescribed for sleep problems for more than 2 weeks. Therefore, taking this medication is not an effective treatment method for a persistent sleep problem such as insomnia.


CBT-I for insomnia

There are alternative psychological approaches for the treatment of insomnia. The main one is cognitive behavioural therapy for insomnia (CBT-I). This approach targets the cognitive factors which are associated with an individual’s insomnia as well as including behavioural techniques to help someone with insomnia to establish a healthy sleep pattern.

Why is this method good for treating insomnia?

Research shows that there are many cognitive aspects of insomnia, such as; heightened arousal, cognitive hypervigilance, the racing mind and an individual’s conscious awareness that they need to get to sleep. All these factors contribute to insomnia. CBT-I is a great way of treating insomnia as it directly addresses these cognitive factors and includes behavioural techniques to treat the condition (Fleming and Macmahon, 2015; Taylor et al, 2014).

These techniques include:


  • Sleep hygiene
  • Cognitive therapy
  • Sleep restriction
  • Stimulus control
  • Relaxation techniques

Sleep hygiene

This aspect of CBT-I emphasises the importance of environmental and physiological factors, as well as habits which promote good sleep. This aspect of CBT-I is relatively straightforward for one to implement themselves to help treat their insomnia. Some important examples include: making sure your environment is comfortable (comfort of bed, lighting, temperature of bedroom), avoiding drinking alcohol too close to bedtime and trying to wind down at night (do not engage in activities which require a great deal of physical activity e.g strenuous housework or going to the gym etc).


Cognitive therapy

This component of CBT-I aims to ‘identify, challenge and change dysfunctional beliefs and thoughts about sleep which may drive sleep-related arousal’ (Fleming and MacMahon, 2015). There are various methods which are used within the cognitive therapy aspect of CBT-I, such as; cognitive restructuring, thought blocking, mindfulness and paradoxical intention.


Cognitive restructuring

This allows someone to think about ‘faulty cognitions’ such as ‘if I do not sleep tonight, I will not function properly tomorrow and so I will have a bad day’. Cognitive restructuring aims to try and train someone to restructure these unhelpful cognitions that someone has in relation to their sleep.

Thought blocking

This is an easy technique that an individual can do to try and stop their thoughts preventing them from getting to sleep. It simply involves repeating the word ‘the’ roughly every 3 seconds, in your head, to try and block out thoughts which may keep an individual awake (Cunnington et al, 2013).


Mindfulness

Focuses on being non-judgemental in the present rather than focussing on the future or past which reduces mind activation, making an individual feel less awake.


Paradoxical intention

This is where insomnia sufferers are encouraged to put effort into trying to remain awake rather than trying to fall asleep which is thought to strengthen an individual’s sleep drive and reduce their performance effort, making an individual more sleepy and fall asleep more quickly (Morin et al, 2006).


Sleep restriction

This aspect of CBT- I involves restricting one’s sleep initially in order to develop a good sleeping pattern and prevent people attempting to ‘catch-up’ on sleep at weekends. This is done through using sleep diaries to establish how many hours an individual gets of sleep on average, each night (sleep effectiveness score). Then an individual is set a specific number of hours they can sleep every night in order to develop a consistent sleep pattern.

Over time, more hours are gradually added on the individual’s set number of hours they can sleep each night, in order to ensure that this method is effective. Research shows that this is actually a very effective method for helping to treat insomnia. However, it is very hard to get people to stick to the set number of hours each night (low adherence).


Stimulus control

This part of CBT-I focuses on re-associating the bed and bedroom with sleep only (aside from intimacy).

If you are lying in bed for more than 15 minutes and do not feel sleepy enough to get to sleep, go into another room and do something which will not stimulate the brain too much (e.g reading, listening to music etc) until you feel sleepy then head back to bed and you should fall asleep quickly.


Relaxation techniques

These techniques help to reduce tension and thoughts at bedtime which may interfere with sleep. Progressive muscle relaxation is one key example, this is when an individual is instructed to contract their muscles as far as possible and then relax them.

