Category Archives: Medicine

Want to Sleep Better? Get Brief CBT-I Therapy for Sleep Instead of Sleeping Pills

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“To sleep–perchance to dream. Ay, there’s the rub”

The New York Times reported on a terrific study at the University of Pittsburgh, looking at ultra short treatment of insomnia in the elderly. According to the article roughly 1/4 of older adults suffer from insomnia. The researchers streamlined an approach called CBT-I, which stands for cognitive behavioral therapy of insomnia.

There were only two sessions of treatment, totaling about 90 minutes. There were also two brief follow-up phone calls, over the first month. They tested this brief treatment and 79 seniors with chronic insomnia.

So what were the results of this study? They couldn’t have been very powerful, right?

Wrong. Two thirds of the CBT-I group reported a clear improvement in sleep, compared with only 25% of the people in the control group. Even better, 55% were cured of their insomnia. And six months later the results were even better.

So what was this magic treatment and the magic rules for curing insomnia? There were only four rules.

  • Spend only seven or eight hours in bed.
  • Set your alarm and get up at the same time everyday.
  • Never go to bed until you actually feel sleepy.
  • If you are tossing and turning and can’t sleep, get out of bed and do something relaxing until you get sleepy again. Then go back to bed.

These are standard cognitive behavioral sleep hygiene rules. And they are very powerful. Although not mentioned in the study, a few other rules are also helpful.

  • Regular exercise performed no later than midday is also helpful.
  • Reducing caffeine, nicotine, and alcohol all are helpful.
  • Avoid all naps.
  • Only use your bedroom for sleep and sex. Don’t watch TV or read in bed.

So why isn’t this treatment widely available? Could it be because there isn’t a powerful drug lobby for sleeping pills pushing this very effective therapy?

What is really tragic is that most seniors end up being prescribed sleeping pills for insomnia. And this is in spite of very clear data from research that shows that modern sleeping pills such as Ambien, Lunesta, or Sonata, have very minimal effects. On average they reduced the average time to fall asleep by 12.8 minutes compared to placebo, and increased the total sleeping time by only 11.4 minutes.

Patients who took older sleeping medications like Halcion and Restoril fell asleep 10 minutes faster, and slept 32 minutes longer.

How can this be? Why is it that patients believe that sleeping pills are much more effective? The answer is very simple. All of these drugs produce a condition called anterograde amnesia. This means that you cannot form memories under the influence of these drugs. So you don’t remember tossing and turning.  If you can’t remember tossing and turning even though you may have, then you perceive your sleep has been better. The drugs also tend to reduce anxiety, so people worry less about having insomnia, and thus feel better.

The hazards of sleeping pills in older adults include cognitive impairment, poor balance, and an increased risk of falling. One study in the Journal of the American geriatrics Society found that even after being awake for two hours in the morning, elder adults who took Ambien the night before failed a simple balance test at the rate of 57% compared to 0% in the group who took placebo. This is pretty serious impairment. Interestingly enough, in the same study, even young adults who took Ambien showed impaired balance in the morning.

So what are the key messages here?

1. Even though sleeping pills give people a sense of perceived improvement in sleep, the actual improvement tends to be almost insignificant, especially with the newer and very expensive sleeping medications. The older medications increased sleep time a little better, but have more issues with addiction and tolerance. Side effects of these medications are potentially very worrisome, since they can cause cognitive impairment and increased falling which leads to injuries, especially in the elderly. Why risk these side effects for such small improvements in sleep quality?

2. Cognitive behavioral therapy for insomnia works better than sleeping pills, has no side effects, is cheaper in the long run, and has a lasting impact on sleep improvement.

3. Most people who suffer insomnia will see their physician, who will prescribe sleeping pills. This is partly because of the lack of availability of cognitive behavioral treatment for insomnia. There are relatively few cognitive behavioral practitioners, and even fewer who regularly do CBT-I. We need to improve the availability of these treatments, and should follow in the footsteps of the University of Pittsburgh researchers in learning how to streamline these treatments. Most people don’t have the patience to spend 6 to 8 weeks in cognitive behavioral therapy for insomnia. Instead we need treatments that can be administered in a single week or two with some brief follow-up.

4. CBT-I availability will always suffer from the fact that there is no powerful corporate interest backing it. There are no CBT-I sales reps going to doctors offices offering free samples of CBT-I for doctors to pass out to their patients. I don’t have a solution for this problem, but would be interested in hearing from my readers as to how we might more effectively promote effective and safe treatments such as CBT-I.

