To fend off nightly tossing and turning, some people with chronic insomnia take a sleep medication. But new guidelines for treating insomnia recommend a type of psychotherapy called cognitive behavioral therapy for insomnia (CBT-i) before considering medication.
“Unfortunately, some sleep medications can induce daytime sleepiness and put you at risk for confusion, falls and accidents,” says Matthew R. Ebben, Ph.D., assistant professor of psychology in clinical neurology at Weill Cornell Medical College in New York.
“Hypnotic medications in the benzodiazepine group can cause respiratory suppression, particularly when mixed with alcohol or pain medication," he says. "And then there’s the issue of dependency. While these remedies can be safe if properly used, they’re typically meant to be a temporary fix. Drugs don’t address behavioral and other underlying issues that cause nocturnal disturbances."
A safer solution
Unlike sleeping pills, CBT-i addresses the underlying causes of sleep disorders. Sleep therapists often recommend CBT-i or a similar behavioral therapy as an initial treatment for insomnia once physical causes, such as a medical illness, a mental health problem, substance abuse or another sleep disorder, are ruled out. CBT-i is sometimes combined with drugs. As insomnia improves, the drug is tapered off.
“It’s one of the little known secrets of sleep medicine that CBT-i is as effective as hypnotic medication. My patients are always surprised to find out about it,” Ebben says.
He explains that, unlike sleep medication, CBT-i has no drug company behind it to spend money on an advertising campaign. Yet, he adds, after just a few sessions, patients have dramatic improvement.
A metaanalysis of 20 studies of nearly 1,200 participants (average age, 56) by Australian researchers, which appeared in the June 2015 issue of the Annals of Internal Medicine, investigated CBT-i’s effectiveness. The researchers concluded that at least four sessions of therapy significantly improved sleep measures over other nondrug treatments.
After their treatment, participants reported improvements in sleep onset latency, or the time it took to fall asleep; the length of time spent awake after they initially fell asleep; total sleep time; and sleep quality.
More research, reported in July 2016 in the Annals of Internal Medicine, found moderate evidence that CBT-I helps people with insomnia fall asleep faster, stay asleep longer, and have more restful sleep. This was true regardless of whether the CBT-I was provided in individual or group therapy, over the phone, on the Internet, or via a book.
The researchers, a group of doctors from the American College of Physicians, generally found weaker evidence that various medications, such as zolpidem (Ambien) and eszopiclone (Lunesta), relieve insomnia.
CBT-i: What to expect
“Cognitive behavioral therapy takes work. It’s not as simple as taking a pill, but the payoff can be huge in terms of restored sleep,” Ebben says. “It also provides patients with lifelong tools they can use.”
CBT-i methods may vary among therapists, but most forms are a combination of the following five components:
1. Cognitive therapy involves discussing irrational beliefs you have about sleep, such as always needing to get at least eight hours of sleep, and then attempts to change your thinking patterns. Other misconceptions can include worry that you’re missing out on sleep, concern about the lack of sleep you’re getting, and overestimation of the consequences of lost sleep.
2. Stimulus control analyzes your sleep habits and actions that may be keeping you from getting a good night’s rest. Examples of recommended measures include using the bedroom primarily for sleep, leaving the bedroom if you can’t fall asleep, and returning to bed when you feel sleepy.
3. Sleep restriction aims to decrease the amount of time you’re in bed. Your doctor may recommend going to bed later to create a feeling of sleep deprivation. The goal is to make you feel more tired the next night.
This phase of therapy may initially leave you feeling worse but should last only a few days. Once your sleep improves, your doctor will gradually increase your time in bed. It’s one of the most valuable components of CBT-i, Ebben says, but it’s also one of the most difficult for patients to adhere to initially because they’ll need to fight through daytime sleepiness and stay alert.
4. Sleep hygiene education addresses such key elements to a good night’s rest as bedroom environment (keep the room cool, dark and quiet), diet (limit alcohol, caffeine and tobacco intake), and anxiety reducers (turn your clock away from you).
However, good sleep hygiene education alone has never consistently been shown to improve sleep quality independently in people with insomnia, Ebben says, which can frustrate some patients. This technique should be used along with other CBT-i techniques.
5. Relaxation encourages you to use techniques to reduce alertness and tension, such as meditation, controlled breathing, and progressive muscle relaxation.
CBT-i typically lasts several weeks for two to eight or more sessions. Although CBT-i has been shown to be an effective treatment, access to the therapy is limited since few clinicians are specially trained to perform it. To find a sleep specialist near you, check out the Society of Behavioral Medicine or the National Sleep Foundation’s site.
Finding a healthcare professional well versed in the cognitive behavior therapy for insomnia can be difficult, so researchers are investigating the effectiveness of online programs.
One such program, SHUTi, is modeled on face-to-face CBT-i and features videos, visuals, and other educational tools presented over several sessions.
Preliminary research points to a reduction in the number of adults considered insomniacs following treatment, but it’s unclear how effectively patients’ irrational beliefs about sleep can be addressed online.
The program costs $135 for 16 weeks or $156 for 20 weeks.
This article originally appeared July 18, 2016, and has been updated.