CBT Effective for Chronic Insomnia

Liam Davenport

June 12, 2015

Cognitive-behavioral therapy (CBT) can improve sleep in patients with chronic insomnia without recourse to drugs or experiencing adverse outcomes, the results of a meta-analysis reveal.

The study, which included data from 20 studies of CBT in chronic insomnia, showed improvements on a range of sleep measures immediately following treatment, with some data indicating that there were further gains over time.

"This supports recommendations that CBT [for insomnia] should be used as the initial intervention for chronic insomnia when possible," the investigators, led by James M. Trauer, MD, Melbourne Sleep Disorders Centre, East Melbourne, Australia, write.

The study was published online June 9 in the Annals of Internal Medicine.

Continued Improvement

Dr Trauer explained that he and his colleagues undertook the research after looking at the profile of the patients in his sleep clinic.

"We were interested by the fact that a lot of our patients with insomnia have quite a lot of medical treatments, and often vitamins and supplements, but haven't ever tried psychological treatments such as CBT for insomnia," he said.

"A lot of the patients we see with insomnia describe having been on the Internet, tried sleep hygiene, tried various sleep tablets that have been prescribed by their GP, but they've never even heard of CBT for insomnia," Dr Trauer added.

To examine the impact of the use of CBT for insomnia on diary measures of overnight sleep in adults with chronic insomnia, the researchers conducted a search of the MEDLINE, EMBASE, PsyhINFO, CINAHL, the Cochrane Library, and the PubMed Clinical Queries databases.

Of 292 initial citations, 20 randomized controlled trials assessing the efficacy of face-to-face multimodal CBT vs comparator control groups in patients with chronic insomnia who were without comorbid conditions were selected, yielding a total of 1162 participants (mean age, 56 years).

The various CBT approaches used in the studies included cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. Each study investigated CBT with at least three components.

Results revealed that at posttreatment, sleep onset latency improved by a mean of 19.03 minutes with CBT, and wake after sleep onset improved by a mean of 26.00 minutes.

In addition, total sleep time improved by 7.61 minutes, and there was a 9.91% improvement in sleep efficiency with CBT. Importantly, no adverse outcomes were reported with CBT.

In performing the meta-analysis, the investigators found there was little consistency in follow-up, which made it difficult to determine the longer-term impact of CBT on insomnia.

"Having said that, there were some data on that, and we think that a signal is beginning to emerge that, months down the track, you continue to maintain the gains that you made with the treatment, and those gains then even augment or get greater with time from the original treatment," Dr Trauer noted.

"For example, for the total amount of time that patients are sleeping, it really didn't change very much immediately after the treatment, but months down the track, it looks as if it has improved significantly by half an hour or more after several months. That's consistent with how we understand the treatment to work," he added.

In order for CBT to be more widely implemented, Dr Trauer believes there needs to be increased awareness and availability of CBT for insomnia.

"For a lot of patients, even if they have heard of it, it's pretty difficult to access the treatment. One of the reasons for that, I suppose, is that the classic model is one-on-one treatment, and that's the studies that we included in our meta-analysis," he said.

"It consists of one-on-one treatment for generally a period of an hour, with four to six sessions with a psychologist, and, given that insomnia is so widespread, if you adopt that model and try to roll it out to all of the population with insomnia, it's going to be difficult to provide those kinds of resources, because about 10% of the population has insomnia."

Cultural Shift Needed

In an accompanying editorial, Charles M. Morin, PhD, Université Laval, Quebec, Canada, notes that other studies have indicated that psychological therapies can produce sleep improvements in patients with comorbid medical and psychiatric conditions, which is a common occurrence with insomnia.

Speaking to Medscape Medical News, Dr Morin said that regardless of whether or not a patient with insomnia has comorbid conditions, the recommendation is the same.

"We used to think that if insomnia was presenting, let's say, in the context of a depression, that we just needed to treat the depression and it would take care of the sleep problems. But oftentimes that was not the case," he said.

"We could treat effectively the depression, but insomnia was the most common residual symptom, and oftentimes the persistence of that residual symptom would increase the relapse rate for depression."

He continued: "Now, clearly the paradigm is different, and most experts would say that we need to treat both conditions...and the overall results will be much better in the end."

Dr Morin believes that a cultural shift is required for CBT to become more widely used in the treatment of insomnia, alongside a change in the way in which CBT is reimbursed.

"As long as we continue reimbursing medication treatment with a medical doctor but we don't for psychological treatment with a psychologist, I think that we are in trouble, because we are taking a very narrow view of how to take care of these kinds of problems," he said.

"The medication is more like a Band-Aid, so in the short run, that's fine, but in the long run, we need to do CBT to address the underlying issues that perpetuate this sleep problem."

Another barrier against the adoption of CBT is linked to education. Dr Morin stated: "We don't do a great deal of education about sleep and the importance of sleep."

"If we only allow enough time in graduate school, in medical school to talk about sleep the way we do about nutrition, about exercise, then maybe people would pay more attention."

Talking more generally about public health education programs, Dr Morin observed that "we don't hear a lot about sleep except maybe when a drug company brings a new medication on the market."

"At least in Canada, we hear a lot about the importance about good nutrition, a good diet, about the importance of exercising to stay fit, but sleep occupies a third of our lives, and we really don't hear a lot about it, so we take it for granted until we start having sleep problems," he added.

One way in which the case for CBT could be strengthened would be to link it to the poor clinical outcomes that are observed in people who suffer from chronic insomnia.

Dr Morin pointed out that there are long-term epidemiologic studies documenting the impact of persistent insomnia, such as depression and hypertension.

"Now what we need to do in terms of studies is to do long-term studies and not only aim at improving sleep but aim at reducing this negative health outcome," he said.

He added that things are moving in the "right direction," because it is no longer taken for granted that the sleep problem will "go away" if, for example, a patient is treated for depression.

"We just need to do a bit more different research, and probably need to do a bit more lobbying with the government and agencies and healthcare insurance companies," said Dr Morin.

The authors' financial disclosures can be found in the original study.

Ann Intern Med. Published online June 9, 2015. Abstract, Editorial

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