Okay, now that I’ve written this, it’s time to trundle off to bed. As Hamlet said, “To sleep — perchance to dream. Ay, there’s the rub!”

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

How Ivan Pavlov Handled a Piece of Steak

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Most psychology students recognize the name of Ivan Pavlov, one of the great minds of psychology, who developed the theory of classical conditioning (dogs salivating when he rang a bell). From the Yale Alumni magazine comes this wonderful tidbit of a story:

“In mid-August 1929, the Harvard Medical School hosted the Thirteenth International Physiological Congress, one of the largest gatherings of scientists ever convened in the United States. Pavlov, the doyen of experimental physiology at almost 80 and honored by a Nobel Prize a quarter-century earlier, was the lion of the gathering. His pioneering work on conditioned reflexes had been crucial to understanding brain function, and he was keen to see the Harvard neurosurgeon Harvey Cushing ’91 operate. The preeminent brain surgeon and father of modern neurosurgery as a field, Cushing, two decades younger than Pavlov, was at the top of his game. Performing for Pavlov in a theater at the Peter Bent Brigham Hospital, Cushing removed a large tumor of the left hemisphere from a cancer patient’s brain. The patient later recalled that Cushing introduced him to Pavlov, saying, “You are now shaking hands with the world’s greatest living physiologist.”

Pavlov was captivated by the new electrosurgical knife Cushing used in the operation, and at the end of the procedure, Cushing got a piece of beef so that the elder scientist could try his hand. After making a few incisions, Pavlov inscribed his name into the meat. “I asked him whether he wanted me to eat the meat in the hope of improving my conditional reflexes,” Cushing wrote in his journal, “or whether we could keep it in the museum, the latter we will proceed to do—’Pavlov’s beef-steak.'” A collector of old medical books and of brain tumors, when he died in 1939 Cushing bequeathed both to Yale, where his rare books would become the cornerstone for creating the Medical Historical Library.”

Anyway, I love this story, especially the concept of him eating the steak, to “improve his conditional reflexes!”

Next time I throw a barbecue party I’ll serve the Pavlov-Steak sandwich…

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

How to Read Media Coverage of Scientific Research: Sorting Out the Stupid Science from Smart Science

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Reading today’s headlines I saw an interesting title, “New Alzheimer’s Gene Identified.”

I was intrigued. Discovering a gene that caused late onset Alzheimer’s would be a major scientific breakthrough, perhaps leading to effective new treatments. So I read the article carefully.

To summarize the findings, a United States research team looked at the entire genome of 2269 people who had late onset Alzheimer’s and 3107 people who did not. They were looking for differences in the genome.

In the people who had late onset Alzheimer’s, 9% had a variation in the gene MTHFD1L, which lives on chromosome 6. Of those who did not have late-onset Alzheimer’s 5% had this variant.

So is this an important finding? The article suggested it was. But I think this is a prime example of bad science reporting. For instance, they went on to say that this particular gene is involved with the metabolism of folate, which influences levels of homocysteine. It’s a known fact that levels of homocysteine can affect heart disease and Alzheimer’s. So is it the gene, or is it the level of homocysteine?

The main reason why I consider this an example of stupid science reporting is that the difference is trivial. Let me give you an example of a better way to report this. The researchers could have instead reported that among people with late-onset Alzheimer’s, 91% of them had no gene changes, and then among people without late onset Alzheimer’s 95% of them had normal genes. But this doesn’t sound very impressive and calls into question whether measurement errors would account for the differences.

So this very expensive genome test yields absolutely no predictive value in terms of who will develop Alzheimer’s and who will not. There is a known genetic variant, called APOE, which lives on chromosome 19. Forty percent of those who develop late-onset Alzheimer’s have this gene, while only 25 to 30% of the general population has it. So even this gene, which has a much stronger association with Alzheimer’s, isn’t a particularly useful clinical test.

The other reason this is an example of stupid science is that basically, this is a negative finding. To scan the entire human genome looking for differences between normal elderly people and elderly people with Alzheimer’s, and discover only a subtle and tiny difference, must’ve been a huge disappointment for the researchers. If I had been the journal editor reviewing this study, I doubt I would’ve published it. Imagine a similar study of an antidepressant, which found that in the antidepressant group, 9% of people got better, and in the placebo group 5% got better. I doubt this would get published.

