A task force of sleep experts commissioned by the American Academy of Sleep Medicine (AASM) strongly recommended the use of multi-component cognitive-behavioral therapy (CBT) for the treatment of chronic insomnia (CBT-I) as part of a new set of behavioral and psychological guidelines published in the February issue of the Journal of Clinical Sleep Medicine.
In other recommendations, the guideline authors suggest such therapies as stimulus control—which attempts to condition patients to psychologically pair the bed and bedroom with sleep; sleep restriction therapy—limiting the time spent in bed to improve sleep efficiency then gradually increasing hours in bed to re-establish a consistent sleep schedule; and relaxation therapy — using breathing exercises, for example, or progressive muscle relaxation techniques. Notably, the guidelines recommend against using sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults.
CBT-I combines one or more cognitive behavioral therapy strategies, such as education about sleep regulation in addition to behavioral strategies such as stimulus control directives and sleep restriction therapy.
CBT-I treatment is not scripted but based on what each patient brings to the session, said one of the guideline authors, Jennifer Martin, Ph.D., a professor of medicine at the David Geffen School of Medicine at UCLA and a member of the AASM board of directors.
“Within cognitive therapy, there are multiple tools that clinicians can use to address unhelpful thoughts, including sleep education, keeping a thought record to identify problematic thinking, and using experiments to test one's beliefs, for instance,” Dr. Martin said. “The best way to know that a patient is getting effective CBT-I is to refer the patient to a provider with training and experience in cognitive-behavioral treatments.”
Based on a meta-analysis of evidence from nearly 50 studies, the task force strongly recommended CBT-I for the treatment of chronic insomnia in adults. According to the literature examined by the task force members, sleep latency and wakefulness after sleep-onset demonstrated clinically significant mean improvements in patients with insomnia and comorbid psychiatric conditions and in patients with insomnia and no comorbidities. Meta-analyses of remission and responder rates were clinically significant for all three subgroups, according to the report.
The task force concluded that the benefits of CBT-I include treatment gains that are potentially durable over the long term without the need for additional interventions.
Taskforce members also made a conditional recommendation that clinicians combine clinical judgment and experience while considering the patient's values and preferences before determining the best course of action.
Dr. Martin noted that a multi-component brief behavioral therapy is a mini-version of CBT-I that emphasizes the behavioral over the cognitive treatment components. Unlike CBT-I, multi-component brief therapies do not typically include extensive cognitive therapy interventions. “Across research studies, a variety of treatment packages were tested, but what most had in common was the use of the core behavioral strategies for sleep restriction therapy and stimulus control therapy,” she said. “As with CBT-I, the recommendations are patient-centered, and there is likely to be some variation across individuals; however, the use of behavioral strategies is fairly consistent,” she said.
Multiple psychological and behavioral treatments exist for chronic insomnia, which is defined as difficulty getting to sleep, difficulty staying asleep, or waking up earlier than desired for at least three months, noted Daniel Barone, MD, FAASM, FANA, associate medical director of the Weill Cornell Center for Sleep Medicine and associate professor of clinical neurology at Weill Cornell Medical College.
“For those who treat patients with insomnia, these findings and recommendations are extremely helpful, but highlight the need for more options in the future,” Dr. Barone said.
He added that CBT-I was previously regarded as the treatment of choice, which was corroborated by the available literature and thus was the only approach to receive a strong recommendation for use by the task force.
“CBT-I is essentially a multimodal treatment program utilized by sleep specialists comprising cognitive, behavioral, and educational components. Cognitive restructuring is used to attempt to change inaccurate or unhelpful thoughts about sleep, and behavioral interventions include relaxation therapy, stimulus control therapy, and sleep restriction, and attempt to establish healthy sleep habits,” Dr. Barone noted.
Relaxation therapy includes exercises designed to reduce somatic tension, such as progressive muscle relaxation, and cognitive arousal, such as meditation, Dr. Barone explained, while stimulus control therapy attempts to improve on the tendency of patients with insomnia to associate their bed and bed environment as not being places of rest.
“During treatment, the bed is only used for sleep and sex, and patients are instructed to get out of bed when it's difficult to fall asleep or when they lie awake for more than 10-20 minutes, only going back to bed when they are tired again, as well as setting an alarm for the same time every morning and avoiding daytime naps.”
He further explained that sleep restriction limits time spent in bed, as patients with insomnia often spend too much time lying in bed awake, adding, “this technique is intended to increase the drive to sleep and can temporarily increase daytime fatigue. It is to be avoided in those with certain medical conditions that can be made worse by losing sleep, such as bipolar disorder and seizures.” He noted that the addition of educational interventions provide information about the connection between feelings and behaviors and sleep and helps to dispel counter-productive thoughts, such as a patient thinking that they will not be able to function in a sleep-restricted state.
Dr. Barone noted that recommendations regarding sleep hygiene, defined as a set of general recommendations about lifestyle factors including diet and exercise, as well as environmental factors such as light and noise that may promote or interfere with sleep— are widely available across the internet. Many other sources, and in many cases, patients will report that they already tried them, incorrectly associating sleep hygiene with CBT-I,” said Dr. Barone. “Thus, the conditional recommendation against use was neither surprising nor unwarranted.”
Unanswered questions remain, Dr. Barone noted, such as when more data are available, where will the newly-described intensive sleep training fit into the recommendation paradigm? “But for those who treat patients with insomnia regularly, this practice guideline was a much-needed confirmation on the best way to take care of our patients.”
Logan Schneider, MD, clinical assistant professor at the Stanford Sleep Medicine Center, observed that the guideline serves as a meaningful update to its last iteration in 2006. He pointed out that the field has continued to grow, and the application of cognitive and behavioral therapies for insomnia have been studied in greater depth, exploring efficacy in various patient populations, using different formats (web, app, telephone, video, individual, group), and assessing assorted outcomes (primary sleep metrics, health outcomes).
The recommendation against using sleep hygiene as a single therapy is consistent with the previous recommendations and general perceptions in the field, he said.
“While the guideline update didn't contain much new information,” he noted, “it did further strengthen the current clinical practice standards with the solid foundation of evidence-based research that has come out in the interim.”
Finally, Dr. Schneider said, it's quite helpful to have such effective therapies as an alternative to pharmacologic agents, but some of the most important things to consider with regard to providing patients the best care are suggested by the AASM's Choosing Wisely guidance: For example, “If we don't ask we'll never know whether our patient is one of the approximately 30 percent of people with insomnia symptoms. We need to increase the number of trained professionals who can implement CBT-I (but the Society of Behavioral Sleep Medicine can help you find the ones that are in your area or you can use various digital CBT-I options), and both patients and providers need the time to invest in proper care, instead of turning to the prescription pad too quickly.”
Dr. Martin serves on the AASM Board of Directors. Dr. Barone had no relevant disclosures. Dr. Schneider reported receiving consulting fees and compensated travel from Alphabet, Inc., consulting fees, paid speaking fees, and compensated travel from Jazz Pharmaceuticals, and speakers bureau fees from Harmony Biosciences.