CBT-I: Put Insomnia to Bed with Behavioral Therapy

Brandon Peters, MD

Even sleep specialists can struggle to manage insomnia. This common sleep complaint can leave medical providers feeling powerless when dealing with increasingly ineffective medications. Fortunately, a treatment option called cognitive behavioral therapy for insomnia (CBT-I) can make a profound difference.

In my fellowship training at Stanford University, I too often felt frustrated in the face of insomnia, an intractable condition that can devastate mood and daytime function of those afflicted. I was not alone. At our sleep clinic, patients with difficulty initiating or maintaining sleep (DIMS) were scheduled on Thursdays. One of the attending physicians would comment weekly, “Thursday is DIMS day and DIMS day is doomsday.” Insomniacs who passed through the clinic were hardened veterans of the condition, immune to sleeping pills and desperate for help.

When an opportunity arose at Stanford to undergo formal training in a therapy technique to solve the puzzle of insomnia, I jumped at it. It was a solution to a problem that bedevils too many patients and physicians. To understand the need for new therapies, one must appreciate the scope of the insomnia problem.

Insomnia is the most commonly encountered sleep problem in the primary care setting.¹ Anyone can develop it, given the proper circumstances. Once insomnia is chronic, unraveling the contributing factors can be difficult. Basic sleep guidelines may not be helpful for addressing perpetuating causes. Therefore, sleeping pills are often employed first.

As I tell patients, you don’t need a medication to feel hungry, so why do you need a medication to feel sleepy? The truth is that you don’t. Nevertheless, according to CDC estimates, between 2005 and 2010 about 4% of American adults used sleeping pills in the previous month.² Prescription drug data reveals that about 59 million sleeping pills were prescribed in the United States in 2012.³ Between 1998 and 2006, the number of sleeping-pill prescriptions issued to young adults aged 18 to 24 tripled.⁴

Though widely used, sleeping pills may have serious consequences and may increase the risk of harm in certain populations. Some long-term repercussions should give us pause. One study, for example, found that people who took sleeping pills were nearly five times as likely to die over two and a half years as those who did not.⁵ Sleeping pills may particularly increase the risk of colon cancer.

In truth, sleeping pills have modest effects on improving total sleep time and sleep efficiency. Many agents add only 20 to 25 minutes to total sleep time, based on objective comparison to placebo with overnight sleep studies. Newer hypnotic agents, including Ambien, profoundly affect memory. This can lead to unrecalled sleep behaviors such as walking, eating and even driving. As a result of the memory impairment, subjective sleep quality improves because the awakenings are not recalled. Sleep seems more continuous, is perceived as less disrupted, and is believed, not surprisingly, to be better. This benefit may not be sustained, however.

Nearly every person with insomnia will note that sleeping pills help initially, work less well over time, and eventually stop working entirely. This ineffectiveness is due to tolerance. Ineffectiveness may lead to escalating medication doses, thereby increasing potential risks, especially among benzodiazepine medications, which can depress breathing and lead to death.

Physical dependence is less common with newer sleeping pills, yet psychological dependence is frequent. The thought of discontinuing sleeping pills prompts anxiety. When sleeping pills are suddenly stopped, insomnia can come back with a vengeance, sometimes worse than it was initially, prompting an immediate resumption of the medication. This circumstance is good for drug companies, who may be interested in such a reinforcing effect, but bad for those who wish to discontinue the medication. Fortunately, the effect is often transient and can be managed with a medication taper and other interventions.

Cognitive behavioral therapy for insomnia offers an alternative to sleeping pills. CBT-I is a scientifically based, effective and proven treatment that can end insomnia. It is best administered by a sleep specialist with additional training in CBT-I, allowing comorbid sleep disorders like sleep apnea, restless legs and delayed sleep phase syndrome to be identified and treated as needed.

Over the course of 4–6 one-on-one sessions, typically over several months, the physician and patient identify and address the causes of insomnia. Sleep education plays a central role, including review of how good sleep occurs with optimization of sleep drive and circadian rhythm. Patients use sleep logs to track the changes that occur through sleep consolidation and extension. Sleeping pills are discontinued. Relaxation techniques, stimulus control and other cognitive interventions are used to build lasting change.

CBT-I is a goal-directed therapy, with the goals set at the initial encounter. The vast majority of patients who complete the program meet all their goals: falling asleep in less than 15 to 20 minutes, spending less time awake at night, getting sufficient hours of sleep, discontinuing sleep aids and feeling less tired during the day.⁶ More than 85% of my patients are able to fix their insomnia. The skill-set can resolve insomnia in weeks, even if it has been present for decades, and it reduces the length of relapses should they recur later in life. There are no side effects with CBT-I, and it can be as effective as sleeping pills, with studies demonstrating longer-lasting benefits.⁷

No one should have to suffer from chronic insomnia. Why prescribe potentially harmful medications when an effective alternative exists? For patients with long-lasting insomnia, CBT-I can lead to the rest that they so desperately need. The therapy can provide relief to patients and sleep specialists alike.

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Dr. Peters is a board certified neurologist, sleep medicine specialist and cognitive behavioral therapist for insomnia at Pulmonary and Sleep Associates of Marin in Novato. He is also a consulting assistant professor in Stanford University’s School of Medicine. He writes as a sleep expert at About.com.

Email: BrandonPetersMD@gmail.com

References
1.  Peters B, “Ethical considerations in sleep medicine,” Focus, 12:64-67 (2014).
2.  Chong Y, et al, “Prescription sleep aid use among adults,” National Center for Health Statistics Data Brief (August 2013).
3.  Aitken M, “Declining medicine use and costs,” IMS Health Report (May 2013).
4.  Russo A, et al, “Prescription sleep aid use in young adults,” Thomson Reuters Research Brief (2008).
5.  Kripke DF, et al, “Hypnotics’ association with mortality or cancer,” BMJ Open 2, e000850 (2012).
6.  Schutte-Rodin S, et al, “Clinical guideline for the evaluation and management of chronic insomnia in adults,” J  Clin Sleep Med, 4:487-504 (2008).
7.  Siebern AT and Manber R, “Insomnia and its effective nonpharmacologic treatment,” Med Clin North Am, 94:581-591 (2010).