Here is a progressive muscle relaxation audio which I used as part of undergraduate dissertation project:


https://www.youtube.com/watch?v=912eRrbes2g&feature=youtu.be



Drawbacks of psychological treatment for insomnia

Although research strongly suggests that these techniques are highly effective for the treatment of insomnia (Taylor et al, 2014; Cunnington et al, 2013), there is limited access to CBT-I for insomnia. This is due to the fact there are not enough clinicians who are trained to deliver this intervention. This problem has been addressed recently through the development of online apps based on CBT-I to allow people to have easier access to this effective treatment for insomnia.


Sleepio app



This app has recently been developed as an alternative to traditional CBT-I. If interested, here is the article which first tested the effectiveness of the Sleepio app:

Additionally, here is a link which will direct you to the sleepio website where you can find more information and can download the app!


https://www.sleepio.com/


So – what can we conclude from all of this?

Research shows that psychological treatment for insomnia is more effective than a pharmacological approach. Although there is limited access to CBT-I face-to-face from a trained clinician, recent development of apps such as ‘Sleepio’ provide an easily accessible, effective alternative to CBT-I delivered by a clinician.

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Available at: https://gcatd.org/resources/Documents/Special%20Interest%20Groups%20(SIGs)/Consultants/AI%20article.pdf [Accessed 2nd July 2018] [Note: This article has been previously published in the conference proceedings, along with a transcript of the whole event, as participants are encouraged to continue the debate/discussion afterwards. Proceedings are only available to attendees; however such articles are the property of authors and so freely available for their use. Thanks to Sean Cudmore, Deputy Organiser of the Scotland Policy Conferences, for confirmation of this permission]
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As part of my final year dissertation I chose to do a STEM outreach project. I was given 10 weeks to create and complete a physiology-based activity, which engaged the public in science. With public engagement ranging from museum exhibitions, cafes, pubs, nursing homes and shopping centres, the possibilities are endless for creating STEM based activities. In the ASPIRES report by Kings College London, I was shocked to see that the demographic least likely to aspire to a career in science were white females, aged 10-14, with no family members working in STEM industries. As a woman studying science this made me wonder how I ever came to study Physiology, but also inspired me to target my project towards young females in Glasgow with the main aim of dispelling the misconceptions that science is ‘too difficult’ or ‘only for boys’. What I did for my project... I taught over 140 children from various groups including Girl Guides, Scouts and Schools. Participants of the ‘All Systems Go Physiology Workshop’ listened to each other’s heart beats using stethoscopes, performed a reaction time experiment, patellar tendon jerk reflex, blind spot test and Ishihara colour-blindness tests. After doing some research, I discovered how having a ‘gore factor’ can lead to greater recollection of scientific tasks. I displayed a fantastic video of a heart beating ( https://www.youtube.com/watch?v=298puWjGaw8 ) and brought a real sheep’s heart along to the workshops. Results I used an evaluation form to determine the success of the workshop and compare the groups I was working with. The group who performed best were the Girl Guides, which shows that perhaps educating and inspiring young girls to pursue science works much better in an informal learning environment rather than a School, but of course this very much depends on the individual learner. On the evaluation form I asked everyone to draw a picture of a heart. I received some beautiful love heart drawings before the session started, and after the session, generally a big red blob! Here are a few of my favourites...
by Dorothy Aidulis 13 January 2019
When I decided to set up STEM Scotland, I produced a huge Mind Map of all the things I could include in the business; a Science Club was just one of them. When an opportunity presented itself to run a Science Club, I threw myself into it, unleashing the creative me. It has been great fun! Even the paperwork in a way, as it is so satisfying to do this for a clearly defined purpose. Resources! Deciding what experiments are suitable for a Science Club depends on a variety of factors. Fun being crucial! Messy is good. Scientific is essential. Using everyday materials is great; cuts down costs, encourages recycling, and helps make it more visible that science is everywhere (I have been stashing takeaway food tubs for months now).. It’s also important to have actual scientific instruments and equipment you may find in a lab, so that pupils/students have exposure to these and hands-on experience of using them. Research! There is a huge amount of material online for science experiments suitable for children; I have spent hours researching, watching YouTube and other clips, partly feeling “guilty” as I was having fun doing this, and taking the time out of my day to do so; I had to keep reminding myself this was work. It was great! My brother reminded me of the legend that is Bill Nye (Science Guy) and from his (Bill’s) video on Bones & Muscles I really loved the few-seconds clip on Dissolving Bones; I will come back to this… An interesting (frustrating?) point