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Therapy, not meds, should be first treatment for chronic insomnia, physician group says

Cognitive behavioral therapy (CBT-I) is recommended for insomnia; it helps people change both their beliefs and their behaviors about sleep.

Although cognitive behavioral therapy requires more time and effort than popping a pill, it has shown to be an effective treatment for chronic insomnia.

The first-line treatment for people struggling with chronic insomnia should be therapy rather than pills, according to new recommendations released Monday by the American College of Physicians (ACP).

Not just any therapy, however. The ACP recommends a specific form known as cognitive behavioral therapy for insomnia, or CBT-I, which helps people change both their beliefs and their behaviors about sleep.

Although CBT-I requires more time and effort than popping a pill, it has shown to be an effective treatment for chronic insomnia. The therapy also has none of the adverse side effects associated with prescription sleeping pills, which can include daytime drowsiness, dizziness, hallucinations and behavioral problems. 

Adverse reactions to sleeping medications send thousands of Americans to hospital emergency departments each year. 

A Minnesota-led review

The recommendations — which are guidelines for physicians — are based on an in-depth review of existing studies on CBT-I. The review was led by Michelle Brasure of the Minnesota Evidence-based Practice Center, a collaboration between the University of Minnesota and the Minnesota VA Health Care System.

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After analyzing 60 studies, Brasure and her colleagues concluded that CBT-I is an effective treatment for chronic insomnia based on almost all the sleep outcomes that were measured. They also found that CBT-I has a much lower potential for harm than medication.

CBT-I typically involves six to eight sessions in which people “are encouraged to change sleep and daytime habits, alter nonproductive sleep schedules, and modify beliefs about insomnia,” explains Dr. Roger Kathol, an adjunct psychiatry professor at the U of M in an editorial that accompanies the new guidelines and evidence review.

The therapy has been shown to resolve or lessen the symptoms of chronic insomnia in 70 percent to 80 percent of people who are treated, he adds.

CBT-I also has the advantage of helping people “develop mastery of effective sleep behaviors that they can call on if insomnia recurs,” says Kathol. “This benefit contrasts with pharmacologic interventions, in which increased doses and/or new preparations are required.”

A response to misuse

The ACP’s guidelines acknowledge that prescription and over-the-counter medications may be needed to treat insomnia, but that they should be used only if CBT-I therapy fails to help — and only for a short amount of time, usually four to five weeks.

In an interview with MedPage Today, ACP president Dr. Wayne Riley of Vanderbilt University School of Medicine in Nashville said that the new guidelines are partially in response to the pervasive problem of prescription drug misuse in the U.S.

“We are trying to get physicians to not be as trigger happy to prescribe medications when there are other effective treatments,” he said. “We know that behavioral therapy works. Many of our patients can benefit from a trial of CBT and they may not need to move on to sleep medications.”

But, as Kathol points out in his editorial, getting doctors on board with recommending CBT-I as the first-line treatment for chronic insomnia raises several challenges.

“First, some clinicians do not recognize insomnia as a health problem, often considering it merely a symptom secondary to another condition,” he writes. “Second, many clinicians and their patients harbor biases against and are reluctant to consider ‘psychological’ interventions. Third, the number of practioners trained to deliver CBT-I in the United States is limited, and most of these practitioners are not located in medical settings.”

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Kathol urges policymakers and CBT-I therapists to improve the reimbursement and delivery of the therapy in medical settings.

A major health problem

Up to 10 percent of American adults have chronic insomnia, according to the Centers for Disease Control and Prevention (CDC).

Although most people have occasional nights when falling or staying asleep eludes them, chronic insomnia is a much more insidious problem. Chronic insomnia is diagnosed when people experience difficulty sleeping for at least three nights per week for a minimum of three months, and when those difficulties cannot be linked to other sleep, medical or psychological conditions.

In addition, the effects of the insomnia — trouble concentrating, daytime sleepiness and mood changes — must be significant enough to interfere with day-to-day activities.

FMI: Both the guidelines and the review were published in the Annals of Internal Medicine. The ACP has also published a one-page summary of the guidelines for patients. You’ll find more detailed information about insomnia and its prevention and treatment on the National Heart, Lung and Blood Institute’s website and at the CDC’s “Sleep and Sleep Disorders” website.