Jill Stein

March 02, 2010

March 2, 2010 (Munich, Germany) — Cognitive behavioral therapy (CBT) in a group setting is an effective treatment for chronic insomnia, new research presented here at the European Psychiatric Association 18th European Congress of Psychiatry, shows.

"The significant improvements in sleep measures and quality of life we observed in our patients following a short course of group CBT are very encouraging and may mean that patients can return to employment or education despite their insomnia," Jane Hicks, MD, PhD, a liaison psychiatrist in Bristol, United Kingdom, told Medscape Psychiatry.

Dr. Hicks and colleagues conducted their research at the Frenchay Hospital’s Burden Centre in Bristol.

The investigators examined results in 102 patients who underwent group CBT during a recent 10-year period offered by the Bristol Insomnia Group. The Bristol Insomnia Group is one of the few teams to provide group CBT in the United Kingdom.

"It is now well established that CBT for chronic insomnia is as effective as hypnotic medications and is also likely to be better at maintaining improved sleep," said Dr. Hicks. "To date, most studies on CBT for chronic insomnia have examined the use of individual rather than group-based CBT."

Group CBT sessions at the Burden Centre are led by a team that includes a physician specializing in sleep disorders, an occupational therapist, and a research sleep scientist. Sessions are held once a week for 90 minutes for a total of 7 weeks.

The intervention includes education about sleep science, information on sleep hygiene and stimulus control techniques, relaxation, and cognitive therapy.

Clinically Significant Results

Patients ranged from 21 to 77 years of age, and about three-quarters of them were female. Of the total cohort, 12% had insomnia for 2 years or less, 30% for 3 to 5 years, 15% for 6 to 10 years, 22% for 11 to 20 years, and 21% for more than 20 years.

Patients with mild to moderate depression were not excluded as in some other group programs for chronic insomnia. The investigators found that the mean total sleep time (TST) increased by a mean of 20 minutes (P = .0025).

The mean sleep onset latency (SOL) decreased by a mean of 17 minutes (P = .0011).

Overall, two-thirds of patients increased their TST by 30 minutes or more, and one-third decreased their SOL by 30 minutes or more. "These are clinically significant results," said Dr. Hicks.

Results on the 36-item Short Form Health Survey (SF36) questionnaire showed significant improvements in all 9 domains. The SF-36 is a patient-completed quality-of-life questionnaire that measures overall functional health and well-being.

The researchers also documented a significant decrease in scores on the Dysfunctional Beliefs and Attitudes about Sleep, a validated, 32-item, self-report measure that evaluates multiple sleep-related cognitions (eg, faulty beliefs and appraisals and unrealistic expectations).

Ingrained Attitudes

"Chronic insomniacs often have very ingrained attitudes whereby they think, for example, that they always won’t be able to perform as efficiently at work because they didn’t sleep well the night before," she said. "Or they may think that they need exactly 8 hours of sleep to function the next day."

Although the investigators did not conduct a subgroup analysis to determine who might respond best to group CBT, some patterns emerged, Dr. Hicks noted.

"It appears that individuals with very entrenched attitudes and beliefs were very difficult to move or change," she said. "Such people are very concrete in their thinking and can’t think psychologically," she added. "These individuals were usually older and male."

Besides clinical efficacy, group CBT is a cost-effective option for the long term, Dr. Hicks pointed out. "It may be expensive initially because you have to pay staff to run group CBT, but in the long term patients are often able to stop taking the medications they have been prescribed for their insomnia," she said.

"As for whether her results will be maintained over time, patients may benefit from contact at follow-up meetings to revise techniques learnt in the group and further outcome data can be obtained," she said.

Finally, Dr. Hicks acknowledged that although her team found good results using group CBT to manage chronic insomnia, she had expected even better results.

"We were slightly disappointed with our TST and SOL data because our figures fall short of those reported earlier by a general practice group," she said.

The Bristol investigator was quick to add, however, that the patient population in her series were from a tertiary referral center and may have had more severe insomnia than those patients usually seen in general practice.

Nonpharmacological Treatment Effective

"The study reinforces the idea that nonpharmacological therapies do work to help people improve their sleep," Joyce Walsleben, RN, PhD, associate professor of medicine at NYU School of Medicine in New York City, said.

"Two drawbacks to this therapy have been the time needed to teach the cognitive therapies and the few number of people trained to do so," she added.

Dr. Walsleben also said the study offers proof that "more time-effective, and presumably cost-effective, group therapy also works. These are hopeful data for the millions of people who suffer from insomnia."

Dr. Hicks and Dr. Walsleben have disclosed no relevant financial relationships.

European Psychiatric Association (EPA) 18th European Congress of Psychiatry: Abstract S27-02. Presented March 1, 2010.

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