Sleep Disorders

03 May 2016

Insomnia: therapy preferable to medication

People with long-term sleep troubles should turn to cognitive behavioural therapy to reboot normal sleeping patterns before trying sleeping pills, the American College of Physicians recommends.

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Specifically, people with chronic insomnia should try cognitive behavioural therapy (CBT), the experts said. This treatment combines talk therapy, behavioural interventions and education.

Insomnia takes its toll

If CBT doesn't work, patients and their doctors should then decide together whether to add drug therapy, the new guidelines said.

"We know chronic insomnia is a real problem that patients present within our [doctors'] offices," said Dr Wayne Riley, president of the American College of Physicians (ACP). "We want to get away from the overtendency to prescribe sleep medications, and clearly CBT can be a very nice tool in the toolkit."

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

Up to 10 percent of adults are affected by insomnia, defined as having trouble falling or staying asleep, the guideline authors said. More common in women and older adults, the condition can produce fatigue, poor thinking and mood disturbance, and takes a toll on workplace productivity, according to the college.

In issuing its first practice guideline on chronic insomnia treatment, the ACP didn't find enough evidence to directly compare behavioural therapy and drug treatment.

But the group incorporated a review of published research indicating behavioural therapy is effective and can be initiated in a primary care setting.

Behavioural factors

Before recommending behavioural therapy to patients, doctors should rule out medical conditions that can cause insomnia – including obstructive sleep apnoea, restless legs syndrome and prostate gland enlargement – and counsel patients on behavioural factors that can contribute to poor sleep, such as heavy alcohol use, Riley said.

Read: Sleepless nights may fuel daytime Facebook binges       

Dr Nathaniel Watson, president of the American Academy of Sleep Medicine, said that "the major advantage of CBT is it has long-lasting effects and teaches patients how to manage their insomnia symptoms and difficulties". Watson wasn't involved in crafting the new guidelines.

"It empowers patients to tackle their insomnia," Watson added. "And since there is no medication involved, you can avoid the cost and potential side effects of medications long-term."

The U.S. Food and Drug Administration has approved drugs such as Valium (diazepam), Ambien (zolpidem), Lunesta (eszopiclone) and Belsomra (suvorexant) for short-term use, around four to five weeks.

FDA labelling also indicates that patients whose insomnia doesn't get better within seven to 10 days after taking medications should be re-evaluated by their doctors.

Read: Insomniacs may be more sensitive to pain

Riley said, "We looked at the issue very broadly; we don't say don't use a medication, we say, give your patient a trial... and if they come back still having problems sleeping, maybe add short-term use of a medication.

"We try to counsel against using [medication] longer than 10 to 14 days because we know dependence can be an issue."

Inexpensive apps

Other prescription sleeping pill side effects include next-day drowsiness; "complex sleep behaviours", such as driving or eating while asleep; and allergic reactions, according to the FDA.

Cognitive behavioural therapy for insomnia is typically administered by physicians or psychologists trained in this type of psychotherapy, Riley said. Between four and six sessions of behavioural therapy are typically needed to improve insomnia, he said. Most health insurers cover the treatment, with an out-of-pocket cost of $45 (R640) to $100 (R1,423) per session if there's no coverage, he added.

Comparatively, prescription sleep medications typically cost $50 (R711)  to $100 (R1,423) for one month's supply, Riley noted.

Watson said that inexpensive apps are also available online to help with sleep, including Sleepio and ShutEye.

Read: Children can suffer from insomnia too

Watson explained that behavioural therapy for insomnia typically addresses sleep hygiene issues, such as changing light levels, temperature and other parts of the person's sleep environment, as well as personal habits including reducing screen time before bed.

Low sleep IQ

Patients are also taught realistic sleep expectations, he added. "Everyone has a bad night of sleep now and again. It's part of life," Watson said.

"I think right now in this country we have a low sleep IQ and it's a problem," he said. "I would encourage people to prioritise sleep in their lives, including creating a better sleep environment.

The bedroom should be reserved for the three S's – sleep, sex and sickness. And parents should model a good sleep environment, including [promoting] consistent bedtimes and wake times on weekdays and weekends."

The new guidelines were released online in the Annals of Internal Medicine.

Read more:

What are sleep disorders?

Symptoms of sleep disorders

Managing sleep disorders

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Sleep disorders expert

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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