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 utility of CBT in chronic fatigue syndrome.) CBT for insomnia (CBT-i) usually involves weekly hour-long meetings with a psychologist. The course of therapy can be as brief as 4 to 8 sessions.
This week, Annals of Internal Medicine published 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 sleep hygiene –behaviors that promote healthy sleep. These behaviors include avoiding caffeine in the afternoon, avoiding alcohol at bedtime, and not staying in bed for longer than 20 minutes if you can’t fall asleep. That last bit of advice may seem counterintuitive, but going to another room until you’re feeling sleepy will train you to associate your bed with sleep. For the same reason you should avoid reading, watching TV, or using electronic screens in bed.
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 online CBT-i program for those who can’t find or can’t afford in-person therapy.
We’ve known for a long time that chronic sleeplessness is a serious problem. But it turns out that before we can fall asleep we first have to knit up the raveled sleeve of care and balm our hurt minds. As of now, the best way we know to do that is CBT-i.
The Evidence Points to a Better Way to Fight Insomnia (NY Times)
To Beat Insomnia, Try Therapy For The Underlying Cause Instead Of Pills (Shots, NPR’s health blog)
Cognitive behavioral therapy offers a drug-free method for managing insomnia (Harvard Health Blog)
Sleep Hygiene (National Sleep Foundation)
SHUTi (an online CBT-i program)
Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis (Annals of Internal Medicine article, abstract available without subscription)
Cognitive Behavioral Therapy for Chronic Insomnia: State of the Science Versus Current Clinical Practices (Annals of Internal Medicine editorial, subscription required)