The American College of Physicians (ACP) recently issued a report recommending cognitive behavioral therapy (CBT), rather than prescription sleep aids, as the preferred treatment for insomnia. Despite standing up to scientific scrutiny and earning praise from the who’s-who in Sleep, however, CBT-i ("i" for insomnia) remains poorly understood and under-utilized by the five-to-15 percent of Americans with insomnia. Here, then, is your guide to this newly appreciated old method.
What CBT Is — and Isn't
As treatment methods go, CBT is neither new or newly lauded. It emerged in the 1960s and has been touted as a first-line defense against clinical-grade sleeplessness since at least 2005, when the NIH published its endorsement. The AASM (American Academy of Sleep Medicine) followed suit in 2008. And researchers around the world have championed it for years. In trial after trial, CBT-i proves effective for a diverse spread of insomniacs, including teens, pregnant women, the elderly and schizophrenia patients. Basically, it's sleep medicine's version of that little-known indie band that will change your life.
Broadly, CBT is a goal-oriented, drug-free approach to treating mental disorders including anxiety, panic disorders, addiction and, of course, insomnia. Let’s focus on the insomnia-specific variety. A typical course of CBT-i involves four-to-12 weekly training sessions with a licensed practitioner during which insomniacs defeat barriers to rest by changing their relationship with it. The precise design of CBT-i courses vary somewhat, but they generally include some combination of up to five cognitive and behavioral techniques.
The “cognitive” part mainly refers to sleep education. Participants learn about the biological and environmental factors affecting sleep to identify and change their disordered (i.e., bad) patterns and attitudes related to it.
The main behavioral components are stimulus control and sleep restriction. Stimulus control sets out guidelines for keeping stimulating activities outside the bedroom. Its central tenets include using beds exclusively for sleep and sex, retiring to bed only when sleepy and leaving bed (for 15-20 minutes) when sleep just isn't happening. As for sleep restriction, it's both a bit controversial and, according to a 2015 meta-study on CBT-i clinical trials, among the most effective components of the whole therapeutic method. The technique requires people to spend only as much time in bed as they actually spend sleeping. For an insomniac, that could mean just a few hours of pillow-time. The goal is to increase sleep efficiency (time-in-bed divided by time-slept) to 85 percent.
Additionally, CBT-i may include two components that don’t fall into either category: sleep hygiene and relaxation. Sleep hygiene is an unsavory umbrella term for laudable sleep habits, such as banishing bluelight in bed, keeping a consistent sleep-and-wake schedule, avoiding daytime naps and cutting out caffeine and alcohol near bedtime. Relaxation techniques include meditation, mindfulness and guided imagery. They don’t show up in every CBT-i course, but can “be used to limit cognitive arousal and reduce muscular tension to facilitate sleep,” per the 2015 meta-study.
To be clear, CBT is not psychoanalysis. Insomniacs don't dredge up childhood memories or analyze their dreams to get to the root of their nighttime jitters. Instead, they tackle the can’t-sleep disease as a problem to fix, rather than explore.
CBT vs. Drugs
In clinical terms, having chronic insomnia means struggling to fall or stay asleep at least three nights-per-week (in the past month). "Successful" treatments, then, are ones that facilitate longer, better nights of sleep on a more consistent basis. We can judge the quality and quantity of rest through various measures: how easily and quickly we fall asleep, how long we stay asleep, how frequently we wake up, how refreshed we feel during the day and how much time we spend dozing in deeper stages of sleep.
The research says CBT-i is as effective (or nearly as effective) as prescription sleep aids (e.g., Ambien, Xanax) in treating short-term insomnia. But, CBT-i has a leg up on meds in the long-term. Pills tend only to work as long as people are popping them. (And, per clinical guidelines, popping should only last for a month-or-so at a time.) The benefits of CBT-i, on the other hand, appear to last for up to six months after therapy ends.
So, it’s not that CBT-i improves sleep measurably better than Ambien does, but instead that it works roughly as well, without the same side effects and risks, and confers a longer-lasting impact. Additionally, patients tend to report preferring CBT-i to drug treatment.
Though, some researchers argue that CBT-i does come with its own, under-recognized issues. One commentary article, for example, noted the tendency of CBT-i studies to gloss over potential downsides of sleep restriction, such as daytime sleepiness and impaired performance (at work, behind the wheel).
But the main, and most commonly recognized pitfall of CBT-i isn't about the therapy itself — it's about access to it. Licensed CBT practitioners are still relatively rare, especially in rural areas. And, even when CBT-i is available, many insurance plans won’t cover the cost of therapy. Let that sink in: The bulk of Americans (most of whom report sleeping difficulties) probably don't have healthcare coverage for the top-recommended insomnia treatment.
Traditionally, CBT-i requires seeing a practitioner in-person for solo or group therapy. But, the past few years have seen the rise of digital CBT-i. Rather than visit a therapist, people can complete modules online and communicate with practitioners electronically. Studies have found the digital version to be similarly effective to its IRL analog. In one 2014 study, for example, insomnia-ridden teens saw comparable sleep improvements with both versions. Teens are statistically unlikely to seek out mental healthcare. The same goes for middle-aged men and African Americans. For groups like these, digital therapy may be especially appealing.
The emergence of digital CBT-i should help make treatment availabile to more of the sleep-starved masses. As of now, however, few (if any) insurance companies pay for, or even offer partial reimbursement, for digital programs. And while remote therapy may be cheaper than in-office visits, it's not free. But we are seeing a push to expand telemedicine services in specialties including sleep research.
In 2016, CBT buzz is coursing through the medical and academic worlds. Going forward, let's make it part of the mainstream conversation, too.