Karl Doghramji, MD: Cognitive Behavioral Therapy in Insomnia


How does the highly recommended practice benefit patients, and where are its gaps in care?

Cognitive behavioral therapy (CBT) currently stands as the primary recommended first-line treatment for adults with insomnia. But that doesn’t mean it’s the end-all, be-all therapy for the chronic sleep condition.

In an interview with MD Magazine®, Karl Doghramji, MD, a professor at Thomas Jefferson University, explained the benefits and limitations of CBT in adults with insomnia.

These expert insights and more will be highlighted at the 1st annual International Congress on the Future of Neurology, a two-day event in Manhattan which will cover a litany of expert insights into neurology while providing attendees and opportunity to gauge and meet with practice-leading clinicians and researchers including Doghramji.

Doghramji will be moderating the “Beyond Counting Sheep: Effective Therapies for Sleep Disorders” session on the weekend of September 27-28 during the Congress.

For more information on the Congress and to register, click here. Receive 25% off registration fees with code Neuro19SI.

MD Mag: What is the recommended first-line treatment for insomnia in adults?

Doghramji: The American Academy of Family Physicians and the American College of Physicians have both recommended—as other societies have recommended—the first approach to the direct management of insomnia in older individuals should really be behavioral modification and cognitive behavioral therapy.

And this is in recognition of 2 facts. Number 1: cognitive behavioral therapy is effective, it works well and has very few side effects, and its effects are more long-lasting. That's number 1.

Number 2: We all recognize now, more and more, that pharmacotherapy can have significant side effects in the elderly who tend to be more fragile, and more vulnerable to the effects of medications. Now, that's not to say that pharmacotherapy should be avoided, however. The first approach to the direct management of insomnia really should be cognitive behavioral therapy.

So cognitive behavioral therapy has a number of advantages. Obviously, it does not introduce the metabolic and side-effect burden of medications. Number 2, it tends to have a longer acting effect—so, many months and even years after the discontinuation of cognitive behavioral therapy, we see evidence of continued death efficacy with insomnia. It still works up to 1 or 2 years after therapy has been completed, whereas this is not something which we see with hypnotic medications or sleeping pills. They stop working very quickly after discontinuing the medication.

Number 3, cognitive behavioral therapy, especially in older individuals, does not introduce many of the of the cost risks associated with medications. And cost factors are significant in older individuals.

On the other side of the equation, the disadvantages of cognitive affective behavioral therapy are that the number of therapists that are available and trained well to do the therapy are few and far between, unfortunately. And some of them don't have adequate insurance coverage.

So the other disadvantage of cognitive behavioral therapy is that it tends to not work quite as quickly as pharmacotherapy. So, if there are individuals who need rapid treatment that may be the less appropriate approach.

Finally, CBT is much more appropriate in individuals who have multiple medical conditions and have multiple drugs on board, because the data clearly show that these folks are better treated and the treatments are more effective when CBT is the choice over pharmacotherapy.

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