Treating Insomnia with Cognitive Behavioral Therapy

 

Need help getting to sleep? Four half-hour therapy sessions work better than sleeping pills, a new study shows.

It's called cognitive behavioral therapy or CBT. CBT helps people recognize, challenge, and change unhelpful thoughts and behaviors. But can this really work better than modern sleeping pills? Yes, finds Gregg D. Jacobs, PhD, a psychologist at the sleep disorders clinic of Beth Israel Deaconess Medical Center and assistant professor of psychiatry at Harvard Medical School in Boston. "If someone has insomnia, [he or she doesn't] have to live with it. An effective treatment exists," Jacobs tells WebMD. "It is not a drug, but CBT. It works better than sleeping pills in the short term and in the long term -- and has no side effects." Jacobs and colleagues report their findings in the Sept. 27 issue of Archives of Internal Medicine.

CBT isn't a new treatment. It's already the mainstay of therapy for most sleep specialists, says Richard Simon Jr., MD, medical director of the Severyns Dement sleep disorder center in Walla Walla, Washington. "My experience says this is right on the money," Simon tells WebMD. "As a sleep specialist I do it and I get very, very good results. No sleep specialist would disagree that CBT is the mainstay of therapy. This study clearly indicates robust effects."

Head-to-Head: CBT vs. Ambien vs. Combination

What makes Jacobs so excited are the results of a study with 63 insomnia sufferers recruited via newspaper ads. The patients were randomly assigned to one of four treatments: CBT, Ambien, CBT plus Ambien, or a placebo pill. CBT consisted of four, 30-minute sessions (once weekly for three weeks, then a final session two weeks later) plus a 15-minute follow-up phone call.

Why Ambien and not some other sleeping pill?

"We picked Ambien because it is one of two approved newer-generation sleeping pills -- the other is Sonata -- that work selectively in brain and have reduced side effects," Jacobs says. " Ambien, from our perspective, is the best choice on the market if you have sleep onset problems, because it works as well as others without as many side effects." It may be the best sleeping pill for people who have trouble getting to sleep. But it doesn't work nearly as well as CBT, Jacobs and colleagues found. Insomnia sufferers got to sleep faster and more efficiently after CBT than after taking Ambien. In fact, nearly 60% of the CBT-treated patients got to sleep just as fast as people without insomnia do -- in 30 minutes or less.

"These results are extremely impressive," Jacobs says. "When you take people who have long-standing insomnia -- who every night need more than an hour to fall asleep -- and say 60% get to normal sleep, that is outstanding data."

CBT-treated patients who didn't achieve normal sleep patterns still got to sleep much faster they did before treatment. "For many of them, instead of taking an hour and a half, they are sleeping in 45 minutes," Jacobs says. "They increase their sleep time and reduce their waking time. That, to them, is a major success." One might think that giving patients Ambien plus CBT would work better. But the combination wasn't any better than CBT alone. "That's a surprise," says Simon.

"If a person comes in with chronic insomnia, it takes a while for CBT to have an impact," Simon says. "So we often give a sleeping pill for the first few weeks. But the Jacobs study shows that the combination does not seem to add much. That is an interesting finding."

CBT: Long-Lasting Effect

The debate over the relative efficacy of sleeping pills versus CBT has smoldered for a long time, notes sleep researcher Milton Kramer, MD, director of psychiatric research at Maimonides Medical Center, New York, and clinical professor of psychiatry at New York University. "The core issue relates to effectiveness over time," Kramer tells WebMD. "A lot of studies show CBT can be effective, and a year after treatment patients still have made gains. With sleep medications, there's always been a question of effectiveness when treatment ends." CBT's long-lasting effect gives it an advantage over sleeping pills, says sleep expert Max Hirskowitz, PhD, associate professor of medicine and psychiatry at Baylor College of Medicine, Houston. "If we treat you with Ambien you will sleep, but when we stop treating, you are likely to go back to not being able to sleep. CBT gives tools with which people can help themselves in the longer run. With CBT, the benefits endure," Hirskowitz tells WebMD.

