CBT Effective for Comorbid Insomnia

July 08, 2015

A new meta-analysis has provided further evidence supporting cognitive-behavior therapy for insomnia (CBT-I) when the difficulty sleeping occurs with another medical or psychiatric condition.

"We are putting the evidence out there. CBT-I is an effective treatment for insomnia even when it occurs with an underlying medical or psychiatric condition. Physicians need to consider this an option," study coauthor, Jason C. Ong, PhD, Rush University Medical Center, Chicago, Illinois, told Medscape Medical News.

Dr Ong explained that CBT-I is a specific form of CBT aimed at treating insomnia. A form of psychotherapy, it typically involves four to eight visits with a therapist who, in consultation with the patient, formulates strategies such as bedtime schedules, what to do if they can't get to sleep or wake up in the night, relaxation techniques, and how to cope with anxieties that may be preventing sleep.

"CBT-I is not the same as sleep hygiene. Sleep hygiene is a list of recommendations that generally apply to everyone. CBT-I is a personalized program which is formulated with the patient to develop an individualized tailored strategy that addresses each patients' particular problems sleeping," Dr Ong said.

The study was published online July 6 in JAMA Internal Medicine.

CBT-I A Valuable Tool

For the study, investigators examined the efficacy of CBT-I across 37 randomized clinical trials that included 2189 patients with insomnia comorbid with psychiatric and medical conditions.

Main results showed that after treatment, 35.6% of the patients who received CBT-I were in remission from insomnia, compared with 17.4% of the controls.

Other findings were that sleep latency (how long it takes to get to sleep) was reduced from 48 minutes before treatment to 23 minutes after treatment, a reduction of 25 minutes, vs no change for the control group. Similarly, the amount of time spent awake in the night after sleep onset was reduced from 68 minutes before treatment to 23 minutes after treatment. Sleep efficiency (the amount of time in bed spent asleep) increased from 71% before treatment to 83% after treatment.

"Overall, our findings indicate that CBT-I has positive effects on reducing insomnia symptoms and sleep disturbances in comorbid insomnia," the investigators conclude.

In addition to helping sleep, the results also showed a beneficial effect of CBT-I on the underlying comorbid condition, with more of an effect on psychiatric conditions than medical conditions.

"Sleep health affects other areas of health. The body is better able to repair itself if it is well rested. And this appears to be particularly relevant to psychiatric conditions. There is a large overlap between mood/anxiety and sleep," said Dr Ong.

He noted that most previous research with CBT-I has been done in primary insomnia, in which sleep difficulties do not occur with other medical/psychiatric conditions. "But insomnia is actually more common in patients who have other medical/psychiatric issues so our research is more relevant to real patients in the real world. We have put all the studies available in this field together — this is the first time that there has been such a comprehensive evaluation of CBT-I in comorbid insomnia."

He made the point that patients with medical/psychiatric conditions are not often assessed for sleep when they visit their primary care doctor. And if they are, and are found to have a problem, then they will normally be given a sleeping tablet. "Primary care doctors have not recognized the potential value of CBT-I. We would like more of them to think about referring for CBT-I. We hope that these new data may help that happen."

Large Effect Size

In an accompanying editorial, Michael A. Grandner, PhD, and Michael L. Perlis, PhD, University of Pennsylvania, Philadelphia, write, "The meta-analysis showed that not only was CBT-I effective in the face of comorbid conditions, but the effects were relatively large (although slightly smaller than might be seen in primary insomnia)."

"Clinicians who provide treatment for patients with insomnia should consider CBT-I; even if the insomnia exists in the context of depression, pain, or some other condition, the therapy is likely to be helpful," they conclude.

The editorialists note that further research is needed to better understand (1) treatment response with CBT-I in co-morbid insomnia; (2) what components of CBT-I work best for comorbid insomnia; (3) to what extent CBT-I affects severity of and tolerance for noninsomnia symptoms; (4) the role of insomnia treatment in other chronic health conditions, such as obesity and cardiometabolic disease; and (5) the role of insomnia as an important indicator of health and functioning.

JAMA Intern Med. Published online July 6, 2015. Abstract Editorial

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