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Practical Integration of Actigraphy with
Cognitive Behavioral Therapy for Insomnia
Dr. Derek Loewy, Ph.D.
1
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
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,
improve daytime alertness through education and practice
and
• Multi-component; incorporates behavioral and cognitive techniques
delivered over weekly sessions (typically four-eight)
• Effectiveness of CBTI is highly dependent on patient compliance
3
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
4
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
5
Actiwatch
Adds valuable quantitative and qualitative
elements to help compensate for sleep
diary limitations.
• Wrist-worn recording device
– Activity (accelerometer)
– Ambient light
– Event marking
• Designed to be worn 24/7
– Multiple-week recording time
Automated creation of a clinician’s report
with objective information about the
rest/activity patterns to evaluate along
with diary input and self-report.
6
Using Actiwatch to enhance a CBTI program
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
7
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)
8
Example actogram #1
Rhythmicity?
Consolidation?
Regularity?
Napping?
9
Example actogram #2
Rhythmicity?
Consolidation?
Regularity?
Napping?
10
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)
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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
12
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
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