The New York Times today had an excellent article The Evidence Points to a Better Way, which summarized what I have written about before. Cognitive behavioral therapy for chronic insomnia (CBT-I) kicks the butt of drug therapy!
One study compared CBT with a common sleeping pill called Restoril and found that the CBT treatment led to larger and longer lasting improvements in sleep. Another study found that CBT treatment outperformed the drug Ambien, and that CBT alone was even better than CBT plus Ambien combined.
Even more impressive are the results of a large meta-study which was published today. This meta-study, which combined data from 20 clinical trials and involved over 1000 patients with chronic insomnia showed that CBT I resulted in these patients falling asleep 19 minutes faster and having 26 minutes less wakefulness during each night on average. The actual study is protected by a pay wall, but the summary results are here.
One might question the clinical relevance of these outcomes. Does falling asleep 19 minutes faster really make that much of a difference? Does sleeping an extra 26 minutes a night make patients feel better the next day? As a good sleeper, I don’t really know the answer to these questions.
But I suspect that the biggest impact of CBT-I is in affecting the person’s perception of control over sleep. One of the horrible things about chronic insomnia is that patients feel out of control in terms of their sleep. They worry tremendously about the impact of loss of sleep on their ability to function the next day. It is this worry cycle that actually can create insomnia.
So I suspect that even though the effects were durable but modest, that the overall treatment made a large difference in how people felt. There is a big difference between taking 45 minutes to fall sleep and 20 minutes to fall sleep. And I suspect that sleeping an extra 26 minutes a night actually does make a difference. I know that I feel much better on eight hours of sleep as opposed to 7.5 hours of sleep.
When I work with patients on CBT-I one of the things I work on is helping the patient lower their anxiety about the impact of sleep restriction. As crazy as it sounds, one of the interventions I typically use is to have the patient stay up all night and go to work the next day. Although they are typically very tired, they discover that they can focus and function, maybe not at 100% but at an adequate level, maybe 75% or so. This lowers a lot of the anxiety about insomnia, since even a bad night of insomnia typically leads to quite a bit more sleep than staying up all night.
Other than the time and energy that a patient must invest in learning CBT-I skills, there are no side effects of cognitive behavioral therapy for insomnia. All sleeping medications have significant side effects the most troubling of which involve impaired cognition and coordination during the night and the following day. This impaired coordination and cognition leads to increased falling in the elderly, and probably also leads to an increase in automobile and other accidents. Because drug companies don’t want studies done on this issue, there are relatively few studies, but one study in Norway found that there was a doubling of traffic accidents among patients who took a variety of sleeping pills. Another study that compared 10,000 sleeping pill users to 23,000 nonusers found that the sleeping pill users were five times more likely to die young than nonusers.
So what does this mean to the person suffering insomnia? It means that you should avoid taking sleeping medications, and get cognitive behavioral therapy for insomnia. This kind of therapy typically does not take very many sessions. I teach the basic skills of CBT-I in about 4 to 6 sessions, and typically the entire course of CBT-I takes less than 10 sessions. There are also options for CBT- I online and even apps that run on your phone. One such app that runs on both android and iPhone is called CBT-I Coach. This app was developed with your tax dollars as part of a large Veterans Administration insomnia treatment program, and is excellent.
It’s getting late, so rather than have to experiment with any of these treatments, I’m off to bed…