Self-help and cognitive behavioral therapy have been proven to be effective methods for treating chronic insomnia

f05a.jpg (5327 bytes)Insomnia, defined as difficulty in initiating, maintaining, or obtaining good quality sleep, is one of the most common complaints seen in general medical practice.1-3 Estimates of prevalence range from 9% to 20% in adulthood with an even greater percentage of individuals suffering from sleep disturbance in later life.4

Sleep is particularly sensitive to the presence of physiological or psychological disorder. Thus, secondary insomnia is often seen in tandem with a wide variety of conditions such as respiratory disorders, anxiety, or depression.5 In some cases, poor habits of sleep hygiene or sleep behaviors may become established during the course of a precipitating illness and endure after the illness has been successfully treated. At this point, many individuals are left with chronic sleep difficulties and may seek treatment from health care professionals.

According to a 1993 report to the US Congress by the National Commission on Sleep Disorders Research, insomnia is undiagnosed and untreated in an estimated 95% of cases, in part because health care professionals receive little or no training in its management. Problems may be further compounded by a lack of secondary services to which patients could be referred.

At present, benzodiazepines are the most commonly prescribed treatment for insomnia, and while studies support their short-term efficacy, they are contraindicated for use beyond 4 weeks.6 The potential side effects include dependence, tolerance, altered sleep stages, daytime hangovers, and rebound insomnia. While more recent, nonbenzodiazepine medications, such as zopiclone or zolpidem, are believed to be less harmful, their efficacy and safety over the longer term have yet to be established.7

Instead, studies suggest that the treatment of choice for chronic insomnia should be cognitive behavioral therapy (CBT).8 CBT involves identifying and changing dysfunctional beliefs and attitudes about sleep and modifying behaviors that contribute to sleep loss. A sizeable literature has developed over the years in support of this approach, with more than 50 controlled studies supporting its clinical efficacy. Meta-analyses report significant effect sizes for improvements in sleep latency (0.87), duration of wakenings (0.65), and sleep quality (0.94).9 Somewhat surprisingly, in view of these findings, the impact of CBT for insomnia on primary health care has been relatively limited.

The reasons for this may be severalfold. As previously mentioned, few primary care medical staff will have a specialist knowledge of the psychological literature on sleep disorders; even if they have an awareness, it is unlikely that they will possess the necessary depth of knowledge to implement an effective treatment program. Referral to a psychologist may also not provide a solution, since few psychologists have a special interest in sleep, and may be in short supply. Finally, there is a tendency for the doctor/patient relationship to raise the patients’ expectations of receiving medication.

In order for CBT to realize its potential as an alternative to the prescription of sleeping pills, it must be available in a format that can be implemented on a wide scale, be available rapidly at a local level, and be cost-effective. Unless these issues are addressed, CBT for insomnia may remain a paradoxical treatment—effective for many patients, yet available to few.

Providing Alternatives
One possible means of overcoming this problem is through the use of self-help treatments. Mimeault and Morin10 reported changes in sleep variables for 54 insomniacs treated through a 6-week bibliotherapy self-help program. Patients were provided with a series of six treatment books at weekly intervals. Half the patients also received a weekly, 15-minute telephone consultation with a psychologist. Improvements in total wake time and sleep efficiency were significant either with or without the minimal weekly involvement of a therapist.

Beyond Mimeault and Morin’s study, the literature on self-help is limited, and, admittedly, this approach yields slightly lower improvements than those seen with a therapist-led approach.9 However, for straightforward cases, without complicating factors, and where the insomnia does not appear to be intractable, bibliotherapy appears to be a promising avenue for exploration.

For those patients with more complex difficulties, or for whom insomnia has been intractable for many years, a therapist-led treatment may be the only solution. The difficulty with this solution, as previously stated, is finding the therapists to treat the patients. However, more widespread training of primary health care staff, with psychological backup available on a consultancy basis, may provide a solution to this shortage.

The Sleep Clinic
In 2001, Espie et al11 published the results of a large-scale controlled study investigating the efficacy of such an approach. In their study, health visitors (trained primary care nurses who deal mainly with health issues in the community) administered a 6-week sleep clinic program of CBT for chronic insomnia.

Therapist training for the sleep clinic took the form of 2 days of intensive instruction with several health visitors in each cohort. Following this training, therapists had the opportunity to serve an apprenticeship by becoming participant observers in ongoing treatments before taking responsibility for their own patients.

The CBT treatment was administered to small groups (of up to six patients) attending six 50-minute sessions, thus requiring an average of around 1 hour of health visitor time per patient. The therapy delivered by the health visitors was highly manualized and took a didactic approach to treatment.

In total, 139 patients from the southwest area of Scotland were recruited and treated. Participants were selected on the basis of having severe and long-standing sleep problems, and were recruited via general practitioners as consecutive presentations at surgery or from repeat prescription lists. Patients were randomly assigned to either a CBT group, or a waiting list control.

