Findings From South Korea Provide Insight Into XDR-TB

Abstract

tee of the American Academy of Sleep Medicine (AASM) recommends CBT-I as first-line treatment for people with both primary and secondary chronic insomnia, including chronic hypnotic users (Morgenthaler T et al. Sleep. 2006; 29[11]:1415-1419). CBT-I usually reduces symptoms of chronic insomnia by 50%, according to Michael Perlis, PhD, associate professor of psychiatry at the University of Pennsylvania School of Medicine, Philadelphia, and director of its behavioral sleep medicine program. Patients who stick with CBT-I tactics—usually taught in 4 to 8 weekly individual or group sessions—often see symptoms fade by another 25% over the next few months. Treatment gains also last at least 2 years, said Perlis, who conducted a 3-day course to train physicians, psychologists, nurses, and others in CBT-I in Arlington, Va, in October. The University of Rochester Medical Center sponsored the event. One hurdle to broad use of CBT-I is the still small population of trained practitioners. To date, 136 doctorallevel US sleep specialists, including 42 physicians, have received AASM’s certification in behavioral sleep medicine, demonstrating knowledge and skill in CBT-I and other behavioral therapies. The AASM will start certifying master’s level practitioners in psychology, nursing, and other healthrelated fields in CBT-I in 2010 (http: //www.aasmnet.org/BSM.aspx). The nearly 1600 AASM-accredited sleep centers are required to have behavioral services available. Because CBT-I is time intensive for both clinician and patient, some sleep specialists are exploring shorter variants that, if effective, would be more practical in primary care settings. One such approach is a brief behavioral treatment for insomnia devised by researchers at the University of Pittsburgh School of Medicine. It consists of a 45-minute session in the primary care office, plus a booster session 2 weeks later. A master’s level nurse practitioner reviews sleep diaries, suggests ways to regularize daily schedules, advises patients to limit time in bed to time spent asleep, and provides a workbook with further instructions. Sleep quality and efficiency improved significantly more in 17 older adults receiving such help than in a matched control group receiving routine sleep habit advice (Germain A et al. J Clin Sleep Med. 2006;2[4]:403406). Self-directed computerized or Web-based CBT-I programs also are under evaluation, but Perlis remains skeptical about their utility. “CBT-I uses evidence-based methods, delivered in a way the patient finds compelling,” he said, “with a coach to follow up and foster compliance.” “Asking every patient, ‘How are you sleeping?’” he said, “elicits an excellent indicator of overall health. Some patients with insomnia can be managed medically, and some need referral to a sleep specialist. Proper treatment will reduce subsequent morbidity and health care utilization.”