For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).
Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.
"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.
The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.
The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.
Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.
"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.
CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.
She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).
CBT-I and cost savings
Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.
The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.
The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.
Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.
Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).
While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.
Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.