Insomnia is extremely common with over 10% of the general population experiencing chronic insomnia. Over 30% of primary care patients experience chronic insomnia. Medical and psychiatric conditions can cause insomnia and persist even when the condition is resolved. Insomnia creates functional impairment, decreased quality of life, increased risk of accidents, and higher health care costs. Furthermore, it has been demonstrated that medical and psychiatric conditions often improve with alleviation of insomnia.
In spite of this prevalence and negative impact, insomnia is widely undiagnosed and largely untreated. Most individuals do not seek treatment and self medicate with over the counter remedies, while the vast majority of medical treatments involve medications. Medications do not address the most important factors of chronic insomnia: behavioral and psychological factors.
Major advances and recent controlled research results have shown that Cognitive-Behavioral Therapy (CBT) are more effective than sleep medications alone in both short and long term sleep improvement. A recent study published in JAMA (2009, 301 (19): 2005-2015 shows that the addition of CBT to medication (Ambien) was superior to Ambien alone during early treatment and that long term outcome was optimized when Ambien was withdrawn during maintenance CBT.
A review and meta-analyses of CBT approaches to insomnia show that 70% to 80% of patients with insomnia show benefit including a 50% reduction in time getting to sleep, number of awakenings and early morning awakenings with improvements in total sleep time and sleep quality. There are robust findings across clinical trials of CBT that are well maintained over time (up to 36 months from treatment completion). This sustained improvement is a clear advantage over medication treatments.
CBT for insomnia includes several approaches with evidence supporting their effectiveness when administered alone or in combination:
- Sleep Restriction Therapy: This involves a method where time spent in bed is restricted and then gradually increased over a period of time ranging from a few days/weeks until optimal sleep duration is achieved.
- Stimulus Control Therapy: This treatment involves a set of instructions that are designed to strengthen the association between bed/bedroom stimuli with sound sleep and to establish a consistent sleep-wake schedule.
- Relaxation Training: This treatment approach involves clinical procedures that are designed to reduce autonomic arousal associated with either the frustration of being unable to sleep or with situational anxiety/depression.
- Cognitive Therapy: This psychotherapeutic approach is designed to address faulty beliefs regarding sleep, insomnia, daytime consequences as well as worry about daytime situational circumstances.
- Sleep Hygiene Education: A list of guidelines of “do’s and don’ts” that are generally agreed upon by sleep experts are given to all insomnia patients with instructions to follow closely. (see below)
SLEEP HYGIENE GUIDELINES
- Develop regular sleep times. Go to bed and get out of bed at about the same time, regardless of how tired you are.
- Avoid naps as this will decrease your sleep requirement and make it more difficult and less likely that you will sleep a satisfying block of sleep at night.
- Use your bed only for sleep and sex. Insomnia is often the result of increased arousal preceding bedtime and while lying awake in bed. Many who have insomnia use the bed for reading, talking on the phone, watching T.V. and worrying. This results in the bed being associated with arousal (anxiety). Therefore, it is recommended that you read, talk on the phone and watch T.V. in another room. If you have friends who call late at night, tell them not to call after a specific hour or turn your phones off. Avoid anxiety arousal during the hour before bedtime (for instance, avoid arguments and challenging tasks).
- If you are lying awake at night for more than 15 minutes (either getting to sleep or falling back to sleep), get up and go in the other room. Do not go back to bed until you feel sleepy. The reason for this admittedly difficult to follow directive is because the arousal associated with the frustration and anxiety of rolling and tossing gets conditioned to the bed/bedroom creating continued sleep disturbance.
- Reduce or eliminate liquid intake several hours before bedtime. Sleep is often disturbed by urinary urgency and frequency.
- Avoid alcoholic beverages several hours before bedtime. Not only does alcohol increase urinary urgency and frequency but it has a negative impact on sleep architecture. Many people use alcohol to fall asleep but it creates problems with sleep maintenance where the probability of sleep disruption (maintenance insomnia) is greatly increased.
- Do not try to fall asleep as this will only increase your frustration and anxiety. Paradoxically, a very effective way of increasing sleep is to practice giving up trying to fall asleep. You can say to yourself, “I’ll give up trying to get to sleep and just concentrate on the relaxing feelings in my body.”
- Write down your negative automatic thoughts and challenge them. Typical automatic thoughts are “I’ll never get to sleep,” “If I don’t get enough sleep, I won’t be able to function,” “I need to get to sleep immediately,” and “I’ll get sick from not getting enough sleep.” The most likely consequence of not getting enough sleep is that you will feel tired and irritable. Although these are uncomfortable inconveniences, they are not catastrophic.
- Regular exercise will increase the need for sleep and improve the quality of sleep. Note: It is generally recommended not exercising within a few hours of scheduled bedtime as exercise can produce a temporary stimulation and delay sleep onset.
- Avoid caffeinated beverages and smoking. Caffeine has a long half life of approximately 12 hours so it is recommended that no caffeinated beverages be consumed 12 hours prior to your scheduled sleep time. Smoking and nicotine is a stimulant and should be avoided for a variety of health reasons. If you are smoking it is recommended to not smoke two hours before bedtime.