Behavioral therapy can improve insomnia without drugs

A new study confirms that cognitive behavioral therapy is an effective option for chronic insomnia, researchers say.

The researchers, who reviewed previously published data, expected that cognitive behavioral therapy (CBT) would be highly effective, said James M. Trauer of the Melbourne Sleep Disorders Centre in Australia, who led the new analysis.

“What surprises us is that there isn't more awareness of this treatment's effectiveness and that there haven't been more attempts to make the treatment more available to patients,” Trauer told Reuters Health by email.

For the review, researchers considered 20 randomized, controlled trials of face-to-face behavioral therapy assessing its effects on overnight sleep for people with chronic insomnia not caused by an underlying medical condition.

Up to 15 percent of people have trouble falling asleep or staying asleep and meet the diagnostic criteria for chronic insomnia, the researchers write, which often also includes impairment of daytime thinking, mood or performance.

The researchers included studies that tested at least three of the five components of cognitive behavioral therapy, including (1) working with a therapist to identify and replace dysfunctional attitudes about sleep, like unrealistic expectations or fear of missing out, (2) instruction in sleep hygiene, (3) limiting time in bed to that spent actually sleeping, (4) controlling sleep stimuli, and (5) relaxation techniques like mindfulness or meditation.

Overall, the 20 studies included more than 1,000 patients. All the studies compared cognitive therapy groups to a waiting list, an ‘education-only’ group, a sham therapy group or a group receiving placebo pills.

On average, people in the therapy groups reduced the time it takes to fall asleep by 19 minutes after treatment, spent 26 fewer minutes waking up in the night and slept for about seven more minutes per night, the researchers reported in the Annals of Internal Medicine.

This validates existing recommendations that CBT should be the first treatment option for chronic insomnia, Trauer said.

“Medications are associated with side effects and also the risk of tolerance,” he said.

“These are important drawbacks, but the biggest problem with medications is that they don't get to the core of the problem,” he said. “Psychological treatments aim to understand what is driving the insomnia and reverse these processes, while medications just mask the symptoms.”

The review did not assess more important outcomes, like fatigue, psychological distress and quality of life, Charles M. Morin of Universite Laval in Quebec, Canada, noted in an editorial.

He writes that “a major gap exists between the current state of the science and actual clinical practice.”

Insomnia is often unrecognized and untreated, and when it is treated, it is often with over-the-counter products with unknown risks and benefits or prescription medications with known side effects, Morin writes. “Cognitive behavioral therapy is relatively unfamiliar to and underused by medical practitioners.”

CBT should be appropriate for most people with chronic insomnia, as long as they accept that some hard work is required, but it is not available to all patients, Trauer said.

“Although we do need to train more therapists to be able to deliver the treatment, even this is unlikely to be sufficient to meet the demand, given that around 10 percent of the population (has) chronic insomnia,” he said.

Internet-based treatment and group-based formats may give patients more access to CBT for insomnia, which needs to be tailored to the individual, he said.