Cognitive behavioural therapy for chronic insomnia
Chronic insomnia is the third most common psychological reason for GP consultations – most patients prefer not to take medication to overcome this problem
Cognitive behavioural therapy for insomnia (CBT-i) including the following components: cognitive therapy, stimulus control, sleep restriction, sleep hygiene and relaxation.
CBT-i may be delivered face-to-face, digitally or using a combination of both.
Chronic insomnia, defined as difficulty either getting to sleep or staying asleep for at least 3 nights per week for at least 3 months, with the sleep symptoms causing distress.
Chronic insomnia increases the risk of developing hypertension and diabetes. It also increases the risk of developing or exacerbating anxiety and depressive disorders.
CBT may improve the following outcome measures (based on sleep diary entries):
- insomnia severity
- sleep onset latency (average time to enter sleep after lights out)
- wake after sleep onset (average time spent awake during the night after first entering sleep)
- number of nocturnal awakenings
- total sleep time (average total night time sleep)
- sleep efficiency (total sleep time divided by average time spent in bed)subjective sleep quality.
CBT is as effective as hypnotics but with better long-term effectiveness and fewer side-effects such as dependence and tolerance over time.
Face-to-face CBT may be provided by GPs or by other primary care clinicians such as psychologists.
Several CBT-i programs are available digitally (e.g. online, downloadable, mobile apps, or on CDs). Some of these are stand alone, whereas others are designed to be used in conjunction with face-to-face therapy. Costs range from free to around $350.
Digital options may be preferred by some patients and may also overcome issues of limited access to a clinician for face-to-face therapy.
There are five key components of CBT-i. These are:
Aims to identify, challenge and replace dysfunctional beliefs and attitudes about sleep and insomnia. Such misconceptions may include unrealistic expectations of sleep, fear of missing out on sleep, and overestimation of the consequences of poor sleep.
Behavioural instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associate bed with other stimulating activities. Such instructions include avoiding non sleep activities in the bedroom; going to bed only when sleepy; and leaving the bedroom when unable to sleep for 15–20 minutes, returning to bed only when sleepy.
Behavioural instructions to limit time in bed to match perceived sleep duration in order to increase sleep drive and further reduce time awake in bed. Time allowed in bed is initially restricted to the average time perceived as sleep per night and the adjusted to ensure sleep efficiency remains >85%.
General recommendations relating to environmental factors, physiologic factors, behaviour and habits that promote sound sleep. Specific instructions include advice on control of the bedroom environment, including avoiding visual access to a clock; regular sleep scheduling and avoiding daytime naps; and limiting alcohol, caffeine and nicotine intake, especially before bed.
Any relaxation technique that the patient finds effective can be used to limit cognitive arousal and reduce muscular tension to facilitate sleep. Specific techniques that may be effective include meditation, mindfulness, progressive muscle relaxation, guided imagery and breathing techniques.
and severity of panic attacks are monitored by the patient and are a guide to progress.
Tips and challenges
The effectiveness of digital CBT-i may be improved by clinician support so that patients engage with, and continue therapy. The longer patients engage with treatment the better the outcomes.
Cunnington D, Junge M. Chronic insomnia: diagnosis and non-pharmacological management. BMJ 2016;355:i5819 doi: 10.1136/bmj.i5819.
Trauer M, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive behavioural therapy for chronic insomnia: a systematic review and meta-analysis. Annals of Internal Medicine 2015:163:191-204. doi:10.7326/M14-2841
Ritterband LM, Thorndike FP, Ingersoll KS, Lord HR, Gonder-Frederick Li, Frederick C, et al. Effect of a web-based cognitive behaviour therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. JAMA Psychiatry 2017;74(1):68-75. doi:10.1001/jamapsychiatry.2016.3249
Zachariae R. Lyby MS, Ritterband LM, O’Toole MS. Efficacy of internet-delivered cognitive-behavioural therapy for insomnia – a systematic review and meta-analysis of randomised controlled trials. Sleep Medicine Reviews 2016;30:1-10