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Cognitive behavioral therapy (CBT) interventions—particularly stimulus control and sleep hygiene—are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of recommendation: A, based on systematic reviews). The long-term efficacy of CBT interventions, and their successful implementation by primary care physicians (as compared with behavioral science providers), is unclear.
Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK
A large proportion of people in my patient population are shift workers, so chronic insomnia plays a large role in my daily workload, both directly and indirectly. This summary tells me that I have a proven and equally efficacious alternative to drugs for these sufferers—which is great.
However, I was disappointed to see that none of the CBT interventions were performed by family physicians in the office. So the good news is that I have a nondrug intervention for insomnia; the bad news is I don’t know if it’s something I can provide without a referral. Maybe it’s time for some practice-based research to see if that is possible.
Evidence summary
Approximately 10% to 15% of adults complain of chronic insomnia, best defined as difficulty initiating or maintaining sleep 3 or more nights per week for 6 months or longer, with secondary impairments in daytime functioning, including fatigue and disturbed mood.1-3
Behavioral and psychological treatments have emerged as increasingly popular adjunctive interventions to pharmacotherapy and as independent interventions for chronic insomnia. No evidence exists that behavioral treatments have adverse effects.1
Sleep hygiene, relaxation training, and cognitive therapy improve sleep
CBT interventions are based on the notion that distorted thoughts about sleep and learned behavior patterns hyperarouse the central nervous system and deregulate sleep cycles, resulting in chronic insomnia.4 CBT interventions combine empirically tested behavioral, cognitive, and educational procedures to alter faulty beliefs and attitudes, modify sleep habits, and regulate sleep-wake schedules.3
These interventions include stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy.5 These methods can be used separately; however, they are increasingly being used together to treat the complexities of individual patients.5
Five recent high-quality randomized control trials (RCTs) confirmed findings from earlier RCTs that CBT methods improve sleep.5 Compared with those given a placebo or placed on a waiting list, CBT-treated patients in these RCTs reported clinically significant improvements in sleep onset latency, sleep efficiency, time awake after sleep onset, and total sleep time. In one RCT, 64% of CBT patients had improvements in sleep efficiency and time awake after sleep onset, compared with 8% who improved with a placebo intervention (number needed to treat [NNT]=1.8).5 Further, sleep onset latency for primary care patients with chronic insomnia was decreased from 61 to 28 minutes, compared with 74 to 70 minutes for a waiting-list group.5 The maintenance of sleep gains from CBT beyond 1 year is unknown since no published RCT clinical trials to date have lasted longer than 12 months.1
An important related meta-analysis of 21 studies validated behavior therapy, and revealed CBT reduced sleep onset latency by an additional 8.8 minutes over medication (95% confidence interval, 0.17–1.04 minutes).6 Although not superior on other outcomes, behavior therapy produced similar short-term results to pharmacotherapy across all other sleep measures, without attendant medication side effects.
Stimulus control is the most effective CBT intervention
A recent systematic review with meta-analysis of 37 clinical investigations determined that stimulus control was the most effective CBT intervention.3 Stimulus control consists of 5 basic instructions (TABLE) designed to help the patient reassociate sleep stimuli (ie, bed/bedroom) with falling asleep and establishing consistent sleep-wake schedules. These 5 instructions are frequently used in combination with CBT sleep hygiene techniques (TABLE) and can be easily integrated into the office setting.3,4
Among the CBT techniques, stimulus control and sleep hygiene are the least time-consuming and may be more easily applied in the primary care setting; however, minimal research has been done into the specific incorporation of CBT into primary care settings.
Researchers conducting a single-blind randomized group study in a Veterans Affairs primary care clinic concluded that an abbreviated CBT approach with two 25-minute sessions effectively improved participant sleep onset latency, and time awake after sleep onset.7 Researchers reviewed participants’ sleep logs and a behavioral health provider offered patients a condensed education on sleep hygiene, stimulus control, and sleep restrictions strategies. The study was limited because of small sample size (<25). Generalizability to practice is restricted because sessions were conducted by a behavioral health provider, not a family physician.
