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Insomina -- the inability to fall asleep naturally -- affects most people at some time in their roller coaster lives. And insomina cures are possible with self-managed changes in behavior in many cases.

Sleepless nights. Missed work days. As anyone with insomnia will attest, a sleep-deprived condition can lead to intense personal suffering.

But combine insomnia with anxiety, depression and chronic pain, and sleeplessness can become even more troubling.

Cognitive behavioural therapy (CBT), however, may be a remedy for this multi-faceted problem, says a Ryerson University professor.

"When you have another disorder, you face unique barriers that other people do not," says Dr. Colleen Carney, assistant professor of psychology, and director of Ryerson's Sleep and Mood Disorder Program. "For example, a conventional insomnia strategy involves getting out of bed at the same time every day. But someone with depression may wonder, "what if I have nothing to get out of bed for?"

Cognitive behavioural therapy (CBT)

Carney's latest book is Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those With Depression, Anxiety or Chronic Pain is the only self-help book that focuses on people with insomnia combined with other health conditions. Quiet Your Mind and Get to Sleep was co-authored by Dr. Rachel Manber of Stanford University in Palo Alto, California.

Insominia is Common...and Disruptive

According to insomina research - one in every seven of us - experiences problems going to sleep and/or staying asleep. Furthermore, insomnia is a characteristic of almost all psychological diagnoses. Sleep clinics also report that insomnia patients with psychological disorders outnumber those without other conditions at a rate of nearly two to one.

Quiet Your Mind and Get to Sleep suggests many cognitive behavioural solutions to insomnia. Some of the tips in this practical book about insomnia cures include:

• Never get into bed earlier than your usual bedtime.
• When you catch yourself "trying" to sleep, remind yourself that this is counterproductive.
• Learn about sleep myths, such as "I absolutely require eight hours of sleep to function during the day."
• Actively challenge unhelpful beliefs that may worsen your sleeplessness, such as "Something terrible will happen to you as a result of insomnia."
• Leave your bed and bedroom if you can't sleep.

Previous insomnia research studies have also demonstrated that CBT offers many advantages over sleep-aid medications. Among them,

• CBT is a non-pharmacological treatment that is just as useful as medication (and has longer-lasting effects).
• CBT doesn't carry the risks of dependency or tolerance (requiring increasing the dosage for the drug to remain effective) that are associated with medication.
• CBT techniques also build confidence in one's ability to sleep.

CBT has also become a popular choice for the treatment of sleeplessness says Dr. Carney. Through worksheets and a structured program, Quiet Your Mind and Get to Sleep helps readers discover and then address the cause of their insomnia.

CBT Can be a Self-Help Solution for Insomnia

"For this reason, CBT makes intuitive sense to people," says Carney. "It's a brief treatment and, as our book proves, it can be done on a self-help basis."

In addition to teaching at Ryerson Universtiy Carney is also president of the Association for Behavioral and Cognitive Therapies, an interest group on insomnia and other sleep disorders.

Ryerson University is Canada's leader in innovative career-focused education, offering close to 100 PhD, master's, and undergraduate programs

Despite a general belief among physicians that extreme obesity is too difficult to treat, except with bariatric surgery, researchers at the Pennington Biomedical Research Center have learned a substantial proportion of individuals with extreme obesity can lose 10-percent or more of their body weight through medical treatment that does not include surgery.

10% Loss Improves Risk Factors and Health

Furthermore, even though those individuals are still obese, they have improvements in risk factors and other health markers.

Weight Loss Surgery Not Often Affordable or Reimbursed by Insurance

"This is important, because surgery is not often affordable or reimbursed by insurance," said leading scientist Dr. Donna Ryan. "In fact, many medical treatments are frequently not reimbursed by insurance if they are for obesity. So this research is needed to show that primary care doctors are capable of helping obese patients lose weight to improve health, even those with extreme obesity. "

Ryan said losing only five-percent of body weight can reap healthy benefits for the extremely obese, and nearly 61-percent of those in her clinical trial achieved that. More than 40-percent lost 10-percent body weight or more.

Physicians Trained in Intensive Medical Intervention

Ryan and her team spread out across Louisiana to recruit and train practicing physicians and their office staffs in eight cities in what she called "intensive medical intervention," in which physicians used a combination of medication, low-calorie diets and behavior changes. All of the techniques were endorsed by national guidelines for obesity management. Training of physicians and their staffs took about a day and a half.

Funded by the Louisiana Office of Group Benefits, which provides health coverage for state employees, the research team contacted state employees, seeking participants to screen for and enroll in the trial. Nearly 400 participants enrolled in the two-year trial, called LOSS, using the nearest trained physicians.

About half of the participants received the intensive medical intervention, the other half received what Ryan called "usual care." 

Program Starts with Low-calorie Liquid Diet

Those in the intense intervention group were immediately placed on a low-calorie liquid diet. They gradually moved to a low calorie, highly controlled diet using meal replacements, and received weight loss medication and group behavioral therapy that included lessons in exercise, activity, self-monitoring and recommendations for walking, water exercise and weight training. The group sessions were supervised by office staff.

Recommended Activities

• exercise
• activity
• self-monitoring
  
• recommendations for walking
• water exercise
  
• weight training

Success in Daily Routine of Doctor's Practice

"We conducted this trial as close to the reality of a typical clinic setting as we could," Ryan said, "We didn't want to learn just if these strategies worked, but if they would work in the daily routine of a doctor's practice."