Interestingly enough, the study hasn’t been published yet, but is being presented as a paper at the April 14 session of the American Academy of Neurology conference in Toronto. This is another clue to reading scientific research. If it hasn’t been published in a peer-reviewed scientific journal, be very skeptical of the research. Good research usually gets published in top journals, and research that is more dubious often is presented at conferences but never published. It’s much easier to get a paper accepted for a conference than in a science journal.

It’s also important when reading media coverage of scientific research to read beyond the headlines, and to look at the actual numbers that are being reported. If they are very small numbers, or very small differences, be very skeptical of whether they mean anything at all.

As quoted in the article, “While lots of genetic variants have been singled out as possible contributors to Alzheimer’s, the findings often can’t be replicated or repeated, leaving researchers unsure if the results are a coincidence or actually important,” said Dr. Ron Petersen, director of the Mayo Alzheimer’s disease research Center in Rochester, Minnesota.

So to summarize, to be a savvy consumer of media coverage of scientific research:

1. Be skeptical of media reports of scientific research that hasn’t been published in top scientific journals. Good research gets published in peer-reviewed journals, which means that other scientists skeptically read the article before it’s published.

2. Read below the headlines and look for actual numbers that are reported, and apply common sense to these numbers. If the differences are very small in absolute numbers, it often means that the research has very little clinical usefulness. Even if the differences are large in terms of percentages, this doesn’t necessarily mean that they are useful findings.

An example would be a finding that drinking a particular type of bourbon increases a very rare type of brain tumor from one in 2,000,00 to three in 2 million. If this was reported in percentage terms the headline would say drinking this bourbon raises the risk of brain tumor by 300%, which would definitely put me and many other people off from drinking bourbon. (By the way, this is a completely fictitious example.) But if you compare the risk to something that people do every day such as driving, and revealed the driving is 1000 times more risky than drinking this type of bourbon, it paints the research in a very different light.

3. Be very skeptical of research that has not been reproduced or replicated by other scientists. There’s a long history in science of findings that cannot be reproduced or replicated by other scientists, and therefore don’t hold up as valid research findings.

4. On the web, be very skeptical of research that’s presented on sites that sell products. Unfortunately a common strategy for selling products, particularly vitamin supplements, is to present pseudoscientific research that supports the use of the supplement. In general, any site that sells a product cannot be relied on for objective information about that product. It’s much better to go to primarily information sites like Web M.D., or the Mayo Clinic site, or one can go directly to the original scientific articles (in some cases), by using PubMed.

So be a smart consumer of science, so that you can tell the difference between smart science and stupid science.

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

New Study Finds the Best Pharmacological Stop Smoking Solution: (Hint, it’s not what you’d think)

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A new study at the Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin, Madison, compared all except one of the current drug treatments that help with quitting smoking. They looked at the following treatments and combined treatments:

  • “bupropion SR (sustained release; Zyban, GlaxoSmithKline), 150 mg twice daily for 1 week before a target quit date and 8 weeks after the quit date;
  • nicotine lozenge (2 or 4 mg) for 12 weeks after the quit date;
  • nicotine patch (24-hour, 21, 14, and 7 mg titrated down during 8 weeks after quitting;
  • nicotine patch plus nicotine lozenge;
  • bupropion SR plus nicotine lozenge; or
  • placebo (1 matched to each of the 5 treatments).”

Everyone received six 10- to 20-minute individual counseling sessions, with the first 2 sessions scheduled before quitting.

What were the results?

Three treatments worked better than placebo during the immediate quit period: the patch, bupropion plus lozenge, and patch plus lozenge.

At six months, only one treatment was effective; the nicotine patch plus nicotine lozenge. The exact numbers , as confirmed by carbon monoxide tests, were: “40.1% for the patch plus lozenge, 34.4% for the patch alone, 33.5% for the lozenge alone, 33.2% for bupropion plus lozenge, 31.8% for bupropion alone, and 22.2% for placebo.”

So we see that the combined nicotine substitution therapy worked best, followed closely by either nicotine substitute alone. Zyban or Welbutrin (bupropion) was a bust, no more effective than the simple nicotine lozenge. The only advantage to Zyban would be if one prefers not to use nicotine substitutes.

Now I mentioned that they omitted one drug treatment, which is the drug Chantix (varenicline). This is probably because the drug is a nicotine receptor blocker, so wouldn’t have made sense to combine with nicotine substitutes. Also, there have been some disturbing case reports of people having severe depressive reactions to Chantrix.