TABLE
Patient needs a good night’s sleep? Offer this advice
| STIMULUS CONTROL INSTRUCTIONS3 |
|
| SLEEP HYGIENE INSTRUCTIONS4 |
|
Recommendations from others
The Agency for Healthcare Research and Quality recommends CBT as an effective treatment in the management of chronic .8 It also recommends that further large-scale RCTs be conducted to establish CBT’s effectiveness across subsets of the population of individuals with chronic (ie, gender, age, shift workers, and those with psychiatric illnesses).
The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.9
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.
1. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consensus Science Statement. 2005; 22(2). Available at: consensus.nih.gov/2005/2005InsomniaSOS026main.htm. Accessed on September 4, 2007.
2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.
3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.
4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.
5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.
6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.
7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.
8. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations of chronic insomnia in adults. Evidence report/technology assessment No. 125. (Prepared by the University of Alberta Evidence-based Practice Center, under Contract N. C400000021.) AHRQ Publication No. 05-E021-1. Rockville, Md: Agency for Healthcare Research and Quality. June 2005. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf. Accessed on September 4, 2007.
9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.
Cognitive behavioral therapy (CBT) interventions—particularly stimulus control and sleep hygiene—are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of recommendation: A, based on systematic reviews). The long-term efficacy of CBT interventions, and their successful implementation by primary care physicians (as compared with behavioral science providers), is unclear.
Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK
A large proportion of people in my patient population are shift workers, so chronic insomnia plays a large role in my daily workload, both directly and indirectly. This summary tells me that I have a proven and equally efficacious alternative to drugs for these sufferers—which is great.
However, I was disappointed to see that none of the CBT interventions were performed by family physicians in the office. So the good news is that I have a nondrug intervention for insomnia; the bad news is I don’t know if it’s something I can provide without a referral. Maybe it’s time for some practice-based research to see if that is possible.
Evidence summary
Approximately 10% to 15% of adults complain of chronic insomnia, best defined as difficulty initiating or maintaining sleep 3 or more nights per week for 6 months or longer, with secondary impairments in daytime functioning, including fatigue and disturbed mood.1-3
Behavioral and psychological treatments have emerged as increasingly popular adjunctive interventions to pharmacotherapy and as independent interventions for chronic insomnia. No evidence exists that behavioral treatments have adverse effects.1
Sleep hygiene, relaxation training, and cognitive therapy improve sleep
CBT interventions are based on the notion that distorted thoughts about sleep and learned behavior patterns hyperarouse the central nervous system and deregulate sleep cycles, resulting in chronic insomnia.4 CBT interventions combine empirically tested behavioral, cognitive, and educational procedures to alter faulty beliefs and attitudes, modify sleep habits, and regulate sleep-wake schedules.3
These interventions include stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy.5 These methods can be used separately; however, they are increasingly being used together to treat the complexities of individual patients.5
Five recent high-quality randomized control trials (RCTs) confirmed findings from earlier RCTs that CBT methods improve sleep.5 Compared with those given a placebo or placed on a waiting list, CBT-treated patients in these RCTs reported clinically significant improvements in sleep onset latency, sleep efficiency, time awake after sleep onset, and total sleep time. In one RCT, 64% of CBT patients had improvements in sleep efficiency and time awake after sleep onset, compared with 8% who improved with a placebo intervention (number needed to treat [NNT]=1.8).5 Further, sleep onset latency for primary care patients with chronic insomnia was decreased from 61 to 28 minutes, compared with 74 to 70 minutes for a waiting-list group.5 The maintenance of sleep gains from CBT beyond 1 year is unknown since no published RCT clinical trials to date have lasted longer than 12 months.1
An important related meta-analysis of 21 studies validated behavior therapy, and revealed CBT reduced sleep onset latency by an additional 8.8 minutes over medication (95% confidence interval, 0.17–1.04 minutes).6 Although not superior on other outcomes, behavior therapy produced similar short-term results to pharmacotherapy across all other sleep measures, without attendant medication side effects.
