For Insomnia, Consider Cognitive Behavioral Therapy Before Medication
Although many patients with insomnia may leave the doctor’s office with a prescription, new guidelines recommend psychotherapy as the first-line treatment.
Insomnia is a debilitating condition. According to the American Academy of Sleep Medicine, it affects up to 35 percent of adults. And about 10 percent of people deal with chronic insomnia disorder, meaning they have difficulties falling or staying asleep at least three nights per week (over a period of at least three months) and the sleep disturbance causes daytime impairment.
In fact, the U.S. spends billions of dollars treating insomnia annually, in addition to an estimated $60 billion in lost productivity alone. Poor sleep affects all aspects of a person’s day, from efficiency at work to the ability to safely drive a car to athletic performance, and it is the second most common complaint behind pain reported to primary care doctors.
Prescription sleep aids are a common recommendation from many physicians. But recent guidelines from the American College of Physicians, in the Annals of Internal Medicine, recommend psychotherapy as a first-line treatment for chronic patients instead of medications.
J. Todd Arnedt, Ph.D., associate professor of psychiatry and neurology who specializes in insomnia, co-wrote an accompanying editorial. Arnedt, also director of the University of Michigan’s Behavioral Sleep Medicine Program, explains why the recommendations have merit for health care providers, though they may not be widely implemented anytime soon.
What can a patient expect from CBT treatment for chronic insomnia disorder?
Arnedt: First, the provider determines if a CBT approach is appropriate for a particular patient. That first visit includes conversations about what symptoms the patient has, how the insomnia affects daytime functioning and what could be causing or contributing to the insomnia, from other sleep disorders to depression to chronic pain or cognitive factors. Patients who report engaging in behaviors and thought patterns that are thought to perpetuate insomnia are particularly good candidates for this type of treatment.
Once treatment begins, there are usually only four to six CBT visits for insomnia, so it’s a shorter course of treatment than CBT for other conditions. CBT for insomnia is a highly structured treatment, with each session focusing on specific cognitive or behavioral techniques that have been demonstrated to improve sleep quality. Patients are then given specific sleep-related recommendations to “practice” at home in between sessions. Over the four to six visits, patients can expect an improvement in both the quality of their sleep at night and the quality of their functioning during the day.
An important element of treatment is the daily sleep/wake diary. We ask patients to record when they go to bed, when they wake up, how long they estimate it took to fall asleep, whether they woke up in the middle of the night and sleep quality. We then use this information to guide recommendations and to evaluate treatment progress. Patients have to be engaged in treatment and be willing to put in some work during the course of treatment in order for their sleep to improve.
The research didn’t prove CBT is better than medications, so why should providers consider recommending it on the first try?
Arnedt: We recommend CBT as the first-line choice because the treatment has been shown to be as effective as sleep medicines and the risks are generally lower. CBT has fewer side effects than most of the first-line medications. It’s not without side effects, but it’s generally a well-tolerated treatment. Some CBT techniques increase sleepiness during the early stages of treatment, which patients find uncomfortable and which can reduce daytime productivity, but it is otherwise a well-tolerated approach.
With sleep medications, patients can build up a tolerance, so the dose becomes less effective over time. That leads to increasing the dose or switching medications to continue treating symptoms effectively. Daytime sedation can also be an issue with some medications. Some patients may also experience changes in thinking and behavior. In elderly patients, there is a concern about increased risk for falls during the night after taking sleep medication.
However, treatment for insomnia does not have to involve only medication or only CBT. There is also emerging evidence to support combination therapy, incorporating CBT strategies into treatment with medication. While this approach has some appeal, the bulk of the evidence indicates that, while medications work more quickly, CBT is equally effective over six to eight weeks and shows superior outcomes to medication in the long term.
If CBT has so many advantages in insomnia treatment, why isn’t it more widely used?
Arnedt: The main reason that CBT for insomnia isn’t used more widely is that there are too few trained providers to deliver the treatment.
There are only about 200 providers nationwide with the necessary expertise to adequately deliver CBT for insomnia. Most, like the three of us at U-M, practice at academic medical centers or in specialty clinics. Very few trained CBT for insomnia providers are located in primary care settings, which is where most patients with insomnia are seen initially.
The good news is that there is a movement to expand access by increasing the number of trained providers and delivering interventions through different formats, such as over the phone or online. This opens up an opportunity for untrained providers to undergo additional training in order to deliver CBT for insomnia. However, these models are still likely to fall short of meeting the demand for CBT for insomnia services. We need to continue to devise innovative strategies for improving access to this effective treatment.
Once a patient finds a provider who is equipped to deliver CBT for insomnia, insurance coverage for services can be an issue. In our clinic, however, we find that most behavioral health plans we work with do cover it.