A SMART way to get better sleep - and improve mental health

Imagine a patient in her 60s who has struggled with sleep since her husband died a few years ago. She’s been taking sleep medications, but they fail to resolve her trouble falling – and staying – asleep.

According to Medical University of South Carolina clinical psychologist Joshua Tutek, Ph.D., this presentation is often observed among patients seen at the Division of Sleep, Mood, Anxiety, Research and Treatment (SMART), an adult outpatient clinic within the Department of Psychiatry and Behavioral Sciences.

Tutek estimates that about [MH1.1]80% of patients who are seen at SMART visit for sleep issues. Although patients may seek help for insomnia, the problem is often complicated by mood and anxiety symptoms that disrupt healthy sleep. At SMART, the clinicians aim to help patients regain quality of life and shed the burden of insomnia, anxiety or depression.

“People can get caught up in expending time and effort trying to control negative experiences – including anxiety, depression, and insomnia – which can actually make those issues loom even larger in their lives and take resources away from pursuing other types of experiences they actually value,” said Tutek.

For patients who have struggled with sleep disturbances for years or even decades, the psychiatrists and psychologists at SMART closely examine their sleep patterns to determine appropriate treatment plans. These plans incorporate both psychotherapy and the management of medications, such as sleeping agents.

Therapy for insomnia

The gold-standard treatment for helping patients to sleep better is a type of psychotherapy called Cognitive Behavioral Therapy for Insomnia (CBT-I). This layered approach to treating insomnia targets the difficulty that patients experience initiating or maintaining sleep and may require six to eight sessions.

For many, the behavioral changes recommended during CBT-I are counterintuitive.

“The treatment involves asking patients to temporarily spend less time in bed in order to build up their body’s natural hunger for sleep, which helps their sleep pattern consolidate throughout the night,” said Tutek.

Staying out of bed longer ensures that patients feel sleepier by the time they do finally get into bed, which reinforces the bed as a cue for sleeping rather than being awake, said Tutek.

“We do all of this in a safe and systematic way, continuously tailoring a time-in-bed schedule for each patient according to information they bring us about how they’ve been sleeping. Once patients are sleeping solidly, we can expand the amount of time they spend in bed until they have enough to get the sleep they need.”

CBT for mood and anxiety disorders

In addition to treating insomnia, the clinicians at SMART also help people with anxiety disorders, such as generalized anxiety and social anxiety, as well as mood disorders, such as depression and bipolar disorder.

“The CBT approach to depression we use most often is called behavioral activation, and the main strategy is to set people up to be able to engage in activities that are consistent with their values,” said MUSC clinical psychologist Allison Wilkerson, Ph.D., the clinical director of SMART.

“Meaningful and rewarding activities get those ‘feel-good’ chemicals and neurotransmitters going in their brains. It takes that downward spiral of depression in an upward direction,” she added.

In the case of anxiety, exposure therapy is the key to successful CBT.

“In exposure therapy, you approach something that you've been avoiding with an eye toward expanding your functioning and developing confidence in your ability to handle it,” said Tutek.

He gave the example of a person with panic disorder who fears grocery shopping. Exposure therapy gradually introduces this environment.

“We gradually tiptoe our way toward spending 10 minutes in the grocery store, spending 30 minutes in the grocery store, spending an hour in the grocery store, actually getting all of their shopping done in the grocery store – so we basically build through increments,” he explained.

The role of medications

At SMART, the goal of treatment is to achieve the best possible quality of sleep that is restorative and refreshing.

According to Thomas Uhde, M.D., Chair Emeritus of the Department of Psychiatry and Behavioral Sciences and the director of the SMART Division, many – if not most – of their clients struggle with either complex medical disorders that negatively affect sleep or primary sleep disorders that impair cognitive function, mood or behavior.

“To achieve an optimal outcome and improvement in co-existing sleep disturbances requires a knowledge of these medical disorders and, therefore, appropriate use of medications to effectively treat the overall medical conditions,” said Uhde.

Uhde noted that he is frequently asked to discontinue a patient’s sleep medications without there being a clear understanding of why they were originally prescribed, how the patient responded, whether the patient experienced negative side effects or what the ultimate goal of changing medications might be.

“Beyond an understanding of the full medical history, these are critical questions to ask and understand when establishing a treatment plan for sleep problems,” Uhde said.

“In patients with complex sleep disorders or medical disorders with secondary disturbances in sleep, they often require a combination of drug and non-drug CBT to achieve an optimal and satisfactory outcome.”