Cognitive Behavioral Therapy in the Treatment of Insomnia

Abstract and Introduction

Abstract

Insomnia disorder is present in as much as 30% of the general adult population. Given the significant adverse effects of pharmacotherapy, cognitive behavioral therapy (CBT) has been found to be an effective alternative in individuals with insomnia. CBT for insomnia (CBTi) encompasses sleep hygiene, stimulus control, sleep restriction, cognitive therapy, and relaxation training. In this article we review evidence that establishes CBTi as a useful treatment affecting remission, sleep onset latency, wakefulness after sleep, sleep efficiency, and sleep quality in adults with insomnia to include older adults and adolescents. In addition, we briefly highlight various CBTi delivery methods as well as barriers to accessing this safe and effective therapy.

Introduction

Thirty percent of the general population complains of at least one symptom of insomnia, including trouble falling asleep, staying asleep, or early awakening.^[1] After applying narrower criteria from both the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition or the International Classification of Sleep Disorders, 3rd Edition, approximately 10% of the population meets the criteria for insomnia disorder, with half of these individuals experiencing a chronic course.^[1,2] The risk factors for insomnia include lower socioeconomic status, female sex, older age, African American race, comorbid depression/psychiatric disorders, and shift work.^[1–3] Furthermore, insomnia often coexists with other conditions, including malignancy, chronic pain, cardiopulmonary disease, and substance abuse.^[1–3]

Both the economic and health effects of chronic insomnia are significant. The incidence of diabetes mellitus, coronary artery disease, hypertension, and the metabolic syndrome are higher in patients with chronic insomnia.^[4] Absenteeism and tardiness are more prevalent in employees with insomnia.^[4] Individuals with chronic insomnia have higher healthcare expenditures than their well-rested counterparts.^[1,4]

Cognitive behavioral therapy for insomnia (CBTi) offers an attractive alternative to the long-term efficacy and safety concerns associated with sedative-hypnotics and the adverse effects of other commonly used sleep medications. CBTi uses several components, including sleep hygiene (SH), stimulus control (SC), sleep restriction (SR), cognitive therapy, and relaxation training (RT).^[3,5] We present the evidence supporting the effectiveness of CBTi in adults, adolescents, and older adults; some potential options for CBTi implementation in primary care; and alternatives and relative contraindications to its use in patients with various comorbidities.

Table 1. Comparative effectiveness of interventions for chronic insomnia in adults ⁶
Intervention	Remission, RR	Treatment response, RR	PSQI, WMD	ISI, WMD
CBTi	2.9 (2.0–4.2)	2.3 (1.1–5.0)	−2.1 (−2.9 to −1.3)	−4.8 (−6.5 to −3.1)
Eszopiclone, 2–3mg	2.7 (2.1–3.4)			−4.6 (MD) (−5.3 to −3.9)
Zolpidem, 5–15 mg
Zolpidem, 10 mg, prn
Zolpidem ER, 12.5 mg
Zolpidem SL, 3.5 mg
Ramelteon, 4–16 mg
Suvorexant		1.3 (1.2–1.5)		−1.2 (−1.8 to −0.6)
Doxepin, 1– 3 mg 6mg

CBTi, cognitive behavioral therapy for insomnia; CGI, clinical global impression; ER, extended release; ISI, Insomnia Severity Index; MD, mean difference; PSQI, Pittsburgh Sleep Quality Index; prn, as needed; RR, relative risk; SE, sleep efficiency; SL, sublingual; SOL, sleep onset latency; SQ, sleep quality; TST, total sleep time; TTB, total time in bed; WASO, wake after sleep onset; WMD, weighted mean difference.

Table 2. Behavioral/cognitive interventions for insomnia defined ⁷
Intervention	Definition
Sleep hygiene	Behavioral interventions designed to educate patients about health and environmental factors they can change to improve sleep
Sleep restriction	Behavioral intervention designed to limit time in bed to sleep only
Stimulus control	Behavioral intervention designed to alter habits associated with bed/bedroom and promote consistency in sleep patterns
Relaxation training	Training to control thought patterns and somatic tension that interfere with sleep
Brief behavioral therapy	Combination of sleep restriction and stimulus control
Cognitive therapy	Intervention to change thought patterns regarding sleep by identifying, dispelling, and replacing dysfunctional beliefs and perspectives
Cognitive behavioral therapy	Multimodal combination of cognitive, behavioral (stimulus control, sleep restriction), and educational (sleep hygiene) interventions
SOL, min, WMD	WASO, min, WMD	SE (TST/TTB), WMD	SQ, WMD	TST, min, WMD	CGI, RR
−11.6 (−16.6 to −6.7)	−21.4 (−35.8 to −7.0)	6.86 (4.6–9.16)	0.39 (0.2–0.6)	43.5 (12.67–74.42)
−19.1 (−24.1 to −14.1)	−10.8 (−19.8 to −1.70)			44.8 (35.4–54.2)
−15.0 (−22.1 to −7.8)				23 (2.0–43.9)
−14.8 (−23.4 to −6.2)				48.1 (34.8–61.5)	2.2 (1.6–3.2)
9 min (not WMD)	16 min (not WMD)			25 min (not WMD)	1.8 (1.6–2.0)
−18 (not WMD)
−3.1 (−7.4 to −1.2)	−5.9 (−6.1 to 17.9)			0.1 (−10 to 10)
−6.0 (−10 to −1.9)	−4.7 (−8.9 to −0.5)			16.0 (4.7–27.2)
	−10.2 (MD) −14.2 (MD)			11.9 (MD) 17.3 (MD)

Table 3. Improvement in sleep parameters for CBTi vs inactive comparators ³
Intervention	SOL, min	WASO, min	TST, min	SE, %
Baseline	57.6	76	344.1	71.8
CBTi	−19.03 (−23.93 to −14.12)	−26.00 (−36.52 to −15.48)	7.61 (−0.51 to 15.74)^a	9.91 (8.09–11.73)
Early follow-up, 1–3mo	−12.18 (−37.52 to 13.15)^a	−41.64 (−101.02 to 17.74)^a	30.31 (−15.14 to 75.76)^a	11.61 (−0.11 to 23.32)^a
Late follow-up, 6–8mo	−14.24 (−58.36 to 29.88)^a	−18.38 (−54.45 to 17.68)^a	38.05 (−5.34 to 81.43)^a	11.10 (−1.67 to 23.87)^a

^aNonsignificant values.
CBTi, cognitive behavioral therapy for insomnia; SE, sleep efficiency (TST/TTB); SOL, sleep onset latency; TST, total sleep time; TTB, total time in bed; WASO, wake after sleep onset.

Table 4. Pretreatment to posttreatment comparison of CBTi to controls in college students ³²
Sleep diary measures	Cohen d effect size, pre-vs post-	P
Sleep efficiency	1.06 (large)	0.009
Total sleep time	0.22	0.574
Sleep onset latency	0.91 (large)	0.26
No. awakenings	1.09 (large)	0.009
Time awake after sleep onset	1.23 (large)	0.003
Terminal wakefulness	0.56	0.144
Sleep quality	1.02 (large)	0.012