Research findings indicate that cognitive behavioral therapy for insomnia can be as effective as drug therapy and offering it to patients is easier than some may think.

It seems a week does not go by lately
when there is not an article in a health magazine or a news piece about how “changing your behavior” may help you sleep better.1 Cognitive behavioral therapy for insomnia (CBT-I), a therapy that works with patients to modify their behavior and thinking related to sleep, appears to be going mainstream. The challenge is that someone with insomnia who learns about CBT-I from the media and pursues treatment with a primary care physician may still be sent home with a prescription instead of receiving CBT-I because few clinicians in primary care settings have the knowledge, expertise, or time to deliver the therapy effectively. The purpose of this article is to provide a snapshot of what CBT-I is all about, who it is appropriate for, why it is effective, and how you and your staff can begin to utilize this therapy effectively.

What we know so far
There is now overwhelming evidence that CBT-I is an effective treatment with longevity when practiced properly. To date, four meta-analyses2-5 and two systematic reviews6,7 have confirmed that CBT-I is a clinically effective treatment for insomnia. It is as effective as medications in the short term5 and sleep improvements are maintained over time. While many patients do not become normal sleepers following treatment, most can expect at least a 50% improvement in their insomnia symptoms. Thus, patients who begin treatment taking on average 60 minutes to fall asleep can expect to be falling asleep consistently within 30 minutes by the end of treatment. Patients’ subjective reports of improvement are confirmed by objective polysomnography, although the magnitude of improvement is typically smaller.6 

For whom is CBT-I most appropriate?
Before the essential ingredients of the therapy are discussed, it is important to consider for whom this treatment is best suited. Generally, patients with persistent difficulties falling asleep, staying asleep, and/or poor quality sleep that cause distress and daytime impairments for longer than 1 month are candidates. More specifically, these patients typically report staying in bed for long periods of time to compensate for sleep loss, feeling aroused in bed, engaging in activities in the bedroom unrelated to sleeping, and worrying excessively about their sleep.

CBT-I should not be limited to patients with “primary insomnia,” insomnia that is not caused by another disorder. It has also been shown to be effective for patients who have comorbid insomnia. For example, CBT-I is effective in treating insomnia related to cancer,8,9 chronic pain,10,11 major depression,12 and, more recently, alcohol dependence.13,14 Overall, CBT-I is most effective for chronic insomnia patients with a “heightened sense of arousal” and for those with “learned sleep preventing associations.”15

CBT-I is not appropriate for every patient. For best results, patients should be willing to invest time and energy into changing their sleep habits and thoughts over several weeks. Some patients may prefer instead to try hypnotic medications for their sleep problems. In these cases, patients should discuss appropriate medication options with their doctors.

Why does CBT-I work?
 CBT-I is a package deal. It is made up of several components that are designed specifically to address the factors that maintain insomnia over time. While we do not know the exact mechanisms involved, treatment targets four major factors: maladaptive behaviors around sleep, excessive worry and concern about insomnia and its consequences, lifestyle and environmental factors that exacerbate nighttime sleep problems, and heightened somatic and/or cognitive arousal (eg, increased physical tension or racing mind in bed).16 Some components of CBT-I can be emphasized more than others to address the chief complaints of a particular patient. More scientific studies are required to determine the therapeutically active ingredients of the multicomponent CBT-I and which combination of ingredients optimizes treatment.

CBT-I’s Main Ingredients
The primary components of CBT-I include a combination of behavioral techniques (stimulus control, sleep restriction, relaxation) combined with sleep hygiene education and cognitive therapy.

Stimulus Control: Introduced in the late 1970s, the primary goals of stimulus control therapy for insomnia17 (SCT) are to help the insomnia patient establish a consistent sleep-wake rhythm, reestablish the bed and bedroom as cues for sleep and sleepiness, and reduce their association with sleep-incompatible activities. There are six primary instructions in SCT that the patient is told to follow on a nightly basis. These instructions are recommended as a first-line treatment in CBT-I.18

1. Lie down intending to go to sleep only when you are sleepy.

2. Do not use the bed for anything except sleep; that is, do not read, watch TV, eat, or worry in bed. Sexual activity is the only exception to this rule. On such occasions, the instructions are to be followed afterward when you intend to go to sleep.

3. If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish and then return to the bedroom to sleep. If you are in bed for more than about 10 minutes without falling asleep and have not gotten up, you are not following this instruction.

4. If you still cannot fall asleep, repeat Step 3. Do this as often as necessary throughout the night.

5. Set your alarm and get up at the same time every morning irrespective of how much sleep you got during the night.

6. Do not nap during the day.

Sleep Restriction: Sleep restriction therapy (SRT) is based on the clinical observation that insomnia patients spend excessive amounts of time in bed to compensate for sleep loss.19 The therapy is designed to have patients limit the amount of time they spend in bed to approximate the amount that they are actually sleeping, as ascertained by baseline sleep logs.

