Nonmedical Interventions Promising in Insomnia Treatment

Brief behavioral interventions may help short circuit chronic insomnia, new studies suggest.

These tactics include providing care in a single 45-minute session plus a booster session in a primary care office, over the course of a 28-hour stay in a sleep laboratory, or even by phone.

The new strategies are variants of cognitive-behavioral therapy for insomnia (CBT-I). Developed over the past two decades, CBT-I equals or surpasses hypnotic medications in helping people with chronic insomnia fall asleep faster, stay asleep longer, and sleep more restfully, noted Michael Sateia, M.D., a professor of psychiatry and chief of sleep medicine at Dartmouth Medical School (See Original article: CBT: Familiar Name, Different Approach for more information).

CBT-I typically involves four to eight weekly individual or group-therapy sessions to teach principles and practices that foster sleep. While medications may improve sleep faster than CBT-I, benefits gained with CBT-I last longer—at least two years after formal therapy concludes, said Sateia, who chaired one of two symposia exploring innovations in CBT-I at the annual meeting of the Associated Professional Sleep Societies in Minneapolis this summer.

An estimated 20 million people in the United States have chronic insomnia, but the paucity of clinicians with expertise in CBT-I limits availability of this treatment. Only 107 doctoral-level sleep specialists—mostly psychologists—have earned the American Academy of Sleep Medicine's certification in behavioral sleep medicine, demonstrating skill in CBT-I and other behavioral interventions.

Training psychologists in fields other than sleep medicine, as well as nurses, physician assistants, and perhaps others to deliver entry-level CBT-I, Sateia suggested, would allow doctoral-level specialists to concentrate on training, supervision, and treatment of patients with complicated problems.

Brief Behavior Treatment Successful

A brief behavioral treatment for insomnia (BBTI) developed in the Department of Psychiatry at the University of Pittsburgh School of Medicine both improves sleep and lowers anxiety and depression in adults aged 60 and older, with benefits lasting up to 12 months, reported Daniel Buysse, M.D., a professor of psychiatry there.

BBTI involves a single 45-minute session in the primary care clinic or another office setting in which a master's level nurse presents a workbook explaining the benefits of regularizing daily schedules and limiting time in bed to time spent asleep.

Patients also receive personalized instructions keyed to sleep diaries they kept prior to the BBTI session. They are advised to get up at the same time every day regardless of how long they slept, go to bed only when sleepy, and get out of bed if wakefulness persists. They return for a 30-minute booster session two weeks later.

About 50 percent of more than 30 older adults randomly assigned to receive BBTI experienced remission of their chronic insomnia, while 90 percent reported some improvement at a session four weeks after treatment. Most maintained their improvement or showed further gains at a follow-up six months after treatment The BBTI group improved significantly more than did control patients given brochures describing good sleep habits—routine care in many primary care offices, said Buysse, who directs this ongoing study.

The researchers aim to develop an effective treatment for use in primary care settings where three-fourths of people seeking help for insomnia receive their care. “A brief intervention won't cure everyone,” Buysse said, “but it permits triaging of patients.” His group published preliminary findings from their study in the October 2006 Journal of Clinical Sleep Medicine.

Sleep Retraining Shows Promise

Australian researchers devised a method of intensive sleep retraining to treat chronic primary insomnia, aiming to show people with habitual trouble falling asleep that they can fall asleep quickly, said Leon Lack, Ph.D., a professor of psychology at Flinders University of South Australia.

For this treatment, 17 volunteers with a mean age of 39 spent 25 to 28 hours in the sleep laboratory. Starting about two hours before their usual bedtime, they were told to “lie down, relax, and let yourself fall asleep.”

Left alone in a quiet, dark bedroom, they were monitored via electroencephalography to determine sleep onset and then allowed to sleep for up to four minutes. If they did not fall asleep, the trial stopped after 25 minutes. The next trial began 30 minutes after the start of the previous one. Each participant completed at least 50 such sleep-onset trials over the 25- to 28-hour treatment period.

Between trials, participants stayed in bed awake, reading, watching videos, or chatting with the experimenter. They were sent home early enough the next evening to go to bed at their usual time.

Two months after the therapy, participants fell asleep about 30 minutes faster, spent 28 minutes less time awake during the night, and slept about 65 minutes longer than at baseline, Jodie Harris, Lack, and colleagues said in a report in the September Journal of Sleep Research. Participants also reported having less day-time fatigue and less anticipatory anxiety before sleep.

Even though the sleep-deprivation regimen was onerous, participants were impressed with their speed of falling asleep, Lack said. While this labor-intensive treatment is costly, some people may be able to follow a similar routine at home. They could set a timer to wake themselves every 15 minutes and would need to find ways to stay awake for 30 minutes between trials.

Another primary care treatment program reported at the annual meeting involved two face-to-face sessions and two follow-up phone sessions provided by a social worker. It helped 20 older adults with chronic insomnia fall asleep faster and sleep more soundly. “Real world providers in primary care centers can deliver effective treatment,” said Christina McCrae, Ph.D., an assistant professor of psychology at the University of Florida, who led this study.

The American Academy of Sleep Medicine plans to publish an evidence-based guideline on the evaluation and treatment of chronic insomnia with CBT-I and hypnotic medications in the Journal of Clinical Sleep Medicine in the next few months. ▪