Practical Integration of Actigraphy with Cognitive Behavioral Therapy for Insomnia

Dr. Derek Loewy, Ph.D.

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

•Wrist-worn recording device

– Activity (accelerometer)

– Ambient light

– Event marking

•Designed to be worn 24/7

– Multiple-week recording time

Adds valuable quantitative and qualitative elements to help compensate for sleep diary limitations.

Automated creation of a clinician’s reportwith objective information about therest/activity patterns to evaluate along with diary input and self-report.

7

1. Statistics – rapid, automated, computation of key sleep variables (TST, WASO, SOL, sleep efficiency, etc.) presented in concise tabular format

a. Objective data that can be compared with diaries

b. “Weekly” and “change from baseline” data

c. Automation reduces time to make sleep scheduling calculations

d. Data contradictions reduced when compared with diaries

Using Actiwatch to enhance a CBTI program

8

Using Actiwatch to enhance a CBTI program (Cont.)

1. Actogram – a continuous, longitudinal “picture” of in vivo rest and activity behavior

a. Visual, qualitative depiction of sleep/wake activity

b. Weekly feedback to the patient

c. 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

14