Stimulus control is the most effective CBT intervention
A recent systematic review with meta-analysis of 37 clinical investigations determined that stimulus control was the most effective CBT intervention.3 Stimulus control consists of 5 basic instructions (TABLE) designed to help the patient reassociate sleep stimuli (ie, bed/bedroom) with falling asleep and establishing consistent sleep-wake schedules. These 5 instructions are frequently used in combination with CBT sleep hygiene techniques (TABLE) and can be easily integrated into the office setting.3,4
Among the CBT techniques, stimulus control and sleep hygiene are the least time-consuming and may be more easily applied in the primary care setting; however, minimal research has been done into the specific incorporation of CBT into primary care settings.
Researchers conducting a single-blind randomized group study in a Veterans Affairs primary care clinic concluded that an abbreviated CBT approach with two 25-minute sessions effectively improved participant sleep onset latency, and time awake after sleep onset.7 Researchers reviewed participants’ sleep logs and a behavioral health provider offered patients a condensed education on sleep hygiene, stimulus control, and sleep restrictions strategies. The study was limited because of small sample size (<25). Generalizability to practice is restricted because sessions were conducted by a behavioral health provider, not a family physician.
TABLE
Patient needs a good night’s sleep? Offer this advice
| STIMULUS CONTROL INSTRUCTIONS3 |
|
| SLEEP HYGIENE INSTRUCTIONS4 |
|
Recommendations from others
The Agency for Healthcare Research and Quality recommends CBT as an effective treatment in the management of chronic .8 It also recommends that further large-scale RCTs be conducted to establish CBT’s effectiveness across subsets of the population of individuals with chronic (ie, gender, age, shift workers, and those with psychiatric illnesses).
The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.9
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.
Cognitive behavioral therapy (CBT) interventions—particularly stimulus control and sleep hygiene—are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of recommendation: A, based on systematic reviews). The long-term efficacy of CBT interventions, and their successful implementation by primary care physicians (as compared with behavioral science providers), is unclear.
Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK
A large proportion of people in my patient population are shift workers, so chronic insomnia plays a large role in my daily workload, both directly and indirectly. This summary tells me that I have a proven and equally efficacious alternative to drugs for these sufferers—which is great.
However, I was disappointed to see that none of the CBT interventions were performed by family physicians in the office. So the good news is that I have a nondrug intervention for insomnia; the bad news is I don’t know if it’s something I can provide without a referral. Maybe it’s time for some practice-based research to see if that is possible.
Evidence summary
Approximately 10% to 15% of adults complain of chronic insomnia, best defined as difficulty initiating or maintaining sleep 3 or more nights per week for 6 months or longer, with secondary impairments in daytime functioning, including fatigue and disturbed mood.1-3
Behavioral and psychological treatments have emerged as increasingly popular adjunctive interventions to pharmacotherapy and as independent interventions for chronic insomnia. No evidence exists that behavioral treatments have adverse effects.1
Sleep hygiene, relaxation training, and cognitive therapy improve sleep
CBT interventions are based on the notion that distorted thoughts about sleep and learned behavior patterns hyperarouse the central nervous system and deregulate sleep cycles, resulting in chronic insomnia.4 CBT interventions combine empirically tested behavioral, cognitive, and educational procedures to alter faulty beliefs and attitudes, modify sleep habits, and regulate sleep-wake schedules.3
These interventions include stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy.5 These methods can be used separately; however, they are increasingly being used together to treat the complexities of individual patients.5
Five recent high-quality randomized control trials (RCTs) confirmed findings from earlier RCTs that CBT methods improve sleep.5 Compared with those given a placebo or placed on a waiting list, CBT-treated patients in these RCTs reported clinically significant improvements in sleep onset latency, sleep efficiency, time awake after sleep onset, and total sleep time. In one RCT, 64% of CBT patients had improvements in sleep efficiency and time awake after sleep onset, compared with 8% who improved with a placebo intervention (number needed to treat [NNT]=1.8).5 Further, sleep onset latency for primary care patients with chronic insomnia was decreased from 61 to 28 minutes, compared with 74 to 70 minutes for a waiting-list group.5 The maintenance of sleep gains from CBT beyond 1 year is unknown since no published RCT clinical trials to date have lasted longer than 12 months.1
An important related meta-analysis of 21 studies validated behavior therapy, and revealed CBT reduced sleep onset latency by an additional 8.8 minutes over medication (95% confidence interval, 0.17–1.04 minutes).6 Although not superior on other outcomes, behavior therapy produced similar short-term results to pharmacotherapy across all other sleep measures, without attendant medication side effects.
