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Insomnia and CBT-i

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Everybody can relate to having had a bad night of sleep. It can be annoying and sometimes you might not feel great the next day, but after a while sleep returns to normal and you go on your merry way. For people with insomnia however it’s a different story, not only is sleep chronically poor, but it is also often very anxiety provoking and can lead to a restricted lifestyle.

For those who don’t know, lets first outline more specifically how insomnia can be experienced. At night, insomnia is characterised by any combination of the following:

  • Difficulty initiating asleep
  • Difficulty maintaining asleep
  • Waking too early

During the day, common signs and symptoms include:

  • Fatigue/lack of energy
  • Mood changes
  • Poor concentration and attention
  • Anxiety
  • Decreased work performance
  • Memory impairments

Insomnia is one of the most common sleep problems in the world. Approximately 10-15% of adults meet criteria for a formal diagnosis, and 33-45% report at least one symptom1-2. Importantly, untreated insomnia increases the risk of other psychological disorders (e.g. depression), health problems (e.g. diabetes), accidents and impaired occupational performance1,3.

Given the prevalence and burden of insomnia, effective treatment is critical. Although it might surprise a few people, the recommended first line treatment for the management of insomnia is not sleep medication. In fact, Australian guidelines state that it’s a psychological treatment called cognitive behavioural therapy for insomnia, otherwise known as CBT-i4-5.

The reason CBT-i is recommended instead of sleep medications is that it targets the underlying causes of insomnia rather than just the symptoms. Hence, the majority of patients see improvements in their sleep. Furthermore, CBT-i has better long-term outcomes, no side effects6-7 and may be more cost effective in the long-run (often patients only need to be seen 4-8 times).

Unfortunately, research in Australia shows that almost 95% of insomnia patients end up being prescribed sleep medication by their GP8, which is a lot of people missing out on the best available treatment. Often when I first meet my patients, they may say something like “I’ve tried everything, this is my last resort”, to which I often respond, “yes, everything except the recommended first line treatment!

So, let’s be more specific, what is CBT-i? Broadly speaking CBT-i is a multicomponent treatment that targets and reverses the maladaptive cognitive and behavioural factors that maintain insomnia. This typically involves weekly visits to a psychologist trained in behavioural sleep medicine, with each session lasting about 50mins. Given that there are multiple targets to address in a short time, treatment is focused, and goal orientated. The main aims are to:

  1. Provide education about sleep and insomnia.
  2. Correct erratic sleep scheduling/sleep hygiene
  3. Associate the bed with being relaxed and sleepy
  4. Limit time in bed in order to consolidate sleep
  5. Upskill in management of worries/stress/anxiety/unhelpful thinking
  6. Reduce fear of poor sleep and tiredness – if patients are no longer fearful, they sleep better and function better during the day
  7. Build tolerance of some poor sleep and tiredness

Seeing a patient come out the other side of CBT-i with their insomnia resolved really is something special. Not only because sleep improves, but also because daytime functioning and mood do as well. Overall though it’s the fact that people no longer feel held captive by their sleep that is the biggest benefit following treatment.

What’s the take home message? CBT-i offers the best approach for the treatment of insomnia. So, although it takes a bit more effort than simply reaching for another sleeping pill, it’s worth it.

Sleep well from the Sleep4Performance Team.

 

References

  1. Adams, R. J., Appleton, S. L., Taylor, A. W., Gill, T. K., Lang, C., McEvoy, R. D., & Antic, N. A. (2017). Sleep health of Australian adults in 2016: Results of the 2016 Sleep Health Foundation national survey. Sleep Health, 3, 35–42. doi:10.1016/j.sleh.2016.11.005
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
  3. Roth, T. (2007) Insomnia: Definition, prevalence, etiology, and consequences. J Clin Sleep Med, 3, 7–10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978319/
  4. Clinical guidelines – insomnia. Retrieved from http://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b/2-evidence-based-guidance-for-benzodiazepines/22-insomnia/
  5. Ree, M., Junge, M., & Cunnington, D. (2017). Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults. Sleep Med, 36, S43-S47. doi.org/10.1016/j.sleep.2017.03.017.
  6. Okajima, I., Komada, Y., & Inoue Y. (2011). A meta-analysis of the treatment effectiveness of cognitive behaviour therapy for primary insomnia. Sleep Biol Rhythms, 9(1), 24-34. Doi: 10.1111/j.1479-8425.2010.00481.x.
  7. Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. Am J Psychiatry, 151(8), 1172-80.
  8. Charles, J., Harrison, C., & Britt, H. (2009). Insomnia. Australian Family Physician, 38(5), 283.

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