Challenge of Keeping Weight Off

Ryan noted that the continual challenge in weight loss is keeping weight off, and that means sticking with a routine.

More than 50% of the LOSS participants stuck with it for two years or more, keeping much of the weight off, but Ryan said that does leave room for improving weight loss maintenance.

The LOSS trial results were published in the current issue of the Archives of Internal Medicine.

The Pennington Biomedical Research Center is a campus of the Louisiana State University System and conducts basic, clinical and population research.

Postmenopausal women who take antidepressants face a small but statistically significant increased risk for stroke and death compared with those who do not take the drugs.

The researchers compared two groups with respect to the incidence of fatal or nonfatal stroke, fatal or nonfatal heart attack and death due to all causes.

• The researchers found no difference in coronary heart disease (defined as fatal and non-fatal heart attacks).
  
• However, they did observe a significant difference in stroke rates: antidepressant users were 45 percent more likely to experience strokes than women who weren't taking antidepressants.
• The study also found that when overall death rates (all-cause mortality) were compared between the two groups, those on antidepressants had a 32 percent higher risk of death from all causes compared with non-users.
  

Overall risk for women taking antidepressants is relatively small

Dr. Wassertheil-Smoller notes that the overall risk for women taking antidepressants is relatively small: a 0.43 percent risk of stroke annually versus a 0.3 percent annual risk of stroke for women not taking antidepressants. However, because antidepressants are among the most widely prescribed drugs in the U.S. - especially among postmenopausal women - small risk increases can have significant implications for large patient populations.

Dr. Wassertheil-Smoller cautioned that "it remains unclear" from the data whether antidepressants are solely responsible for the greater mortality rate among users. The link observed in this study between antidepressant use and increased stroke risk for older women might partially be due to the underlying depression, since several studies have found that depression itself is a risk factor for cardiovascular problems.

Antidepressants are valuable drugs for treating a condition that can be debilitating or even fatal. Dr. Wassertheil-Smoller advises women who may be concerned about taking their antidepressants based on this study to discuss the matter with their physicians. "You have to weigh the benefits that you get from these antidepressants against the small increase in risk that we found in this study," she says.

The researchers also pointed out other limitations to their findings. This was an observational study, so the findings are not as conclusive of causality as would be the case for a randomized controlled trial; and since the WHI study is comprised primarily of older white women, the findings might not extend to other groups.

The group's paper, "Antidepressant Use and Risk of Incident Cardiovascular Morbidity and Mortality Among Post-Menopausal Women in the Women's Health Initiative Study," appears in the December 14 online edition of Archives of Internal Medicine.

The new findings are from the federally-funded, multi-institution, Women's Health Initiative Study sponsored by the National Institutes of Health, and the results are published in the December 14, 2009 online edition of Archives of Internal Medicine.

Senior author Sylvia Wassertheil-Smoller, Ph.D., is a principal investigator in the Women's Health Initiative and is division head of epidemiology and professor of epidemiology & population health at Albert Einstein College of Medicine of Yeshiva University.

Depression often coexists with other long-term health problems, presenting additional complexities. About 60 percent of depressed outpatients have at least one other chronic medical condition as well, such as a heart problem, high blood pressure, or diabetes.

The US Department of Health & Human Services, through the Agency for Healthcare Research and Quality  has funded research to track effective care of depression. 

Heart Attacks and Depression

Research results have shown that patients with a history of heart attacks have 1.8 times more depressive spells in a year and more persistent symptoms than depressed patients without a history of heart attacks.

Chronic Conditions and Depression in Older Persons

The challenge of treating depression as one of multiple chronic conditions is especially an issue in older persons. AHRQ research comparing elderly patients with and without depression in a primary care clinic found that the depressed patients had:

• Nearly $200 more in annual diagnostic test costs.
• Almost 1.5 more ambulatory care visits per year.
• Over 12 percent more annual visits to the emergency department.
• Five percent more hospitalizations each year.

To reduce the cost of care and improve outcomes for older persons with depression, coexisting psychiatric and medical illnesses must be targeted for treatment.

Best Care:  Mental Health Specialists or Medical Care Providers?

The organization of care can affect care delivery for depression. One AHRQ-sponsored study showed that shifting patients away from mental health specialists to general medical providers (as is the practice in some managed care arrangements) may lead to fewer improvements in patient functioning but costs two to three times less.

Other AHRQ-funded research on the effects of changes in health care payment and delivery found that after switching to a prepaid plan, the health status of outpatients with depression did not appear to suffer although they were 12 percent less likely to use antidepressants and made 35 to 40 percent fewer visits to their mental health care providers.

Even where there is substantial agreement about how treatment for depression can be improved, changes to everyday practice have been slow. Past efforts by managed care organizations to improve compliance with guidelines for improving diagnosis and treatment of depression have met with only modest success.

Two AHRQ studies investigating academic detailing and continuous quality improvement interventions in managed care organizations concluded that these approaches were only mildly effective in improving clinicians' adherence to the recommended guidelines for care. However, promising early results from a current study evaluating ways to increase use of antidepressants and psychotherapy in managed primary care practice suggest that depressed patients in the intervention groups were more likely to receive these interventions and exhibit better outcomes.

The National Guideline Clearinghouse™ (NGC) sponsored by AHRQ in partnership with the American Medical Association and the American Association of Health Plans, allows physicians and other Internet users to assess and compare guidelines online at http://www.guideline.gov. The NGC is being used by Georgetown University Medical Center's Mood Disorder Program in the development of clinical practice guidelines on depression for primary care physicians in managed care settings.