A Look at Cognitive Behavioral Therapy for Insomnia in Patients With Other Medical Conditions

Insomnia is a condition marked by difficulty getting to sleep and staying asleep[1] for the needed seven to nine hours per night that are recommended for most adults.[2] Chronic insomnia is characterized by at least three months with three or more days per week of such sleep disturbance.[3]

Although there are many tranquilizers and sleeping pills approved for insomnia, they carry the substantial risk of serious adverse effects including dependence (physical need for higher doses), daytime sedation, confusion, memory loss, impaired learning and death.[4] Accordingly, Public Citizen’s Health Research Group recommends against use of all these drugs in most situations, especially for older adults. These drugs include the heavily marketed nonbenzodiazepine “Z drugs” eszopiclone (LUNESTA), zaleplon (SONATA) and zolpidem (AMBIEN, EDLUAR, ZOLPIMIST), all of which we have designated as Do Not Use.[5]

Nondrug treatments for insomnia include lifestyle interventions, such as avoiding caffeine intake later in the day, avoiding screen time and large meals before bedtime, and various relaxation techniques,[6] but if such strategies are not successful then more formal psychotherapies (talk or behavioral therapies) may be useful.

New research described below examined a specific form of nondrug psychological therapy referred to as cognitive behavioral therapy for insomnia (CBT-I). The results show that CBT-I was only slightly better than other non-drug treatments for chronic insomnia in patients with other major physical or mental disorders.

New study

The new study was a meta-analysis (analysis of multiple prior studies) published in the December 2020 issue of Psychiatric Quarterly. It examined randomized clinical trials that compared CBT-I with other non-drug interventions.[7] Previous meta-analyses have shown that insomnia not associated with physical or psychiatric conditions responds well to CBT-I; thus, this treatment is currently recommended by the American Academy of Sleep Medicine and by other experts as a first-line insomnia therapy.[8]

The Psychiatric Quarterly meta-analysis represents scientific advancement in three ways: (1) focusing on patients diagnosed with physical (for example, cancer) or psychiatric (for example, depression) disorders besides insomnia, (2) relying upon standardized definitions of insomnia and (3) assessing only randomized clinical trials. The focus on patients with other physical or psychiatric disorders is important because such illnesses increase overall health risks and because sleep disorders may cause other maladies, or other maladies may spark sleep problems.

This meta-analysis pooled data from 13 relevant clinical trials identified by a systematic literature search. Seven trials were conducted in the U.S., and the rest in Canada, Sweden or Spain.

Overall, those studies included 441 CBT-I subjects and 412 control subjects. The mean age of the subjects was 51 years, and 78% were women. The trials included patients with the following conditions: depression/anxiety or bipolar (four trials), migraines (one trial), cancer (four trials), knee osteoarthritis (one trial) and fibromyalgia, a chronic disorder characterized by widespread musculoskeletal pain, fatigue and localized areas of tenderness (three trials).

Treatment frequency varied from weekly to every other week and the total number of therapy sessions ranged from three to 12. Control treatments were: brief check-in calls (one trial), Tai Chi (one trial), lifestyle modifications (one trial), behavioral desensitization (one trial), relaxation training (one trial), psychoeducation (two trials), mindfulness-based cancer recovery or stress reduction (two trials) and sleep hygiene (four trials). These control treatments differentially overlap with the five cores of full CBT-I: stimulus control (adjusting external factors, such as lighting, that impede or promote quality sleep), sleep restriction (time rules for when to sleep — avoiding naps, excessive variation and lying awake), sleep hygiene (developing diet, exercise and bedroom strategies that encourage quality sleep), relaxation training (such as breathing exercises) and cognitive restructuring (replacing dysfunctional thoughts about sleep with useful ones).[9]

The primary endpoint of the meta-analysis was three-month follow-up of insomnia symptoms assessed using standardized measurement instruments. Overall, CBT-I performed better than other non-drug therapies. Specifically, measures of sleep efficiency, time to fall asleep, waking up in middle of the night, sleep quality and combination scores of these measures all significantly favored CBT-I. However, the effects were generally small. For example, compared with control therapy subjects, scores for subjects receiving CBT-I showed an average improvement of 0.74 on a 28-point Insomnia Severity Index scale (which ranges from 0 for extremely satisfied with sleep to 28 for not at all satisfied),[10] so the clinical improvement was evident but small in magnitude.

