Cognitive Behavioral Therapy Should Be First-Line Insomnia Treatment

Caroline Cassels

November 10, 2006

November 10, 2006 — Behavioral approaches for the treatment of chronic insomnia are effective, produce longer-lasting effects than medication, and should be used as first-line treatment, a large review suggests.

The results of the study, which included more than 2029 patients from 37 treatment studies conducted between 1998 and 2004, consistently found treatments such as cognitive behavioral therapy (CBT) and relaxation were effective for primary insomnia as well as insomnia associated with some medical conditions and, to a lesser extent, some psychiatric illnesses.

"CBT is an effective therapy [for insomnia], but it is underutilized, largely because there is a misperception by clinicians that it takes too much time to implement. But the fact is, there are some CBT methods that can be efficiently integrated into clinical practice that do not take an undue amount of a practitioner's time," the study's lead author, Charles Morin, PhD, from Université Laval, in Québec, told Medscape.

The study is published in the November 1, 2006 issue of Sleep.

Most Recent Research

In 1999, Dr. Morin's group published a similar literature review to help direct insomnia practice guidelines published by the American Academy of Sleep Medicine.

This current study, said Dr. Morin, is an updated version of the previous review that includes the most recent insomnia research. "It was felt that there has been a significant amount of research conducted since 1999, and it was time to update insomnia practice parameters."

The investigators reviewed 37 studies and assessed study design, sample, diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings.

The main sleep diagnosis was either primary or secondary insomnia, with at least 1 treatment option that was either psychological or behavioral. Study designs were randomized controlled trial, nonrandomized group design, clinical case series, or single-subject experimental design with a minimum of 10 subjects.

Each study included at least 1 of the following dependent variables:

  • Sleep-onset latency.

  • Number and/or duration of awakenings.

  • Total sleep time.

  • Sleep efficiency.

  • Sleep quality.

New Evidence

One of the review's major findings was strong evidence in support of treating insomnia in patients with comorbid conditions.

"Insomnia rarely comes in isolation, but the direction of the relationship between it and other conditions is often unclear. Previously it was assumed insomnia was always the result of another condition, but there is now evidence showing it may actually be a risk factor for some conditions," Dr. Morin said.

He added that since the last review in 1999, there have been several studies showing behavioral and psychological interventions are effective for both primary and comorbid insomnia.

The other piece of new evidence pertains to treatment of insomnia in older adults. In the past, studies have been conducted predominantly in younger, mainly healthy adults.

"The systematic exclusion of older individuals was somewhat paradoxical, because we know older adults are at greater risk for insomnia than younger individuals. However, in the past 8 to 10 years a number of studies have shown that even though older adults may present with more severe insomnia initially, they respond to behavioral and psychological interventions as well as their younger counterparts," he said.

Better Than Medication

While medication remains first-line therapy, Dr. Morin is optimistic the evidence supporting CBT will help change practice. One of the major barriers to its use, he said, is clinicians' perception that it is unduly time-consuming. However, he said, this is not necessarily the case.

"The evidence supporting [CBT] is there, and as a medical community we can't look away. There are a number of clinical approaches, what we describe in the paper as brief therapy, that can be efficiently integrated into practice. Granted, they may not be brief relative to writing a prescription, but they are effective and have longer-lasting effects than medication."

In addition, said Dr. Morin, CBT offers physicians who are not comfortable prescribing sleep medication an effective alternative therapy.

Sleep. 2006;29:1415-1419.


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