Of course, there was one glaring omission that any card-carrying psychologist would spot in a moment–the lack of a behavior therapy component. Giving 6 ten minute sessions is hardly therapy. I would have liked to see true smoking cessation behavior therapy combined with the drug treatments.

So, if you’re trying to quit smoking, combine nicotine patches with nicotine lozenges, sold in any pharmacy. If you do, you have a 40 percent chance of succeeding at 6 months.

Now I am off to have a cigarette….just kidding.

Study: http://cme.medscape.com/viewarticle/712074_print

Copyright © 2009/2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

So Much for the Germ Theory: Scientists Demonstrate That Sleep Matters More Than Germs

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More in a continuing series about one of my favorite topics, something we all do every day, and spend roughly a third of our lives doing…sleep!

Since we are in the middle of the common cold season, this post will be particularly relevant.

It turns out, grandma was right. Getting good sleep really does prevent colds. This supports a favorite belief of mine—that I don’t believe in the germ theory of illness.  Read on and you will see why I liked the referenced article.

Researchers at a variety of universities collaborated and did a clever study looking at sleep and its effects on susceptibility to the common cold. First they had their 153 subjects, healthy men and women between 21 and 55, report their sleep duration and efficiency for 2 weeks. (Efficiency is what percent of the time you are actually sleeping while in bed.) Next, these diabolical researchers sprayed cold virus up the noses of all the subjects (in quarantine), and watched what happened over the next 5 days.

The results were very interesting. Those subjects who slept less than 7 hours were almost 3 times more likely to develop a cold than those who slept 8 hours or more. In addition, those whose sleep was less than 92% efficient were 5.5 times more likely to develop a cold than those with 98% or more sleep efficiency. Interestingly, how rested subjects reported feeling after sleep was not associated with colds.  The lead author of the study concluded, “The longer you sleep, the better off you are, the less susceptible you are to colds.”

Now I promised that I would report evidence that this study bolsters my theory that germs don’t really matter that much. Remember the researchers sprayed virus up everyone’s noses. After five days, the virus had infected 135 of 153 people, or 88% of the people, but only 54 people (35%) got sick. What this suggests is that even among the people who were infected with cold virus, 60% stayed healthy, while 40% got sick. And the ones who got sick were much more likely to have reported less and lower quality sleep in the two weeks before infection. 

This is very relevant for everyday life, since much of the time we can’t really avoid exposure to common germs like colds and flu. If good sleep protects us even when infected with such germs, then it may be the key to staying healthy.

What is truly fascinating about this study is the precise immune regulation showed by those who got infected, but stayed healthy. To understand this let me digress for a moment with a short primer on the common cold. Most people think cold symptoms are caused by cold virus. This is wrong. Actually, cold symptoms are caused by our bodies’ immune reaction to the cold virus. Our bodies produce germ fighting proteins called cytokines, and when our bodies make too much, we get the congestion and runny nose symptoms. If our bodies make just the right amounts of cytokines, we fight the virus without feeling sick.

So getting 8 or more hours of sleep a night may allow your body to fine tune an immune response, and make just the perfect amount of germ fighting proteins.

Another interesting finding is the relationship of sleep efficiency and illness. Sleep efficiency was an even more powerful predictor of getting sick than total sleep. (Of course, this might reflect an overall difference in sleep quality. Those who sleep deeply may tune up their immune systems better, and they are likely to spend most of their time in bed asleep.)

But assuming that increasing sleep efficiency is useful, then those people who take a long time to fall asleep, and who sleep fitfully may benefit from spending less time in bed, and working on sleeping more of the time they are in bed. On the other hand, those who fall asleep as soon as their head hits the pillow, and who are sleep like logs, would probably benefit from spending a little more time in bed, since they are not getting enough sleep.

So there you have it. Sleep 8 hours or more, try to sleep well, and you can lower your odds of getting a cold greatly. Even if you are exposed to the virus, if you have good sleep quality, you probably won’t get sick. So much for the simple germ theory! I suspect that this applies to all infectious diseases. So getting good quality and quantity in sleep may be one of the most important health behaviors for staying well.

It’s late, and I’m off to bed now…..zzzzzzzzzzzzzzz.

Copyright © 2009 The Psychology Lounge/TPL Productions/Andrew Gottlieb