January 19, 2020

Best Treatment for Chronic Insomnia is Cognitive Behavioral Therapy

I’m having trouble trying to sleep
I’m counting sheep but running out
As time ticks by…
And still I try…
— Brain Stew by Green Day from the album Insomniac

Sleep that knits up the raveled sleave of care,
The death of each day’s life, sore labor’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
— Shakespeare, Macbeth

Chronic insomnia affects 5% to 15% of Americans. It is far from only a nighttime problem. As all of us know from occasional sleepless nights, the following day is unproductive and sometimes dangerous. Sleep deprived people are more prone to accidents, and are more likely to have depression, anxiety, diabetes and high blood pressure.

It is no surprise then that many patients seek relief from sleep medications. But most medications are only modestly effective. Many medications also slowly decline in efficacy over time, and some have worrisome side-effects.

Cognitive behavioral therapy (CBT) has been known to be effective for chronic insomnia for some time. CBT is a specific kind of psychotherapy that focuses on thinking and on behavior. It is unlike older kinds of psychotherapy (like psychoanalysis) in that it’s much more brief and pragmatic. It has been proven to be effective in many anxiety disorders, and unlike medications, the benefits of CBT have been shown to persist long after the therapy ends. (Four years ago I wrote about the ” target=”_blank”>a review of prior studies of CBT-i. The study reviewed 20 randomized controlled trials involving over 1,000 participants. CBT-i significantly improved sleep and did not have adverse outcomes. On average, subjects who underwent CBT-i fell asleep 20 minutes faster and spent 30 fewer minutes awake during the night compared with people who didn’t undergo CBT-i. This may not seem like a large benefit, but it is the same magnitude as the benefits seen in trials of sleep medications, and without the side-effects that medications can cause. Like other studies of CBT, this review showed that the benefits of CBT-i persist after the therapy ends. This is another positive comparison with medication. At best, the benefits of sleep medication end as soon as the patient stops taking it. At worst, stopping the medication leads to rebound insomnia making the symptoms worse than before the medication was started.

Much of CBT-i focuses on teaching good ” target=”_blank”>A related editorial in Annals of Internal Medicine makes the point that changes in attitude and behavior are necessary to treat other health problems like high blood pressure, obesity, and diabetes. Drug therapy alone is not adequate for these chronic problems. We should not be surprised then that this is also true for chronic insomnia.

So doctors should do a better job of referring patients with chronic insomnia to CBT-i. And patients should realize that there is a safer and more effective option than medication. Of course finding a psychologist who has been trained in CBT isn’t always easy, especially outside of large cities. There is also an” target=”_blank”>The Evidence Points to a Better Way to Fight Insomnia (NY Times)
” target=”_blank”>Cognitive behavioral therapy offers a drug-free method for managing insomnia (Harvard Health Blog)
” target=”_blank”>SHUTi (an online CBT-i program)
” target=”_blank”>Cognitive Behavioral Therapy for Chronic Insomnia: State of the Science Versus Current Clinical Practices (Annals of Internal Medicine editorial, subscription required)

"Please note that the posts on The Blogs are contributed by third parties. The opinions, facts and any media content in them are presented solely by the authors, and neither The Jewish Journal nor its partners assume any responsibility for them. Please contact us in case of abuse."