In July, the organization that represents the internal medicine community in the United States — the American College of Physicians, or ACP — officially endorsed what many meta-analysesopens in new window have found: Cognitive behavioral therapy for insomnia, or CBT-I, is the best treatment for chronic insomnia disorder and should be the first line of treatment for the approximately 24 million adults suffering from the condition.
It's the first time a psychological treatment has been given the thumbs up as the preferred treatment by a medical organization, at least in the United States. (For major depression, the ACP recommends selecting between either CBT or second-generation antidepressants, while for mild to moderate depression, the United Kingdom's medical system recommends CBT with behavioral activation and problem-solving as the go-to treatment.)
CBT-I is a combination of treatments that includes behavioral therapy interventions, such as sleep restriction and stimulus control; cognitive interventions, including restructuring dysfunctional beliefs and decastrophizing negative thoughts about sleep; and sleep hygiene to address factors that may augment treatment outcomes.
While studies are underway to determine if one of the components of CBT-I is more potent than others, experts hold that the behavioral interventions produce the most rapid and largest clinical effects. The strongest and most extensive research is on in-person treatment, but CBT-I is also conducted in groups, in briefer formats, via telephone and Skype, by internet programs and with self-help books.
Addressing a key risk factor
The recommendation that CBT-I be the first-line treatment for insomnia appeared as a practice guideline in the July 19 Annals of Internal Medicine opens in new window, ACP's flagship journal. The article was written by a team led by Philadelphia internist Amir Qaseem, MD, PhD, who heads the ACP's evidence-based medicine and clinical practice guidelines program.
The endorsement is particularly salient because research is finding increasing evidence that sleep disorders can accompany or signal other psychiatric and medical conditions including weight gain, hypertension, diabetes, cardiovascular disease and even Alzheimer's disease, says Michael Perlis, PhD, director of the behavioral sleep medicine program at the University of Pennsylvania.
"While chronic insomnia is a risk factor if not a precursor to a variety of diseases," says Perlis, "the good news is it represents one of the most modifiable risk factors you could imagine."
CBT-I is equally effective for simple insomnia and insomnia with co-morbidities, says Perlis, who studies a range of behavioral sleep medicine issues. Acute, in-person treatment of four to eight sessions cuts in half the time it takes people to fall asleep or get back to sleep when they've woken up during the night, and two-year follow-up assessments show those gains last. As many as 40 percent of patients remit entirelyopens in new window, often after treatment is discontinued, he adds.
What's more, CBT-I can help to address the co-morbid conditions, research finds. For example, studies show that compared with antidepressant medication alone, CBT-I can significantly reduce depressive symptomsopens in new window and increase remission rates when used in conjunction with medications, as well as reduce suicidal ideationopens in new window in veterans.
More training needed
In an editorial accompanying the AIM article, University of Minnesota physician Roger G. Kathal, MD, and University of Michigan psychologist J. Todd Arnedt, PhD, underscore that challenges lie ahead in implementing CBT-I on a large scale. Those include a short supply of trainers and practitioners, reimbursement issues, and bringing standardized methods for assessing and treating chronic insomnia into all levels of the health-care system. They propose ways to tackle these issues, such as physician education about the evidence of CBT-I so physicians can properly refer patients, and convincing insurers to reimburse CBT-I services the same way they'd cover other medical and psychological services.
"It is frustrating that an intervention as effective as CBT-I is difficult for many patients to access," they write.
Despite such barriers, it is prime time for more psychologists to learn a treatment known to vastly improve clients' health and well-being, Perlis says.
"The clarion call has been sounded," he says. "The good news is that here's a form of CBT that is fairly easy to learn and can be a wonderful tool in your toolbox."
