Considering Cognitive Behavioral Therapy for Insomnia


Expert perspectives on the benefits of and limitations to cognitive behavioral therapy for insomnia.


Michael J. Thorpy, MD:Sleep hygiene is just 1 of many treatment options. The American Academy of Sleep Medicine and other organizations have produced guidelines for how we should treat insomniacs. Nate, would you like to talk a little bit about what the recommendations are from these professional organizations about treatment of insomnia?

Nathaniel Fletcher Watson, MD: Definitely. When you look at these guidelines, the No. 1 thing that jumps out from both the American College of Physicians and the American Academy of Sleep Medicine is called cognitive behavioral therapy for insomnia [CBT-I], which is something that occurs over a number of visits, typically with a trained psychologist to help people understand their insomnia. Then it gives them tools for how to address their insomnia without need of medications, and there’s good evidence that this works as well if not better than medications long term for people with insomnia.

Sometimes, people will associate their bedroom environment with not sleeping because they’re having insomnia while they’re in bed. [CBT-I will have] people get out of bed go to a different part of their house, don’t turn on the lights, do something that makes them drowsy. When they get sleepy again, go to bed and repeat that as many times as they need to until they’re able to fall asleep. But don’t linger in bed awake because then they begin to associate the bed in the bedroom with not sleeping. You’ll see these folks go on vacation, go to a hotel, and sleep great because they’re not seeing all the typical cues that tell them that insomnia is going to be imminent. It’s a great treatment but from a practical perspective, it has a lot of problems, and 1 of them is access.

As far as board-certified sleep doctors in the country, we have about 1 for every 45,000 individuals. There are even fewer trained psychologists who do CBT-I. Even though it’s the No. 1 recommendation, access is a huge problem. Most sleep medicine expertise is concentrated in urban areas. We have vast swaths of the country that have little to no sleep medicine expertise from a specialty perspective, so we have that as our No. 1 thing. But I think we have to continue to work on these access issues.

There are some digital CBT-I things that are out there now. Somryst is 1 of them. There are some others, and they’ve been shown to be effective. One way to overcome this access issue is if apps and ways people can engage digitally with CBT-I can provide them with this same value and the same treatment as a trained licensed psychologist. But we’ll have to see. There are some issues with engagement with these apps, so that’s a problem as well. CBT-I definitely is No. 1 on our list. It works great, and people benefit from it. There’s just not enough of it out there to have the impact we want on this problem.

Michael J. Thorpy, MD:If we don’t have access to a trained person and CBT-I, what can the physician do? What are the main elements of CBT-I that the physician could do in a modified in their office?

Nathaniel Fletcher Watson, MD: In addition to what I already mentioned, any board-certified sleep medicine physician is adequately trained to do CBTI. But we’re so busy addressing sleep apnea that we often don’t have enough time in the day to tackle this. One thing is to get a sleep diary on these individuals and figure out exactly how much time they’re sleeping. Then restrict their time in bed to the amount of time they tell you they’re asleep. You continue to monitor that with a sleep diary. Once their sleep efficiency—the percentage of time in bed that they’re asleep—goes above 85%, you begin to extend the amount of time they spend in bed. You’re in bed, so essentially, you’re building up their sleep drive to help them fall asleep at night by restricting the amount of time they’re in bed with an opportunity to sleep. That’s 1 of many things we could do in our offices to help these patients.

Michael J. Thorpy, MD:That’s a technique that we call sleep restriction therapy, where we limit the amount of time the person spends in bed at night. There’s a stimulus control therapy that you touched on with regard to going to bed only when you’re sleepy and getting up at a regular time in the morning. What about the cognitive parts? How can the general physician assess the cognitive aspects? If the patient says, “If I don’t sleep tonight, I’m going to die tomorrow” or “I’m not going to be able to go to work”—yet they’re able to get up and go—how do we address those cognitive issues?

Nathaniel Fletcher Watson, MD: That’s a great question. As sleep doctors, we always want to prioritize sleep. We talk about how important it is all the time. These patients are unique in the sense that we almost have to have the opposite conversation with them. We say, “Sleep is important, but tell me about the last time that you had a really bad night’s sleep.” Then we say, “What happened the next day?” They woke up, they went to work, they got the job done— whatever it was they were doing, wasn’t catastrophic. You’re just trying to turn down the volume on their internal dialogue around the importance of sleep to create an environment that allows sleep to happen. You’re just trying to reduce the anxiety. You’re trying to normalize some things. You’re trying to reset expectations. As I said, before everybody wakes up a bunch of times during the night or a handful of times. The only problem is if you can’t go back to sleep but you’re not always going to fall right back asleep. That’s still OK. Thus, we’ve got to find a way for people to get peace of mind, to relax, to keep their body relaxed instead of developing this anxious fight-or-flight feeling when they’re not sleeping, which is antithetical to sleep.

Michael J. Thorpy, MD:Vikas, are there any particular elements of cognitive behavioral therapy for insomnia that you’ve found particularly helpful in your patient population?

Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE: Yes, several. Sometimes, instituting sleep restriction to 8 hours. As you mentioned, there are patients who have a very long sleep window. Try talking to them about it. We need to try to match your sleep opportunity to your sleep ability to help increase that sleep efficiency. That makes a big difference in these patients. Certainly, access to CBT-I and online CBT-I resources can be very helpful as well. The other thing I try to tell patients is that I need you to stop worrying about tonight. If you’re worried about sleeping tonight, you’re not going to sleep tonight. We already know it. But my goal is not to help you sleep tonight. It’s to help you sleep tomorrow night, and the night after that, and the night after that. If you don’t get sleep tonight, it’s going to increase our likelihood of you sleeping the next night. That’s the goal: we want to make you a better sleeper across a longer spectrum.

Transcript edited for clarity.

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