The authors of this new meta-analysis concluded that CBT-I generally was more effective for treating insomnia than the control therapies tested in patients with other medical or psychiatric disorders. However, the differences were very small; thus, for most insomnia patients with other medical conditions, other simpler non-drug therapeutic approaches to improve sleep hygiene are likely the best and least expensive approach.

Finally, a preference for CBT-I or other behavioral therapies over medication as first-line insomnia therapy has been endorsed in the clinical practice guidelines of the American Academy of Sleep Medicine,[11],[12] the British Association for Psychopharmacology,[13] the American College of Physicians[14] and the European Sleep Research Society.[15]

What You Can Do

Do not take sleeping pills, including nonbenzodiazepine hypnotics and other tranquilizers, as a remedy for insomnia as they often do not yield quality rest and also have dangerous adverse effects including dependence, cognitive impairment and overdose. If you are currently taking any such drug, work with your doctor to create a schedule to stop it gradually to avoid withdrawal reactions.

To manage sleep problems, take steps to improve your sleep hygiene practices, including avoiding caffeine-containing products, nicotine or alcohol (especially later in the day); avoiding heavy meals within two hours of bedtime; and creating an atmosphere conducive to sleep, such as using earplugs to block out noise and sleeping in a dark room. If your insomnia persists after implementing these steps, talk to your doctor about a trial of CBT-I or some type of related behavioral therapy.

It is important to consult a health care professional about any medical condition that may be contributing to your insomnia.
 

References

[1] National Heart, Lung, and Blood Institute, National Institutes of Health. Insomnia. https://www.nhlbi.nih.gov/health-topics/insomnia. Accessed March 10, 2021.

[2] National Institute of Neurologic Disorders and Stroke. National Institutes of Health. Brain basics: Understanding sleep. Last modified August 13, 2019. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep. Accessed March 10, 2021.

[3] National Heart Lung and Blood Institute, National Institutes of Health. Insomnia. https://www.nhlbi.nih.gov/health-topics/insomnia. Accessed March 10, 2021.

[4] Worst Pills Best Pills News. Sleeping pills and tranquilizers. November 5, 2004. https://www.worstpills.org/chapters/view/20. Accessed March 10, 2021.

[5] Winkelman JW. Overview of the treatment of insomnia in adults. UpToDate. January 25, 2021.

[6] Worst Pills Best Pills News. Sleeping pills and tranquilizers. November 5, 2004. https://www.worstpills.org/chapters/view/20. Accessed March 10, 2021.

[7] Zhou FC, Yang Y, Wang YY, et al. Cognitive behavioural therapy for insomnia monotherapy in patients with medical or psychiatric comorbidities: a meta-analysis of randomized controlled trials. Psychiatr Q. 2020;91(4):1209-1224.

[8] Qaseem A, Kansagara D, Forciea MA, et al. Clinical guidelines committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125-33.

[9] Newsom R, Dimitriu A. Cognitive behavioral therapy for insomnia (CBT-I). https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia. Accessed March 10, 2021.

[10] Taylor DJ, Peterson AL, Pruiksma KE, et al. Internet and in-person cognitive behavioral therapy for insomnia in military personnel: a randomized clinical trial. Sleep. 2017;:40(6). doi: 10.1093/sleep/zsx075.

[11] Edinger JD, Arnedt JT, Bertisch SM et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021; 17(2):255-262.

[12] Sateia MJ, Buysse DJ, Drystal AD et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017; 13(2):307-349.

[13] Wilson S, Anderson K, Baldwin Det al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol. 2019;33(8):923-947.

[14] Qaseem A, Kansagara D, Forciea, et al. Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125-133.]

[15] Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26(6):675-700.