SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.
Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.
Dr. Donna M. Sudak
"It’s really rapid," she said of the intervention and its effects on insomnia.
Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.
"CBT works really well, and it also may be important in terms of managing other conditions," she said.
In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.
"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.
She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.
In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).
Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.
CBT-I for comorbid insomnia, psychiatric illness
CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.
"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.
Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.
"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.
However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.
"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.
Indeed, data increasingly suggest that CBT-I is such a treatment.
In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.
CBT-I in older adults
In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.