But there are drawbacks. "The disadvantage to CBT is that it is not widely available. In many locations, it is difficult to find a practitioner who knows how to do it properly," Hirskowitz says. "And it is time consuming."

That's just what Jacobs is trying to get around. He notes that his team gets results with just four half-hour sessions -- less than the six to eight CBT sessions common for other psychiatric treatments. True, he says, doctors and psychologists need training before they can treat insomnia with CBT. But not everyone with insomnia needs a top-notch CBT therapist. "Whether a person will benefit from simple guidelines or in-depth CBT depends on the patient," Jacobs says. "Some can go on WebMD and see this article, or reference my book, Say Goodnight to Insomnia, and that is all they need. This is not something you necessarily have to find at a sleep clinic."

Elements of CBT for Insomnia

As its name implies, CBT has two parts: cognitive and behavioral. The cognitive portion of CBT requires people with insomnia to recognize, challenge, and change the ways of thinking that keep them from falling asleep. "It involves educating insomnia patients about the fact they often engage in distorted, stress-inducing behavior about insomnia," Jacobs says. "We place an emphasis on their worries and anxieties about how their insomnia will affect their next-day performance and long-term health. We educate them about research showing that in most cases their concerns are not accurate."

CBT therapists provide information to counter negative thoughts relating to their problem. People with insomnia also have distorted ideas about how well they actually sleep. "Insomnia patients say, 'I never slept at all last night,' or, 'It took me until 4 a.m. to fall asleep,'" Jacobs notes. "But if you measure their sleep, you see they slept for four or five hours. In therapy sessions, they learn their perceptions of sleep are not quite accurate. And in these sessions we role play a little bit to give them replacement sleep thoughts."

The second part of CBT is behavior. This is what many sleep experts call "sleep hygiene." The most important rule, according to Jacobs and Simon: Get out of bed if you can't sleep. Go to another room and do something that makes you drowsy. "The most important thing is restricting time in bed so it most closely matches sleep time," Jacobs says. "People with sleep-onset insomnia average five hours of sleep -- but eight hours in bed. There is a huge mismatch between their actual sleep time and their time in bed. It actually inhibits their sleep drive. If they are out of bed, they build up more sleep drive and sleep better at night."

Here are Simon's other rules for sleep hygiene:

  • Get up at the same time every day. Wake up by the clock. That should be within one or two hours of the same time, workdays as well as on weekends.
  • Get as much light as you can during your desired waking hours. The biological clock is reset when you are exposed to bright light and we want as little light as possible during sleep hours.
  • Go to bed at night only when you think you can fall asleep. Wake by the clock, but go to bed when your body tells you to.
  • If you are having trouble sleeping, minimize naps during the day. Patients with insomnia often take naps. We tell them not to.
  • Minimize drugs that disturb sleep. Caffeine has to be minimized. Minimize nicotine and alcohol, particularly in the hours before bedtime.
  • Exercise regularly. The best time is early morning to midday. Try not to exercise within five to six hours of bedtime.
  • It takes about an hour or so to unwind before going to sleep. So shut off the day an hour or two before bedtime. Stop watching news shows. If you need to, write down your daily worries in a journal and close it. Then take warm bath. Drink some warm milk with honey.
  • Make your bedroom your sanctuary. This is where you get to enjoy eight hours a night of refreshing sleep.

SOURCES: Jacobs, G.D. Archives of Internal Medicine, Sept. 27, 2004; vol 164: pp 1888-1896. Gregg D. Jacobs, PhD, sleep disorders clinic, Beth Israel Deaconess Medical Center; and assistant professor of psychiatry, Harvard Medical School, Boston. Richard Simon Jr., MD, medical director, Katheryn Severyns Dement sleep disorder center, Walla Walla, Wash. Milton Kramer, MD, director of psychiatric research, Maimonides Medical Center, New York; and clinical professor of psychiatry, New York University. Max Hirskowitz, PhD, associate professor of medicine and psychiatry, Baylor College of Medicine, Houston.

 

Fritz Hershey specializes in treating insomnia with CBT.