Insomnia and CBTi: Benefits for Patients and Opportunities for Dentists

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Daniel Gartenberg, PhD, talks about insomnia and the various treatments, like Cognitive Behavioral Therapy for Insomnia (CBTi) and safe and effective pharmacological interventions.
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by Daniel Gartenberg, PhD

Insomnia is the most pervasive sleep disorder in the United States, impacting roughly 1 in 5 adults.1 This physiological and psychological disorder often co-occurs with obstructive sleep apnea, where 39-58% of sleep apnea patients also have insomnia.2-4 But the problem of poor sleep health in general is even larger than this. About 1 in 2 Americans suffer from poor sleep health due to a combination of sleep disorders, sleep deprivation, and poor sleep quality. Poor sleep health is a primary cause of chronic disease, including heart disease, Alzheimer’s and related dementia, cancer, and diabetes.5-12 As William Dement stated, the father of sleep medicine, “We are a sleep sick society.” Dentists may hold the keys to solving this public health crises of poor sleep health, for both insomnia and sleep apnea.

The first line treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBTi), recommended by both the American College of Physicians (ACP) and the American Academy of Sleep Medicine.13 CBTi is typically administered by a sleep medicine specialist or a psychologist certified in behavioral sleep medicine. The main components of CBTi include sleep restriction, stimulus control, cognitive training, relaxation, and sleep hygiene. By focusing on cognitive, behavioral, and emotional-based strategies to change sleep, CBTi is designed to get at the root causes of sleep challenges. Sleep restriction, or the gentler method of sleep compression, involves reducing time in bed until ideal sleep efficiency of ~85% is reached. Sleep logs are typically kept to inform the recommended sleep schedule. Stimulus control refers to using the bed for only sleep (with sex being the exception), to reestablish the association between bed and sleep. Cognitive training involves psychoeducation about normal sleep and skills to challenge and cope with unhelpful thoughts, including those about sleep. Finally, relaxation includes behavioral techniques to decrease hyperarousal, which is thought to be a primary contributor to insomnia. Relaxation training includes breathing exercises, progressive muscle relaxation, and mindfulness skills.

Yet the medical community has failed at addressing the public health issue of poor sleep health with this proven solution. Most people who have sleep disorders remain undiagnosed and untreated.14 This failure is due to issues of access, cost, and adherence. Medical doctors typically only receive about two hours of didactic training in sleep health and there are only ~7,500 MDs board certified in sleep medicine. Psychologists certified in Behavioral Sleep Medicine (BSM) can also administer CBTi, but again, there is an issue of access. In 2023, the New York Times reported that in the United States there are less than 700 providers trained in BSM. Many communities completely lack effective care, given that 58% of BSM providers reside in only twelve U.S. states.15 Cost is another major limiting factor because CBTi treatment involves at least six consultations, typically ranging from weekly to monthly, with a clinician, at a potential cost up to as much as $3000. This treatment can be onerous and time consuming for patients, with homework assignments and changes to typical habits. This makes adherence another major challenge of CBTi.16,17

As a result of access, cost, and adherence limitations, few people receive the gold-standard treatment of CBTi and often turn to risky alternatives (i.e. drugs and alcohol). The most common treatment for insomnia is sedating anti-depressant and hypnotic medications. However, these solutions are not as effective in the long-term as CBTi,18 can negatively impact sleep quality,19 cause falls in the elderly,19 and have other negative side effects, such as doubling the risk of developing dementia.20,21 Recently, FDA approved digital therapeutics for CBTi (dCBTi) solutions, such as Somryst and Sleepio, have improved the cost, access, scalability, and ease of dissemination for CBTi, in addition to demonstrating efficacy.22-25 However, these solutions are still currently not accepted by insurance and are costly for most Americans, ranging in price from $450-$850. Additionally, adherence to these solutions is poor,26 which negatively impacts the effectiveness of these interventions. There is currently no easy and affordable way for patients to access dCBTi, and when they do, they are unlikely to complete treatment.

Recently, FDA approved digital therapeutics for CBTi (dCBTi) solutions, such as Somryst and Sleepio, have improved the cost, access, scalability, and ease of dissemination for CBTi, in addition to demonstrating efficacy.22-25 However, these solutions are still currently not accepted by insurance and are costly for most Americans, ranging in price from $450-$850. Additionally, adherence to these solutions is poor,26 which negatively impacts the effectiveness of these interventions. There is currently no easy and affordable way for patients to access dCBTi, and when they do, they are unlikely to complete treatment.

Building on the work of prior dCBTi solutions, and through funding from the National Institutes of Health (NIH) and major venture capitalists, SleepSpace.com was developed. SleepSpace is a software platform that activates the sensors available in any smart phone to track sleep, includes a digital version of the consensus sleep diary, sounds and meditations to help with sleep, and automated notifications and content based on cognitive behavioral therapy for insomnia. SleepSpace can be either fully automated or administered by a trained sleep specialist.

