Cognitive Behavioural Therapy for Insomnia (CBT-I) is the first-line recommended treatment for chronic insomnia in adults and older adults.1 CBT-I is a short and highly effective treatment: 70-80% of patients who participate in CBT-I show a clinically meaningful therapeutic response with moderate-to-large effect sizes.2 Patients on hypnotic medications equally benefit from CBT-I, and this treatment can also be effectively applied to improve sleep and prevent relapse during hypnotic medication tapering or discontinuation.
Insomnia is a common comorbidity in a range of medical conditions with particularly high prevalence (70-90%) in psychiatric conditions, such as depression, anxiety disorders, trauma-related disorders as well as alcohol and substance-use disorders. Evidence has accumulated in the past 20 years demonstrating that CBT-I is as effective in treating comorbid insomnia as it is for insomnia in otherwise healthy individuals.3 Moreover, CBT-I lessens anxiety and pain and improves depression symptoms.
BENEFITS OF CBT-I
Given that insomnia is a chronic condition, durability of treatment effects is crucial. An advantage of CBT-I over hypnotic medication treatment is that sleep improvement achieved with CBT-I is maintained after treatment completion without any further active intervention. Evidence also reveals improvement in sleep duration, sleep quality, mood and pain after the treatment has been completed.4 The enduring effects of CBT-I can be attributed to the fact that the treatment specifically targets psychological factors that maintain insomnia. These perpetuating factors are different from those that trigger insomnia and the relative contribution of these factors to chronic insomnia increases over time. By changing insomnia—perpetuating sleep behaviours, beliefs, thinking patterns, and alleviating psycho-physiological and cognitive arousal, CBT-I leads to long-term sleep improvement.
ACCESS TO CBT-I
Clinical guidelines recommend that CBT-I should be offered as the first-line treatment for every patient with insomnia disorder, given its long-term efficacy and cost effectiveness. In reality, patients may not receive timely and accurate information about CBT-I. Instead, they may be directed to non-therapeutic or low efficacy tools —for example general “sleep hygiene” tips or apps that have not been tested in clinical research. Patients often prefer in-person CBT-I treatment, which is available in the greater Toronto area, though access to treatment in other geographical areas has been a long-standing concern. It has been recently shown that CBT-I provided via telehealth systems is as effective as in-person face-to-face treatment.5 It is likely that telehealth treatment will become widespread in the near future, making treatment available in locations where there are no local treatment providers. For patients with limited extended health care coverage, group CBT-I can provide an equally effective option with a lower cost than individual treatment.6 Alternatively, motivated patients can use self-help options (e.g. books, evidence-based online programs or apps). Traditionally, self-help methods have been less effective than treatment provided by a therapist, but more recent methods demonstrate similar efficacy to in-person treatment (see key resources below).
KEY CBT-I Resources
Sleep on the Bay: in person and telehealth expert behavioural sleep medicine - including CBT-I services. Website: sleeponthebay.ca
Sleepio: CBT-I App (available in App stores)
Carney, C. E & Manber, R. (2009). Quiet Your Mind and Get to Sleep. New Harbinger Publications, Inc., Oakland, CA: CBT-I book
KEY TAKEAWAYS
Recommend CBT-I as the first-line treatment to every adult patient with chronic insomnia.
Sleep hygiene is not CBT-I; sleep improves when effective therapy is delivered.
Direct patients to trained providers or to CBT-I tools that have been tested in research.
References:
1. Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2016; 165:125-133.
2. Morin CM & Benca R. Chronic insomnia. Lancet. 2012; 329:1129-1141.
3. Geiger-Brown JM, Rogers VE, Liu W, et al. Cognitive behavioural therapy in persons with comorbid insomnia: a meta-analysis. Sleep Medicine Reviews. 2015; 23: 54-67.
4. Taylor DJ & Pruiksma KE. Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: A systematic review. International Review of Psychiatry. 2014; 26(2): 205–213.
5. Arnedt JT, Conroy AA, Mooney A, et al. Telemedicine versus face-to-face delivery of cognitive behavioural therapy for insomnia: a randomized controlled non-inferiority trial. Sleep. 2020; (accepted for publication).
6. Koffel EA, Koffel JB, Gehrman PR. Sleep Medicine Reviews. 2015; 19: 6-16.
Development of this article was made possible through the financial support of EISAI Ltd. The opinions expressed herein are those of the author and do not necessarily reflect the views and opinions of EISAI Ltd. The author had complete editorial independence in the development of this article and is responsible for its accuracy. The sponsor exerted no influence in the selection of content or material published.