After 12 months, CBT patients showed significant, maintained improvements in self-report measurements of sleep quality including reduced sleep onset latency and wakefulness during the night and increased total sleep time. Reductions in sleeplessness for the average patient were substantial, amounting to 60 minutes per night, and two-thirds of our patients were clinically improved, no longer meeting criteria for a sleep disorder, and sleeping within normal limits. Of the 59 patients initially on hypnotics, 50 (84%) had successfully withdrawn at the 1-year follow-up. Of particular note is the lack of contraindications with this treatment program. Patients responded equally well, regardless of medication status or demographic profile prior to entry into treatment.12

The findings of this study are important on several levels. First, it demonstrates that a fairly rapid training program, in combination with a manualized program and minimal psychologist backup, may enable health care professionals (without previous psychological training) to provide effective treatment for insomnia. Furthermore, the successful use of a group format further reinforces its application as a cost-effective remedy.

Session 1. Sleep and insomnia: general information.
Aim: To learn about normal sleep processes and about sleep disorders.
    •      Understand the need for sleep and its functions;
    •     Understand sleep pattern and how it varies during the lifetime;
    •     Understand sleep as a process with stages and phases;
    •     Understand factors that adversely affect sleep pattern and sleep quality;
    •     Understand the effects of sleep loss;
    •     Understand the concept of insomnia and how it can be measured;
    •     Understand personal sleep histories and patterns in the above context;
    •     Begin to correct previous misunderstandings about sleep and
Session 2. Sleep hygiene and relaxation.
Aim: To introduce practical steps toward developing a healthy sleep pattern without recourse to drugs.
    •      Review progress so far and maintain treatment goals;
    •     Create a bedroom environment that is comfortable for sleep;
    •     Take regular exercise that promotes fitness and enhances sleep;
    •     Develop a stable and appropriate diet;
    •     Reduce the undesirable effects of caffeine on sleep;
    •     Moderate alcohol consumption and eliminate “nightcaps”;
    •     Support people to reduce use of and stop taking sleeping pills;
    •     Design individualized reduction programs; and
    •     Learn relaxation skills to apply in bed.
Session 3. Sleep scheduling.
Aim: To reshape sleep patterns to correspond with individual sleep needs and to strengthen sleep rhythms.
    •      Review progress so far and maintain treatment goals;
    •     Develop a good presleep routine;
    •     Define parameters for the individual’s sleep period;
    •     Increase sleep efficiency through scheduling sleep in relation to needs;
    •     Distance waking activities from the bedroom environment;
    •     Eliminate daytime napping;
    •     Establish a stable night-to-night sleep pattern; and
    •     Encourage and support people in changing their sleep routines.
Session 4. Dealing with thoughts and worries.
Aim: To learn ways of reducing the mental alertness, repetitive thoughts, and anxiety that interfere with sleep.
    •      Review progress so far and maintain treatment goals;
    •     Identify thought patterns that interfere with sleep;
    •     Develop accurate beliefs and attitudes about sleep;
    •     Prepare mentally for bed by putting the day to rest;
    •     Learn thought distraction and imagery techniques;
    •    Reduce efforts to control sleep and allow it to happen naturally;
    •     Utilize these techniques to combat intrusive thoughts
    •     Encourage and support people in changing their mental approach.
Session 5. Developing a strong and natural sleep pattern.
Aim: To integrate advice from previous sessions and to maintain implementation at home.
    •      Review progress so far;
    •     Systematically rehearse the elements of the sleep clinic program;
    •     Address implementation problems experienced;
    •     Plan further adjustments to the sleep period to maintain sleep efficiency;
    •     Encourage and support people in maintaining their new sleep routines
           and their mental approach; and
    •     Learn relapse prevention approaches if a sleep problem recurs.
Table 1. Contents of the sleep clinic’s treatment sessions.

The Second Sleep Clinic
A randomized-controlled trial is currently under way at the University of Glasgow to examine the implementation of the sleep clinic on a wider scale. The number of treatment sessions have been reduced to five (Table 1), and various different grades of primary care nurses are being trained. An objective measure of sleep change (by means of wrist actigraphy) in patients is being taken, in addition to the traditional, subjective measures. Formal evaluation of the health/economic cost of the sleep clinic is also being made in order to explore whether this approach will incur any additional costs to health care providers. By this approach, we seek to answer whether nurse-delivered CBT for insomnia will provide the solution to the paradox of an effective treatment that is unavailable to patients.

At present, the evidence suggests that by far, the most effective treatment for chronic insomnia is CBT. The difficulty comes in actually delivering this treatment to patients. Health care staff may not be trained in sleep disorders, and furthermore, the resources for onward referral of patients, such as clinical psychologists trained in CBT for insomnia, may not even be present. As such, it appears that examining other methods for delivering this treatment to patients is appropriate.

At present, self-help treatment appears to be a promising direction, although the literature on this area is small and may be suitable only for the relatively straightforward cases of insomnia that present. Another alternative means is the training of primary care nurses in CBT for insomnia. From the large-scale trial conducted in Scotland, this appears to be an effective solution. The trial currently under way in our department will add evidence to this case, and evaluate, more fully, the economic impact of implementing the sleep clinic in primary care.

Kenneth M.A. MacMahon, MA, PhD, is a research fellow working on CBT for insomnia in the Department of Psychological Medicine; and Colin A. Espie, MA, PhD, is professor of clinical psychology and head of the Department of Psychological Medicine, both at the University of Glasgow, Scotland.

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