Cognitive Behavioral Therapy for Insomnia | Patient Advice | US News

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By Michael O. Schroeder

Many, many people have difficulty falling asleep or staying asleep. Research generally suggests that around a third of Americans have insomnia at any given time, and about 1 in 10 have chronic insomnia, lasting three months or longer.

Not getting adequate rest can affect mood (while depression can also contribute to insomnia), undermine motivation, increase irritability and make it difficult to just get through the day. “For those who take care of small children or have a lot of family and work responsibilities to balance,” the National Sleep Foundation notes, “insomnia can make these tasks feel even more overwhelming when you are tired.”

Often people try over-the-counter sleep aids or nothing at all – just thinking they have to live with it – rather than seeking help from a professional.

It’s common for patients who see Dr. Rafael Pelayo to have been struggling with insomnia for years. It’s “not unusual for me to see someone with decades of poor sleep,” says the sleep specialist and clinical professor of psychiatry and behavioral sciences at the Stanford Center for Sleep Sciences and Medicine. But even those who’ve had chronic insomnia for years can still get better when the insomnia is addressed correctly, he says.

And although the treatment isn’t new, there’s growing recognition of a tailored therapeutic approach used to change a person’s thinking and behavior that has lasting benefits for the majority who undergo it: cognitive behavioral therapy for insomnia. Most who undergo four to eight sessions of CBT-I experience a significant reduction in their symptoms – namely the time required to fall asleep, the amount of time spent awake or both – notes Michael Perlis, director of the behavioral sleep medicine program in the department of psychiatry at the University of Pennsylvania.

While experts note that sleep medication, prescribed in combination with CBT-I or alone, is another option, CBT-I’s “durable results” – generally continuing after a person stops the therapy – make it an optimal approach. “It is recommended as the first line treatment,” Perlis says.

It’s not just mental health professionals advocating for the treatment either, but the medical establishment. The American College of Physicians led the way in guidelines published in 2016ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder,” the medical society asserted.

Perlis explains that CBT-I has four components: sleep restriction, stimulus control, sleep hygiene and cognitive therapy. Often it’s counterintuitive, too, like with sleep restriction. One might think that if you can’t sleep you should stay in bed for longer. But actually experts say it’s important to match your sleep opportunity, or how long you’re in bed, with how long you’re able to sleep, and then gradually work on increasing sleep time. “It doesn’t aim to restrict actual sleep time but rather to initially restrict the time spent in bed,” Stanford Health Care’s website explains, regarding the sleep restriction component of CBT-I. “Subsequent steps consist of gradually increasing the time spent in bed.”

While some people may feel they’re familiar with certain concepts and components of CBT-I, like sleep hygiene (being mindful of how factors like substance use, such as caffeine and alcohol consumption, can affect sleep), implementing it correctly tends to be more complex and involved. Experts say that’s why it’s key to see a professional experienced in CBT-I for effective treatment. “Those that try to do CBT-I to themselves are likely to not be successful,” Perlis says. “But worse is that they will believe that they’ve been there, done that, and so the likelihood of seeking out professionally administered CBT-I goes way down.”

One significant limitation with CBT-I, however, is access. “Finding a therapist is not easy,” Perlis says. “CBT-I is not yet available in every state or every city.” However, there are some directories – he recommends a couple through Perelman School of Medicine at Pennsylvania University and the Society of Behavioral Sleep Medicine, respectively – that can be used to find therapists who do CBT-I.

Pelayo points out that for those who aren’t able to see a professional who does CBT-I in their area, there are online CBT-I programs that allow a person to engage in the therapy from home virtually. “I’m OK with somebody doing it online if they want to – if they live far away,” Pelayo says. “And if they got better, I’m happy for them, of course. But if they don’t get better, if they’ve done the online thing, then we actually want them to have a face-to-face.”

He says patients typically pay cash for online CBT-I.

Insurance coverage of in-person cognitive behavioral therapy for insomnia varies. So it’s important to check in advance to determine that. As the therapy is more widely used, and given the support for its effectiveness, clinicians are hopeful insurance coverage of CBT-I will improve, but it’s not universal today.

Pelayo says some individuals, like those with profound autism or schizophrenia, aren’t able to participate in CBT-I. Others, he says, either prefer not to undergo therapy, or aren’t able or don’t want to make the time commitment.

Certainly, CBT-I has advantages – notably the lasting benefits, after a person has stopped therapy; that differs from medication that provides benefit while on it. But experts say, first and foremost, it’s key that those with chronic insomnia generally seek help to get a better idea of what’s behind it and explore treatment options.

In some cases, it may be a medical or mental health issue that’s causing sleep problems or making things worse, and cognitive therapy may still be useful (like with depression). But having a fuller picture, is critical. For example, often thyroid disease can contribute to sleep woes and is overlooked, Pelayo says. Or a person may have another disorder like sleep apnea, along with insomnia, that needs to be addressed as well, he says.

None of that will be rectified through an online search in your pajamas (though you might find a sleep specialist that way).

“I tell all my patients that if they don’t wake up feeling refreshed, something is wrong,” Pelayo says. When sleep problems persist, experts say, instead of trying to put them out of your waking mind – seek help to get them addressed.

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