Insomnia and Its Effective Non-pharmacologic Treatment

Insomnia is a public health problem

In 1995 the direct cost of substances used and health care costs related to insomnia in the United States were estimated to be $13.9 billion per year.¹⁰ A broader insomnia-related estimate includes direct costs (inpatient, outpatient, emergency room health care utilization, over-the-counter supplements and pharmaceuticals); indirect costs (workplace absenteeism, loss of work productivity); and related costs (those that do not fall into direct/indirect, such as damages caused by on the job

Health risks

Prolonged insomnia is associated with significant health problems. In a study of 3445 primary care subjects, in which 50% had chronic insomnia, individuals who experienced insomnia symptoms defined as most or all nights a week for the previous 4 weeks were more likely to also have physician-diagnosed myocardial infarction (odds ratio [OR]: 0.9); congestive heart failure (OR: 2.5); and diabetes mellitus (OR: 1.0); and patient-reported comorbidities, such as osteoarthritis (OR: 1.6); rheumatoid

Health utilization

Insomnia is associated with increased health care utilization, such as medical visits and hospitalizations.²¹ In a sample of 350 subjects with insomnia in a sleep clinic, who were receiving behavioral management of insomnia, 82% reported having a medical office visit in the past 2 months and 44% had reported having a mental health visit in the past 2 months.²² Simon and VonKorff found a relationship between insomnia and greater general medical service utilization. Specifically, those

Insomnia is undertreated

Only one in five individuals with difficulty sleeping in the United States makes an appointment to see a physician with a chief complaint of difficulty sleeping.²⁶ Of the 30% that have discussed sleep with their doctor four out of five mentioned concern about sleep within the context of a visit about a different chief complaint.²⁶ Predictors of whether patients would discuss insomnia with a physician include perceived daytime fatigue, symptoms of depression and anxiety,²⁷ poor physical well

Who is at risk for the development of insomnia

Some groups have been identified as being more at risk for the development of insomnia. One such group is women who are two times more likely than men to have insomnia.³¹ Sleep disruptions increase during certain junctures in a woman's life, such as pregnancy, postpartum,³² and menopause.³³ However, the prevalence of insomnia disorder during these junctures has not been fully assessed. Another risk factor for insomnia is aging. Older adults are more likely to have insomnia, which may be related

Non-pharmacologic treatment of insomnia

Cognitive behavioral therapy for insomnia (CBTi) is a brief and effective non-pharmacologic treatment for insomnia that is grounded in the science of sleep medicine, the science of behavior change and psychological theories. There is strong empirical evidence that CBTi is effective.37, 38 Direct comparisons of CBTi with sleep medication in randomized control trials demonstrate that CBTi has comparable efficacy with more durable long-term maintenance of gains after treatment discontinuation.39,

A model of insomnia

A behavioral model of insomnia, put forth by Spielman and colleagues⁴⁵ in 1987, identifies predisposing characteristics, precipitating events, and perpetuating attitudes and practices – three factors that together explain the development and course of insomnia. Predisposing characteristics are individual attributes that lower the threshold for the development of insomnia during unsettling or stressful periods and hence increase the likelihood of the development of insomnia.⁴⁵ These

Time-in-bed restriction (sleep restriction)

Time-in-bed restriction (also known as sleep restriction) is a procedure designed to increase the homeostatic sleep drive, one of two components involved in the regulation of sleep. The homeostatic drive to sleep, known as process S, increases in a linear fashion from rise time to bedtime. The longer we are awake the stronger the sleep drive. The second component involved in the regulation of sleep is the circadian clock, known as process C. Process C, generated in the suprachiasmatic nucleus,

Stimulus control

Stimulus control, developed by Bootzin, is a set of instructions aimed at breaking conditioned arousal and strengthening the bed and bedroom as stimuli for sleep.⁵⁰ Stimulus control is used for sleep onset and sleep maintenance insomnia. The four instructions and their rationale are

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  Go to sleep only when sleepy. This instruction will likely increase the probability of sleeping by aligning the bedtime to coincide with low arousal and strong homeostatic drive to sleep. It is important that

Relaxation therapy

There are a variety of factors, such as cognitions and emotions, that influence the activation of the arousal system that can interfere with or supersede the sleep promoting system. A person should attempt to sleep when they feel calm because wakefulness and sleep are two distinct systems and do not operate like an on-off switch but rather on a continuum of continual communication. Research has shown that those with insomnia compared with good sleepers have higher heart rates, stress hormones,

Cognitive therapy

The cognitive therapy component of the CBTi targets thoughts and beliefs that interfere with sleep directly by increasing arousal in bed or indirectly by interfering with adherence to sleep restriction and stimulus control. A common reaction to difficulties with sleeping is to worry about sleep or lack thereof. As times goes on and poor sleep continues, an anticipation of not sleeping well each night begins to emerge. The daytime consequences of not sleeping well also become worries, such as

Sleep hygiene

Standard sleep hygiene therapy includes “limiting caffeine intake, avoiding alcohol before bed, incorporating daily exercise, having a bedtime snack, and keeping the bedroom quiet, dark, and at a comfortable temperature.” There is insufficient evidence to support sleep hygiene as a lone intervention⁴⁴ but it is often included along with other more potent interventions. A comparison of standard sleep hygiene with CBTi in a sample of 81 subjects revealed that CBTi produced greater decrease in

Multimodal approach

CBTi is a multimodal approach that combines behavioral and cognitive strategies. The most commonly used behavioral components are time-in-bed restriction and stimulus control, which can be combined into a single set of instructions. The cognitive component is added as a means for reducing cognitive and emotional hyperarousal and for increasing adherence with the behavioral components. Sleep restriction and stimulus control are counter-intuitive. Some patients may respond to a reduction in the

Cognitive behavioral therapy for insomnia providers and where to find them

CBTi is a form of cognitive behavioral therapy, an approach to therapy that was developed by psychologists to deal with many psychiatric conditions and aims to modify cognitions and behaviors relevant to each disorder. Historically, CBTi was developed and provided by psychologists whose training included the science of behavior change, cognitive and behavioral interventions, psychological assessment, and additional specialized training in sleep medicine. Specialized training in sleep medicine

Summary

Cognitive behavioral therapy for insomnia is an effective non-pharmacologic treatment for insomnia. In direct comparisons with sleep medication in randomized control trials, CBTi demonstrates that it has comparable efficacy with more durable long-term maintenance of gains after treatment discontinuation. Because of the strong empirical support of CBTi, the National Institutes of Health Consensus and the American Academy of Sleep Medicine Practice Parameters recommend that CBTi be considered