Along with collaborators Professor Orfeu Buxton at the Pennsylvania State University and Professor Daniel Taylor at the University of Arizona, a randomized controlled trial was performed showing that an Internet of Things (IoT) solution like SleepSpace, when administered by a trained BSM psychologist, can more effectively treat insomnia.27-30 The study showed that when a BSM trained psychologist used the SleepSpace system alongside 6-weeks of telehealth administered CBTi, compared to treatment-as-usual and a sleep hygiene control that also involved 6-weekly sessions with a clinician, there was increased remission of insomnia.29,30 This was based on the Insomnia Severity Index (ISI), the gold standard measure of insomnia, in addition to improvements across other sleep statistics. The SleepSpace system was built off of proven CBTi-based interventions and designed to increase adherence, which was shown to be an effective and safe solution for individuals suffering from insomnia. This technology is currently available on all iPhone and Android platforms to improve at an affordable price ($49.99 / year) that includes a 7-day free trial.

Such dCBTi or dCBTi-based solutions can be made more efficacious when combined with safe and effective pharmacological interventions.31 Therefore, SleepSpace was recently combined with a pharmacological solution called MDbio – The Doctors Brand™. MDbio ran the largest non-melatonin randomized, double-blind, placebo-controlled trial showing that this nutraceutical significantly reduced symptoms of insomnia.32 The formulation, called MDsleep, has a mechanism of action that utilizes GABA, L-theanine, and botanicals, which are non-psychoactive and do not have risks like addiction or falls. The benefit of combining dCBTi-based solutions with nutraceuticals is that they can compound one-another’s effects on reducing the activation of the sympathetic nervous system. An overactive fight-or-flight response is a primary driver of both insomnia and sleep apnea. GABA is the most common inhibitory neurotransmitter, which is why it plays a key role in reducing the stress response physiologically, while CBTi-based solutions act on addressing the root causes of stress and anxiety, reducing the likelihood of excessive rumination and staying up with insomnia.

This combined dCBTi and nutraceutical solution was recently coined the “Sleep Corner,” which is currently being piloted with a number of dental offices and longevity centers. Dentists can play an important role in increasing access for these new technologies for addressing the public health issue of poor sleep. To provide a complete and holistic solution for society’s sleep health crises, at-home-sleep-apnea testing is also optionally included in the Sleep Corner to evaluate breathing health when appropriate. This solution can pivot into a fully reimbursable medical diagnosis for sleep apnea that includes a treatment plan with reliable referrals to develop a Mandibular Advancement Device when appropriate. The solution can be a medical or non-medical sleep health tool administered by coaches, members of the dental team, or licensed sleep specialists. Only 2-hours of virtual training is needed to activate to sleep corner in dental practices. Digital and physical assets for identifying what sleep solutions are right for the patient and driving the purchase of this comprehensive product offering are also provided to help get more people’s sleep health under control. As many as 80% of people with sleep apnea remain undiagnosed and untreated. A dentist can now easily incorporate CBTi-based solutions, nutraceuticals, and an at-home-apnea-test with a medical diagnosis into their practice through signage and digital assets. This provides a turnkey and comprehensive sleep health solution for the 1 in 2 patients that suffer from poor sleep.

Dentists have access to more patient time than any other doctor. They are therefore best positioned to deal with the issue of poor sleep health. Identifying issues like bruxism, snoring, daily fatigue, and problems falling asleep and staying asleep can be easily screened for. The next logical step is to then get patients quick access to sleep solutions and a pathway to get diagnosed and treated. The Sleep Corner can be a first step in dental practices becoming more acquainted with sleep medicine before engaging in more extensive training in sleep medicine. Once certified in dental sleep medicine by accredited organizations like Nexus Dental Systems, practices can play an important role in treating sleep apnea with MADs. Such training can further improve the positive healthcare footprint of dental practices and finally solve the public health issue of poor sleep. For more information on how to incorporate Sleep Corner to your practice today, contact dan@sleepSpace.com.

Dr. Lee Surkin offers insights into the connection between insomnia and heart failure here: https://dentalsleeppractice.com/the-link-between-insomnia-and-heart-failure/.

daniel gartenberg, phd, ceo of sleepspaceDaniel Gartenberg, PhD, is a world-renowned sleep scientist and the founder and CEO of SleepSpace, a company that develops innovative solutions for improving sleep quality and health. He has a PhD in cognitive psychology from George Mason University and more than 15 years of experience in sleep research and technology. He is also an Adjunct Assistant Professor at Penn State University’s Department of Biobehavioral Health. He is a scientific consultant for a number of sleep related companies including MDbio – The Doctors Brand, Wesper, CPAP.com, Perfectly Snug, and Biostrap. Dr. Gartenberg is at the forefront of sleep science innovation. His work, supported by over $3.5 million in grants from the National Science Foundation and the National Institute of Aging, focuses on developing cutting-edge technologies and strategies to address the global challenge of poor sleep health. As a biohacker who founded the DC chapter of the Quantified Self, a former insomniac, and a sleep apnea patient, improving sleep is deeply personal to him. Yet sleep is also still a mystery. Scientists have made great strides in understanding sleep, but there is still a ton we don’t know about when we close our eyes for the night. Dr. Gartenberg has more than 20 peer-reviewed publications and a viral TED Talk with over 5 million views.

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