The major goal of this strategy is to build the “drive for sleep” by restricting sleep to shorter periods of time spent in bed and by prohibiting sleep at times outside of this restricted sleep schedule. For example, if a patient reports spending 8 hours in bed every night on his or her baseline sleep log, but sleeps only an average of 6 hours, the prescribed sleep time will be 6 hours. The clinician and patient negotiate a wake time and time in bed (sometimes called the “sleep window”) that the patient maintains 7 days per week until sleep quality improves. When sleep becomes more consolidated, the sleep window is gradually extended, until a sleep/wake schedule that optimizes daytime alertness is achieved.19

Relaxation Therapy: Relaxation therapy (RT) is considered a second-line intervention for insomnia. Patients who “cannot relax” or who report feeling too “keyed up” to sleep may respond well to RT. There are several types of RT, including progressive muscle relaxation, diaphragmatic breathing, autogenic training, guided imagery, and biofeedback. Patients with pre-bedtime anxiety or who report mind-racing in bed may benefit more from guided imagery whereas patients who are physically tense in bed may benefit from muscle relaxation or breathing exercises. Relaxation training is often used in conjunction with other CBT-I behavioral components and may be particularly effective for sleep onset problems.16

Sleep Hygiene Education: Most people have already had some sleep hygiene (SH) education through news stories and magazine articles, but may not have known it was “sleep hygiene” that they were reading about. SH education is a set of guidelines about health practices and environmental considerations that can either help or hurt the quality and quantity of sleep.

Some examples of sleep hygiene education are:

• Eat regular meals and don’t go to bed hungry.
• Cut down on caffeine products and alcohol in the evening.
• Exercise regularly.
• Keep a dark, cool, and quiet bed room environment.

SH is recommended as part of a comprehensive treatment approach. It is considered a second-line intervention21 because there are insufficient data supporting its use as a stand-alone treatment for insomnia. Changing only one or a few habits (eg, stopping caffeine intake), is unlikely to help in resolving insomnia.22-25 SH should be practiced in conjunction with other strategies like SCT and RT. Poor sleep hygiene is rarely the primary initial cause of insomnia, but it may play a big role in perpetuating it and may even increase the likelihood of insomnia relapse. To be most effective, patients must adhere to as many good sleep hygiene practices as possible over the long term.26

Cognitive Therapy: Cognitive therapy for insomnia alters dysfunctional beliefs about sleep that perpetuate insomnia and helps patients to develop realistic expectations about their sleep.16 The best candidates are those patients who worry about how much sleep they need (eg, “I need 8 hours!”), the consequences of their insomnia (eg, “without adequate sleep, I can barely function next day!”), the predictability of their sleep (“I’m losing control of my sleep!”), or strategies used to promote sleep (“I should stay in bed and try harder to fall asleep”). Recent studies also suggest that, similar to the beliefs found in depressed or anxious patients, insomnia patients often have a sense of hopelessness (“there is little chance of getting better”) and helplessness (“there’s nothing I can do”).27 These negative beliefs and thoughts about sleep, especially those that are self-focused,28 are capable of compromising daytime functioning.29 Cognitive therapy is considered integral to a comprehensive treatment for chronic insomnia.20,30,31

Adjunctive Treatments
In addition to the primary components of CBT-I, patients often require adjunctive treatments to address other factors that may be contributing to their insomnia. For example, patients whose primary insomnia symptoms are related either to difficulties falling asleep or to waking too early in the morning may have an internal body clock that is misaligned relative to the external environment. In extreme cases, a circadian rhythm disorder may develop and present as the primary condition; other times, there may be more subtle signs of delay or advance that may respond to adjunctive treatments. These issues can be addressed by using strategies that can help to reset the body’s internal clock, such as appropriately timed light therapy or over-the-counter melatonin.

How to Implement CBT-I
CBT-I can be done individually or in a group setting, or the clinician can provide telephone consultations.32 Studies show that on average, clinicians (mostly psychologists or psychology trainees) conduct six consultation sessions over about 7 weeks.6 However, CBT-I is not a one-size-fits-all approach. Some patients may require only one or two consultation sessions; others may need significantly more. While most of the data on the effects of CBT-I collected to date has been on individual treatment,6 group and phone consultations have been shown to be equally effective.33 Internet-based and self-help CBT-I manuals have been developed to disseminate the treatment more widely, but more well-controlled studies are needed to evaluate their efficacy.34 Many health insurance companies reimburse for CBT-I under either medical or mental health benefits, although reimbursement rates vary widely between carriers.

Who should implement treatment?
Psychologists with knowledge, skills, and training in sleep medicine combined with experience in behavioral therapy are the most appropriate health care professionals to deliver CBT-I. Experience in sleep disorders medicine is important for detecting symptoms relating to other occult sleep pathology. However, CBT-I has now been effectively delivered by primary care physicians35 and nurse practitioners in general medical practice, who are frequently the front-line providers of care in busy primary care practices.36 The American Academy of Sleep Medicine offers the Behavioral Sleep Medicine certification examination, which is open to clinicians with a PhD, MD, DO, or PsyD in a health-related field. More information about eligibility and the examination can be found at www.aasmnet.org/BSME.aspx.

In summary, CBT-I is an empirically based treatment that has both short- and long-term benefits. The treatment focuses on changing behaviors and thinking related to sleep that have played a role in perpetuating the insomnia. The limitations of this therapy include the lack of availability to some patients and the time, effort, and cost to the patient. Given its time-restricted nature, however, CBT-I may be a more economical insomnia treatment than hypnotic medications over the long term. It is important that health care professionals on the front lines of patient care communicate the main points outlined in this article to their insomnia patients and, if available, refer them to a behavioral sleep medicine specialist in their area.

Deirdre A. Conroy, PhD, DABSM, is a research fellow for the University of Michigan’s Addiction Research Center (UMARC) in Ann Arbor. J. Todd Arnedt, PhD, CBSM, is a clinical assistant professor of psychiatry and neurology at the University of Michigan. Their research is supported by the National Institute on Alcohol Abuse and Alcoholism.

References
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