Sleep Disorders

09 June 2015

Behavioural therapy can improve insomnia without drugs

If you suffer from chronic insomnia but don't like the idea of using sleep medication, cognitive behavioural therapy (CBT) could be the treatment you're looking for.


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

The researchers, who reviewed previously published data, expected that cognitive behavioural 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 behavioural 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.

Read: 6 ways to prevent insomnia

5 components of CBT tested

The researchers included studies that tested at least three of the five components of cognitive behavioural 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 either 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.

Read: Tossing and turning: do you really need sleeping pills?

"Medications mask symptoms"

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 unrecognised 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 behavioural 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.

Read more:

Poor sleep linked to depression and ADHD in kids

Jawbone adjuster may help with sleep apnoea

Insomniacs may be more sensitive to pain

Image: Portrait of couple sleeping in bed from Shutterstock


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Dr Alison Bentley is a general practitioner who has consulted in sleep medicine and sleep disorders, in both adults and children of all ages, for almost 30 years. She also researches and publishes on a number of sleep-related topics both in formal research journals and lay publications including as editor of Sleep Matters, an educational newsletter on sleep disorders for doctors.

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