Imagine the following scenario: You have a big presentation at work tomorrow and know you need a good night’s sleep tonight so you don’t look tired or forget your lines. You get to bed at a reasonable hour but can’t turn off your anxiety and begin mentally berating yourself about your inability to fall asleep, which only prolongs your wakefulness. Eventually, you get frustrated and hit the medicine cabinet so you can finally get some much-needed shuteye.
One in three adults report problems with insomnia, and when you’re feeling stressed or anxious, it is easy to pop some sleep aids for a quick fix every so often. Usually this helps, but for the 5 to 15 percent of adults suffering from chronic insomnia, relying on prescription pharmaceuticals such as benzodiazepines and related “Z drugs” (such as Ambien or Lunesta) is not an attractive option. These compounds can present a risk of chemical or psychological dependence, and patients often develop a tolerance to their effects over time. As part of efforts to provide patients with more options, some doctors lately have proposed psychological interventions such as cognitive behavioral therapy for insomnia (CBT-i).
CBT is a kind of talk therapy used to treat a variety of mental illnesses. At its foundation is a model known as the “vicious circle,” also known as spiraling. The vicious circle explains how negative thoughts lead to feelings and then to self-destructive behaviors, and so on. CBT is a technique that intervenes when these negative thoughts start, with the goal of influencing the behavior that follows.
For insomnia, treatment is administered in five phases: Therapists prompt their patients to identify negative beliefs about sleep that might contribute to insomnia, such as an irrational fear of not getting enough sleep, and then explains why these ideas are unhelpful or suggests alternative, more positive thoughts. In the second part of the treatment, stimulus control, therapists try to maximize the association of the bed with sleep by instructing patients on behavioral changes such as avoiding stimulating activities in the bedroom. Third, they advise patients to go to bed only when sleepy, with the idea of minimizing the amount of time there spent lying awake. Fourth, they make recommendations on how to keep good “sleep hygiene,” which refers to environments and habits that promote sound sleep, such as avoiding daytime naps and limiting caffeine intake before bed. Finally, therapists suggest patients try relaxation techniques such as meditation and mindfulness just before bed to try to quiet their racing minds.
Physicians at the Melbourne Sleep Disorders Center (MSDC) in Australia recently undertook a systematic review and meta-analysis of studies pertaining to the efficacy of CBT-i in the treatment of chronic insomnia. James Trauer, a sleep physician at MSDC and lead author of the paper, says he undertook the review because he was surprised by how few of his patients have tried or even heard of CBT-i, “despite it being the most effective technique, as it gets at the core of the problem, which is frustration with time awake in bed.” Based on the results of the studies they analyzed, the authors concluded that CBT-i is effective and a good alternative to pharmacological intervention for the treatment of chronic insomnia. Their findings were published in Annals of Internal Medicine on June 8.
Out of 292 citations and 91 full-text articles, the authors selected 20 trials that met their selective criteria — ruling out studies that, for example, incorporated fewer than three of the five components of CBT-i or only included patients that had other medical conditions as well as insomnia. These studies measured four determinants of sleep quality: time taken to fall asleep, time spent awake throughout the night after initially falling asleep, total sleep time and sleep efficiency (the total sleep time divided by the total recorded time). The authors reported the average of the results of all 20 studies, which showed that after participating in a course of CBT-i, patients fell asleep 19 minutes earlier, spent 26 fewer minutes awake in the middle of the night, got 7.6 more minutes of sleep overall, and improved their sleep efficiency by almost 10 percent.
Although the change in total sleep time was not statistically significant, the remaining three measures showed marked improvement. Based on these statistics, the authors reported that CBT-i resulted in similar levels of improvement to those measured in trials of benzodiazepines for treating insomnia but without the risk of side effects associated with such pharmaceuticals. The authors did not include comparisons with trials of Z drugs, despite their rise in popularity in the past several years. Because of the recentness of their development, data on their long-term effects and safety is limited.
Of greatest significance, however, was that the effects of CBT-i were found to be more sustainable in the long run than those of pharmacological interventions. Charles Morin, a cognitive neuroscientist at Laval University in Quebec who was not involved in the study, points out that CBT-i provides a more lasting solution than pills alone because it addresses the underlying psychological and behavioral factors that perpetuate insomnia over time. This means the CBT-i option, compared with a lifetime of taking pharmaceuticals, “is likely to be a cost-beneficial investment in the long run,” Morin says.
Although the findings have implications for managing insomnia’s symptoms, there are caveats. The studies included in the review only measured quality of sleep and did not address the impact of CBT-i quality of life and other factors. Insomnia has consequences beyond the seven or eight hours spent in bed, including health problems, psychological distress, and economic burden due lost productivity.
In addition, pursuing CBT-i requires more time and motivation than taking a pill before bedtime. Sleep medications are attractive because they allow insomniacs to take one pill before bed that helps them fall asleep and stay asleep without any effort on their part. With CBT-i, one of the recommendations of stimulus control, for example, is leaving the bed if unable to fall asleep after 15 minutes and trying again later.* Studies establishing that CBT-i directly improves quality of life would be required to show CBT-i is truly a better alternative to all pharmacological intervention.
If CBT-i proves to be the best option for troubled sleepers, researchers will also need to find ways to spread the word about this treatment. In contrast to the marketing campaigns common among pharmaceutical companies, behavioral treatments often go unnoticed. And, even with awareness of CBT-i, patients may not have the time, money or inclination to work with a psychotherapist on a regular basis.
One solution is an online app called Sleepio, developed by University of Oxford neuroscientist Colin Espie, that allows people to input their sleep patterns and negative thoughts about sleep, then generates a personalized CBT-i plan. The program “rings a bell with people because it is engaging, imaginative and evidence-based,” Espie says.
The MSDC meta-analysis comes at a time when society has become highly aware of the heavy physical and emotional burden of insomnia. Chronic insomnia puts people at risk for countless health conditions, including hypertension, diabetes, and depression, as well as increases the likelihood of substance abuse and vehicular accidents. Indeed, the studies provide evidence of CBT-i’s efficacy but they also provide sufferers with a choice as to how they want to manage their care.
“The most important message for patients,” Trauer says, “is that there is an effective treatment out there that is safe, doesn’t rely on popping pills, and gets to the core of the problem.”
*Editor's Note (6/12/15): Due to a misquote, the sentence following this one was removed from this article after posting. Also, the article incorrectly stated that Patricia Haynes was a psychiatrist. She is a psychologist at the Mel and Enid Zuckerman College of Public Health at the University of Arizona.