to note is that in my searches so far I have come across very few videos with women presenters…I will come back to this too…. Human Communication Never underestimate the power and value of talking to other people; there is so much we can learn from each other, and sometimes I think this gets forgotten in our increasingly online world. Attending the Scottish Learning Festival (SLF) at the SEC Glasgow (September 2018) gave me so many ideas, from the excellent presentations, the trade stalls, talking to people in sessions and at coffee breaks, and probably most importantly, the STEM Expo 2018! This was a new feature of SLF, where a large room (Lomond) was set aside for real proper hands-on try-it-out sessions for conference participants. Tables/stalls/floor space was occupied by various groups including several schools (pupils and teachers), organisations such as Institute of Physics (IoP, who were presenting their material on gender equality in science), and STEM Glasgow. The children were absolutely fantastic at not letting anyone (me!) pass by without trying out their experiment/creation. What great salespeople never mind budding scientists! I learned about global warming, plastics in the ocean, how to build and test a helicopter, and how to make a catapult among other exciting things. The whole room was buzzing; the enthusiasm was palpable, and the creativity and potential in that room were inspirational! I took as many examples, leaflets, samples and contact details as I could; this became source material for my Science Club ideas and resources. Perhaps most important though, was the clear knowledge that children do want to do science. We need to help them fulfil that early potential and talent. Experiment Practice (and chickens) Going back to the bones…I set up an experiment in the kitchen with some bones from the Christmas turkey, in test tubes (herb containers) of red wine vinegar, Pepsi (this one fizzed!) and tap water as a control (pictured below). At the same time as carving off the meat to obtain the bones, I also set up a frying pan with onions and korma sauce, into which I stirred the turkey meat (end result also pictured). This is a very important part of the experiment. I am wondering if there would be interest in making a video series… The china chicken (you can just make out a corner of it in the pic below) was a Christmas present. We were not quite sure what to do with it, so it has carved a role for itself as a star in the Science Club preparation and delivery. I then began to wonder; are the properties of bone affected if they are cooked? Maybe I need to use uncooked bones? So I bought an uncooked supermarket chicken; off came the bones (and on went the casserole; I sense a theme developing here). I managed to dissect out the thigh bones, breast bone and rib cage, the latter being particularly challenging but well worth the effort. These bones are now the subject of the first session of Dr Dot’s Science Club, currently resting in vinegar in a box in my garage, and will be reported on at a later date. Risk Assessment and Insurance There are several examples online of Risk Assessments (RAs) for various purposes and contexts; I began with looking at the STEM Ambassador resources and followed links from there. The first step to producing an RA for a Science Club is to actually decide just what experiments you want to do (witness the fun I had researching this!). Making the decision I found was perhaps the hardest part, more so than the actual paperwork. However once I had a clear list, I adapted an online template to produce a grid, starting with the list of experiment titles on the left. Opposite each, I detailed the possible hazards; location; who might be affected; the risk rating; control measures; and finally the risk rating after these measures are taken. I also included for clarity an appendix showing how the risk is calculated. This can all be quite time-consuming; but once produced, your own template/draft can then be adapted/updated as required. I was able to complete mine while on the train down to London for the Pharmacology 2018 conference, which was a most satisfying and very productive use of the journey time (possibly more so than if I had been in the office….)! If running a Science Club, Public Liability Insurance is a good idea; it is not a legal requirement (unlike Employer Liability Insurance), but many organisations can request it or even insist on it, and it makes absolute sense to just have this from the beginning even if it is not required officially. Some companies do not offer Public Liability Insurance for a Science Club and refer you on to a more specialised broker so leave plenty of time to shop around, particularly as there can be quite a bit of to-ing and fro-ing with underwriters before giving a quote. Timing and Logistics How many children there are (can you set upper or lower limits?); ages/stages; whether people work in pairs, groups or individually; whether you have any assistance....how best to allocate/divide up equipment; what's the optimum number of set-ups to provide; are there occasions where a demo would be better; how many eyes in the back of your head you have...these all require careful consideration. And be prepared to revise as you go. It goes without saying that planning is absolutely essential, but don't be afraid to completely change or adapt procedures. It could be argued that for a successful well-run Science Club, organisation is just as important as the science (perhaps even more so). The Bare Bones So there it is; the Anatomy of a Science Club. To be continued…or evolved….!
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