Practical Integration of Actigraphy with Cognitive Behavioral Therapy for Insomnia

1. Practical Integration of Actigraphy with Cognitive Behavioral Therapy for Insomnia Dr. Derek Loewy, Ph.D.

2. Overview • Background information • Cognitive behavioral therapy for insomnia (CBTI) • Sleep diaries • Actigraphy • How actigraphy can enhance CBTI • Sample actograms • Program content overview • Fitting actigraphy into the CBTI session • Actigraphy/CBTI reimbursement update

3. CBTI Basics • Clinically effective, behaviorally-based approach to improve sleep for patients with insomnia • Delivered individually or in groups • Helps optimize the potential for good sleep, improve sleep quality, and improve daytime alertness through education and practice • Multi-component; incorporates behavioral and cognitive techniques delivered over weekly sessions (typically four-eight) • Effectiveness of CBTI is highly dependent on patient compliance

4. CBTI program from Philips Respironics • Brief, four-session, CBTI program incorporating conventional interventions: • sleep hygiene • sleep restriction • stimulus control • Integration of actigraphy as a central therapeutic assessment tool

5. Sleep diary use in CBTI • Useful and important component of the therapy • Completed and tracked through therapy using paper and pen • Patient’s perspective on sleep/wake pattern • Informative for the patient and the therapist regarding sleep perceptions • Input on progress, compliance, and therapeutic adjustments • Limitations: • Entirely subjective • Retrospective completion and recall errors • Contradictory data • Requires time-consuming, manual computation of sleep/wake data

6. Actiwatch Adds valuable quantitative and qualitative elements to help compensate for sleep diary limitations. • Wrist-worn recording device • Activity (accelerometer) • Ambient light • Event marking • Designed to be worn 24/7 • Multiple-week recording time Automated creation of a clinician’s report with objective information about the rest/activity patterns to evaluate along with diary input and self-report.

7. Using Actiwatch to enhance a CBTI program • Statistics– rapid, automated, computation of key sleep variables (TST, WASO, SOL, sleep efficiency, etc.) presented in concise tabular format • Objective data that can be compared with diaries • “Weekly” and “change from baseline” data • Automation reduces time to make sleep scheduling calculations • Data contradictions reduced when compared with diaries

8. Using Actiwatch to enhance a CBTI program (Cont.) • Actogram – a continuous, longitudinal “picture” of in vivorest and activity behavior • Visual, qualitative depiction of sleep/wake activity • Weekly feedback to the patient • Therapist and patient can collectively identify critical aspects of sleep/wake behavior (circadian rhythmicity, sleep consolidation, sleep schedule regularity, and napping)

9. Example actogram #1 Rhythmicity? Consolidation? Regularity? Napping?

10. Example actogram #2 Rhythmicity? Consolidation? Regularity? Napping?

11. Integrating Actiwatch into the CBTI program • Preparation for program • Provide to the patient at least one week before Session 1 along with a sleep diary • Before each session • Retrieve data (one-two minutes) • Generate clinician’s report and review data (three-five minutes)

12. Integrating Actiwatch into the CBTI program (Cont.) During each session • Review previous week’s sleep diary and actigraphy data • Patient feedback: rhythmicity, consolidation, regularity and napping • Compliance review; adjust/troubleshoot as needed • Review/modify sleep restriction plan Preparation for the next session • Reconfigure (one-two minutes) • Recharge (if needed during the session) • Return device to the patient

13. Reimbursement • Insurance coverage for actigraphy and CBTI are variable • 95803 – code for actigraphy • E&M codes for office visits, etc. • Individual or group psychotherapy codes • Health and behavior (H&B) codes for assessment and treatment • Roughly 30% of patients have coverage for CBTI • Nationwide clarification of reimbursement rates for actigraphy July 2009 • Out-of-pocket approach may be the most cost effective • Group therapy will be appealing from a cost perspective • $500-$1200 for CBTI depending upon the number of sessions and time