CBT-I Benefits Go Beyond the ‘I’

Cognitive behavioral therapy has long been used to treat insomnia (CBT-I). Typically, patients are instructed to not just change sleep habits and scheduling, but their misconceptions about sleep and insomnia that in and of themselves can perpetuate sleep difficulties.

CBT-I can be a lot of work, but it is safe and quite effective, getting to the underlying issues at the root of the insomnia rather than attempting to bombard it away with hypnotic drugs.

And now, a recent meta-analysis finds that CBT-I in patients also suffering from psychiatric or other medical conditions can alleviate these conditions as well.

The results are surprising because sleeplessness occurring in conjunction with medical or psychiatric conditions is already much harder to treat. A non-drug intervention would need to be a powerful one indeed, but it looks as though CBT-I is just that.

When these so-called “comorbid” factors exist, the key to treating the insomnia is to improve the underlying conditions, which often requires pain medications or psychiatric drugs, depending on the condition. The fact that drug-free cognitive behavior modification—that is, a change in thinking—can significantly treat these problems as well is very good news.

In the meta-analysis, researchers examined 37 randomized clinical trials that tested two to 10 sessions of CBT-I against a range of control or comparison conditions in 2,189 patients with comorbid medical and psychiatric conditions. CBT-I is a treatment package including a range of interventions such as stimulus control, sleep restriction, sleep hygiene, and of course the essential “cognitive restructuring” that makes any CBT what it truly is.

The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep. For instance, this may include learning how to control or eliminate negative thoughts and worries that keep you awake. The behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.

Here are what some of the additional therapies look like in more detail:

Stimulus control therapy. This method helps remove factors that condition the mind to resist sleep. Patients are coached to set a consistent bedtime and wake time and avoid naps, use the bed only for sleep, and leave the bedroom if you can't go to sleep within 20 minutes.

Sleep restriction. Lying in bed when you're awake can become a habit that leads to poor sleep. This treatment decreases the time you spend in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased.

Sleep hygiene. This addresses basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise.

Sleep environment improvement. This offers ways that you can create a comfortable sleep environment, such as keeping your bedroom quiet, dark and cool, not having a TV in the bedroom, turning off all phone and tablet screens, and hiding the clock from view.

Relaxation training. To calm your mind and body, meditation, imagery, and muscle relaxation techniques may be deployed.

Remaining passively awake. Worrying that you can't sleep can actually keep you awake, therefore letting go of this worry by actually avoiding any effort to fall asleep can help you relax and make it easier.

Biofeedback. This method allows you to observe biological signs such as heart rate and muscle tension and shows you how to adjust them. You may take a biofeedback device home to record your daily patterns to then use the information to identify the patterns that are affecting your sleep.

In the studies, patients who received CBT-I showed significantly greater beneficial effects on subjectively reported onset of sleep (latency), sleep efficiency, waking time, and sleep quality. In the 22 studies with validated global sleep questionnaires, CBT-I patients achieved higher rates of remission from insomnia as well (36% vs. 17%).

Even better, the presence of comorbid conditions did not affect outcomes—these conditions also improved, with greater effects on psychiatric conditions, including depression, PTSD, and alcoholism. Data from 13 of the studies showed continued benefits on sleep quality and efficiency for up to a year.

Sleep disorders affect roughly 60 million Americans each year, disproportionately women and people over 65. Rather than have over a fifth of the population taking sleep aids, doctors would do well to treat patients with CBT-I. Knowing that this cost-effective, side-effect-free, and potentially long-lasting approach can improve many underlying psychiatric and/or physical conditions too makes it even harder to argue against. 

NEJM Journal Watch, July, 2015, http://tinyurl.com/NEJM-JW-CBT-I

National Sleep Foundation, http://sleepfoundation.org/sleep-news/cognitive-behavioral-therapy-insomnia

Mayo Clinic, http://www.mayoclinic.org/diseases-conditions/insomnia/in-depth/insomnia-treatment/art-20046677

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