EVIDENCE-BASED ANSWER
Cognitive behavioral therapy (CBT) interventions—particularly stimulus control and sleep hygiene—are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of recommendation: A, based on systematic reviews). The long-term efficacy of CBT interventions, and their successful implementation by primary care physicians (as compared with behavioral science providers), is unclear.
Clinical commentary
Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK
A large proportion of people in my patient population are shift workers, so chronic insomnia plays a large role in my daily workload, both directly and indirectly. This summary tells me that I have a proven and equally efficacious alternative to drugs for these sufferers—which is great.
However, I was disappointed to see that none of the CBT interventions were performed by family physicians in the office. So the good news is that I have a nondrug intervention for insomnia; the bad news is I don’t know if it’s something I can provide without a referral. Maybe it’s time for some practice-based research to see if that is possible.
Evidence summary
Approximately 10% to 15% of adults complain of chronic insomnia, best defined as difficulty initiating or maintaining sleep 3 or more nights per week for 6 months or longer, with secondary impairments in daytime functioning, including fatigue and disturbed mood.1-3
Behavioral and psychological treatments have emerged as increasingly popular adjunctive interventions to pharmacotherapy and as independent interventions for chronic insomnia. No evidence exists that behavioral treatments have adverse effects.1
Sleep hygiene, relaxation training, and cognitive therapy improve sleep
CBT interventions are based on the notion that distorted thoughts about sleep and learned behavior patterns hyperarouse the central nervous system and deregulate sleep cycles, resulting in chronic insomnia.4 CBT interventions combine empirically tested behavioral, cognitive, and educational procedures to alter faulty beliefs and attitudes, modify sleep habits, and regulate sleep-wake schedules.3
These interventions include stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy.5 These methods can be used separately; however, they are increasingly being used together to treat the complexities of individual patients.5
Five recent high-quality randomized control trials (RCTs) confirmed findings from earlier RCTs that CBT methods improve sleep.5 Compared with those given a placebo or placed on a waiting list, CBT-treated patients in these RCTs reported clinically significant improvements in sleep onset latency, sleep efficiency, time awake after sleep onset, and total sleep time. In one RCT, 64% of CBT patients had improvements in sleep efficiency and time awake after sleep onset, compared with 8% who improved with a placebo intervention (number needed to treat [NNT]=1.8).5 Further, sleep onset latency for primary care patients with chronic insomnia was decreased from 61 to 28 minutes, compared with 74 to 70 minutes for a waiting-list group.5 The maintenance of sleep gains from CBT beyond 1 year is unknown since no published RCT clinical trials to date have lasted longer than 12 months.1