What’s New in Cognitive Behavioral Therapy of Insomnia?

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Source: Photo by Alexandra Gorn on Unsplash

Cognitive-behavioral therapy of insomnia (CBT-I) is considered the most effective treatment for insomnia currently available. As I have noted in previous posts, creating new treatments for this common and difficult sleep problem is very challenging. Still, innovative methods like intensive sleep retraining are being developed. I’ve described the primary components of CBT-I in previous posts. Since then, there have been some additional developments in CBT-I that I will review below.

Insomnia and Standard CBT-I

Insomnia is typically defined as difficulty falling or staying asleep, resulting in daytime symptoms such as fatigue, low mood, irritability, and memory problems. Insomnia may be associated with other problems such as depression or may be a problem in its own right. It can be acute, lasting a few days to weeks, and can become chronic, meaning that it lasts more than three months.

Once established, insomnia can last indefinitely. Some people seem to have it from childhood. In contrast, most people develop it during times of stress, such as coping with the challenges of the Covid-19 pandemic or after a significant change in sleep habits such as starting a third shift work schedule. Acute insomnia most often resolves independently or with a brief use of sleeping medication, but it can also evolve into chronic insomnia.

CBT-I is typically applied to the chronic form of insomnia and involves both behavioral and cognitive interventions. These can be delivered in self-help, group, individual, or virtual formats. The major behavioral interventions are sleep restriction, which reduces time in bed to increase sleep drive, thus deepening and consolidating sleep, and stimulus control which limits the use of the bed environment to sleep and intimacy, to break the association between being in bed and being awake. Relaxation techniques can be helpful to reduce the arousal that contributes to insomnia. Cognitive interventions are directed at increasing knowledge of sleep and good sleep hygiene and challenging and restructuring negative sleep thoughts, such as that spending more time in bed is necessary to get enough rest, even if one is not sleeping. A program employing these techniques is typically provided in four to six sessions.

Brief Interventions

Efforts have been made to increase the efficiency of CBT-I. Brief behavioral treatment of insomnia (Germain, & Buysse, 2011) focuses on sleep restriction and stimulus control with some sleep education in a two-session format during a four-week program. This intervention does not extensively restructure negative sleep thoughts and is most effective for less chronic insomnia where patients have not developed extensive negative cognitions and beliefs. I have found it remarkably effective clinically, and properly screened patients can make rapid progress with this approach.

Single Session Protocols

Efforts have been made to shorten the intervention even more, and there are situations in which this is especially important. For example, it is estimated that over 60% of prison inmates experience insomnia, which can contribute to problems such as increased anger, impulsivity, and aggression. In such environments, where behavioral health resources are limited, it is important to provide an extremely time-efficient intervention. Charlotte, Sara, & Ellis (2019) developed a single-session intervention for inmates with acute insomnia that involved keeping a sleep diary and focused on sleep education and sleep restriction.

The sleep education provided the rationale for the intervention. The sleep diary was used to calculate the amount of restriction needed for each prisoner with instructions to continue the restriction process independently. An information pamphlet was provided that explained stimulus control and imagery distraction. Inmates could be briefly seen by the therapist after the session, if requested by the inmate, to check diaries and use sleep restriction. Interestingly, 20 of the 30 participants in the study requested extra meetings. Results were impressive, with 73% of the participants having remission of their insomnia symptoms and reductions in ratings of anxiety and depression. Such a program could help prevent the development of chronic insomnia and reduce the risk of both violence and health care utilization.

Boullin, Ellwood, & Ellis (2016) used a similar intervention and had similar results for patients with acute insomnia in a community setting. They used individual and group formats with similar outcomes for both. A randomized controlled trial using this single session protocol demonstrated effectiveness for the intervention (Ellis, Cushing, & Germain, 2015).

Use of Telemedicine

Since the start of the Covid-19 pandemic, many health care professionals have been providing much of their service by telehealth. While telemedicine has been, to some degree, in use for many years, the pandemic rapidly accelerated its use. It was, therefore, a relief to know that recent research has indicated that providing CBT-I by telehealth is effective (Conroy, et al., 2019). In fact, no difference in factors such as therapeutic alliance and confidence in therapists’ skills were found between live and online sessions.

Insomnia Essential Reads

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The Medical Implications of Insomnia During Pregnancy

CBT-I and Other Sleep and Non-sleep Disorders

CBT-I is helpful in the treatment of patients with sleep apnea that also has insomnia (Sweetman et al., 2020). Cognitive-behavioral therapy can help teenagers who have had sports-related concussions that often result in insomnia. When teens have post-concussive symptoms, about two-thirds experience severe sleep disruption that can interfere with school work and family life—a six-week individual program using CBT-I techniques resulted in rapid improvement in sleep and post-concussive symptoms.

Another recent study showed that CBT-I effectively treated insomnia among cancer survivor patients, and this decrease in insomnia helped reduce their depression (Peoples, et al., 2019).

A study that I was involved with at the Yale Nursing School demonstrated significant improvements in insomnia and fatigue in patients with heart failure and was delivered in a four-session group format (Redeker, et al., 2015).

Non-Medication Treatment Modalities

In addition to CBT-I interventions, several other promising, non-medication techniques are being developed or improved (Chi, Cao, & Gu, 2020). These include repetitive transcranial magnetic stimulation (which is not currently practical to use outside of the laboratory setting) to reduce cerebral arousal. White noise, which has similarities to soothing nature sounds, has been used to help with mood and relaxation and thus facilitate sleep. Meditation is being used more often to help people focus and relax, which could help with sleep onset. Aromatherapy uses calming natural smells to facilitate relaxation. I have had mixed reviews on this one, with some patients finding it extremely helpful and others not so much. Phototherapy, in which light levels are changed in the morning and before bedtime to optimize the circadian rhythm, can be very helpful to people who have circadian dysrhythmia and standard insomnia.

As you can see, cognitive-behavioral and other innovative approaches promise further improvement in the treatment of insomnia. While medication can be helpful, especially for acute insomnia, other approaches can help ease or eliminate insomnia without the risk of loss of effectiveness, dependency, and the other negative side effects that are often associated with sleeping medication.