American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, July 15, 2015

Best treatment for chronic insomnia is cognitive behavioral therapy

I'm having trouble trying to sleep
I'm counting sheep but running out
As time ticks by …
And still I try …
—”Brain Stew” by Green Day from the album Insomniac

Sleep that knits up the raveled sleave of care,
The death of each day's life, sore labor's bath,
Balm of hurt minds, great nature's second course,
Chief nourisher in life's feast.
—Shakespeare, Macbeth

Chronic insomnia affects 5% to 15% of Americans. It is far from only a nighttime problem. As all of us know from occasional sleepless nights, the following day is unproductive and sometimes dangerous. Sleep deprived people are more prone to accidents, and are more likely to have depression, anxiety, diabetes and high blood pressure.

It is no surprise then that many patients seek relief from sleep medications. But most medications are only modestly effective. Many medications also slowly decline in efficacy over time, and some have worrisome side-effects.

Cognitive behavioral therapy (CBT) has been known to be effective for chronic insomnia for some time. CBT is a specific kind of psychotherapy that focuses on thinking and on behavior. It is unlike older kinds of psychotherapy (like psychoanalysis) in that it's much more brief and pragmatic. It has been proven to be effective in many anxiety disorders, and unlike medications, the benefits of CBT have been shown to persist long after the therapy ends. (Four years ago I wrote about the utility of CBT in chronic fatigue syndrome.) CBT for insomnia (CBT-i) usually involves weekly hour-long meetings with a psychologist. The course of therapy can be as brief as 4 to 8 sessions.

Annals of Internal Medicine published a review of prior studies of CBT-i. The study reviewed 20 randomized controlled trials involving over 1,000 participants. CBT-i significantly improved sleep and did not have adverse outcomes. On average, subjects who underwent CBT-i fell asleep 20 minutes faster and spent 30 fewer minutes awake during the night compared with people who didn't undergo CBT-i. This may not seem like a large benefit, but it is the same magnitude as the benefits seen in trials of sleep medications, and without the side-effects that medications can cause. Like other studies of CBT, this review showed that the benefits of CBT-i persist after the therapy ends. This is another positive comparison with medication. At best, the benefits of sleep medication end as soon as the patient stops taking it. At worst, stopping the medication leads to rebound insomnia making the symptoms worse than before the medication was started.

Much of CBT-i focuses on teaching good sleep hygiene–behaviors that promote healthy sleep. These behaviors include avoiding caffeine in the afternoon, avoiding alcohol at bedtime, and not staying in bed for longer than 20 minutes if you can't fall asleep. That last bit of advice may seem counterintuitive, but going to another room until you're feeling sleepy will train you to associate your bed with sleep. For the same reason you should avoid reading, watching TV, or using electronic screens in bed.

A related editorial in Annals of Internal Medicine makes the point that changes in attitude and behavior are necessary to treat other health problems like high blood pressure, obesity, and diabetes. Drug therapy alone is not adequate for these chronic problems. We should not be surprised then that this is also true for chronic insomnia.

So doctors should do a better job of referring patients with chronic insomnia to CBT-i. And patients should realize that there is a safer and more effective option than medication. Of course finding a psychologist who has been trained in CBT isn't always easy, especially outside of large cities. There is also an online CBT-i program for those who can't find or can't afford in-person therapy.

We've known for a long time that chronic sleeplessness is a serious problem. But it turns out that before we can fall asleep we first have to knit up the raveled sleeve of care and balm our hurt minds. As of now, the best way we know to do that is CBT-i.

Learn more:
The Evidence Points to a Better Way to Fight Insomnia (NY Times)
To Beat Insomnia, Try Therapy For The Underlying Cause Instead Of Pills (Shots, NPR's health blog)
Cognitive behavioral therapy offers a drug-free method for managing insomnia (Harvard Health Blog)
Sleep Hygiene (National Sleep Foundation)
SHUTi (an online CBT-i program)
Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis (Annals of Internal Medicine article, abstract available without subscription)
Cognitive Behavioral Therapy for Chronic Insomnia: State of the Science Versus Current Clinical Practices (Annals of Internal Medicine editorial, subscription required)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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