Stimulus control is the most effective CBT intervention
A recent systematic review with meta-analysis of 37 clinical investigations determined that stimulus control was the most effective CBT intervention.3 Stimulus control consists of 5 basic instructions (TABLE) designed to help the patient reassociate sleep stimuli (ie, bed/bedroom) with falling asleep and establishing consistent sleep-wake schedules. These 5 instructions are frequently used in combination with CBT sleep hygiene techniques (TABLE) and can be easily integrated into the office setting.3,4
Among the CBT techniques, stimulus control and sleep hygiene are the least time-consuming and may be more easily applied in the primary care setting; however, minimal research has been done into the specific incorporation of CBT into primary care settings.
Researchers conducting a single-blind randomized group study in a Veterans Affairs primary care clinic concluded that an abbreviated CBT approach with two 25-minute sessions effectively improved participant sleep onset latency, and time awake after sleep onset.7 Researchers reviewed participants’ sleep logs and a behavioral health provider offered patients a condensed education on sleep hygiene, stimulus control, and sleep restrictions strategies. The study was limited because of small sample size (<25). Generalizability to practice is restricted because sessions were conducted by a behavioral health provider, not a family physician.
TABLE
Patient needs a good night’s sleep? Offer this advice
| STIMULUS CONTROL INSTRUCTIONS3 |
|
| SLEEP HYGIENE INSTRUCTIONS4 |
|
Recommendations from others
The Agency for Healthcare Research and Quality recommends CBT as an effective treatment in the management of chronic .8 It also recommends that further large-scale RCTs be conducted to establish CBT’s effectiveness across subsets of the population of individuals with chronic (ie, gender, age, shift workers, and those with psychiatric illnesses).
The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.9
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.
1. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consensus Science Statement. 2005; 22(2). Available at: consensus.nih.gov/2005/2005InsomniaSOS026main.htm. Accessed on September 4, 2007.
2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.
3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.
4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.
5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.
6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.
7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.
8. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations of chronic insomnia in adults. Evidence report/technology assessment No. 125. (Prepared by the University of Alberta Evidence-based Practice Center, under Contract N. C400000021.) AHRQ Publication No. 05-E021-1. Rockville, Md: Agency for Healthcare Research and Quality. June 2005. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf. Accessed on September 4, 2007.
9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.
1. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consensus Science Statement. 2005; 22(2). Available at: consensus.nih.gov/2005/2005InsomniaSOS026main.htm. Accessed on September 4, 2007.
2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.
3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.
4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.
5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.
6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.
7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.
8. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations of chronic insomnia in adults. Evidence report/technology assessment No. 125. (Prepared by the University of Alberta Evidence-based Practice Center, under Contract N. C400000021.) AHRQ Publication No. 05-E021-1. Rockville, Md: Agency for Healthcare Research and Quality. June 2005. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf. Accessed on September 4, 2007.
9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.
Evidence-based answers from the Family Physicians Inquiries Network