Making the Case for Cognitive Behavioral Therapy for Insomnia Treatment

By Brandon R. Peters, MD

Insomnia can be a devastating disorder. Its impacts on quality of life can be significant. Effective treatment of insomnia may be elusive. Unfortunately, sleeping pills have side effects and may be dangerous or ineffective. Cognitive behavioral therapy for insomnia (CBTI) can be helpful, and online therapy may make the treatment more accessible for millions of people in need of it.

The Costs Associated with Untreated Insomnia

It is miserable to experience insomnia. Difficulty falling or staying asleep that occurs for at least 3 nights per week, for at least 3 months, is defined as chronic insomnia (1). More than 30 minutes is often spent awake at night, on average, but hours can be lost struggling to sleep. There are common symptoms associated with insomnia, including:

• Fatigue
• Decreased energy
• Poor concentration
• Short-term memory loss
• Mood problems (anxiety or depression)
• Headache or pain complaints
• Feeling unwell (malaise)
• Upset stomach (dyspepsia)

Beyond these complaints, insomnia can be associated with increased risks of drug or alcohol abuse, suicide, and other psychiatric disorders like bipolar disorder or schizophrenia (2). There may be higher rates of errors at work and accidents (3). The associated sleep deprivation may also lead to poor weight control, cardiovascular disease, immune dysfunction, and even cancer (4).

There is a high incidence of chronic insomnia: it is the most common sleep complaint seen in the primary care setting. Chronic insomnia affects approximately 10% of the population (5). It may occur more in certain groups, in particular among older people and women.

The costs associated with untreated insomnia are high. It is estimated that at least $10 billion per year is spent to treat insomnia in the United States. When factoring in the expenses to treat associated medical problems and lost work time and productivity, the figure climbs to a staggering $100 billion per year (6).

Not only does someone with insomnia suffer from poor, restless sleep—they are robbed of daytime function, productivity, and quality of life. This often leads to a desperate search for a solution.

An Empty Promise: Seeking Insomnia Relief with Sleeping Pills

When insomnia persists, the most commonly sought treatment is the use of over-the-counter or prescription sleep aids and sleeping pills. Though of modest benefit, there can be significant side effects and long-term harms associated with their use.

According to the Centers for Disease Control, it is estimated that between 2005 and 2010 about 4% of adults who were 20 or older had used a sleeping pill in the previous month (7). The number of prescriptions for sleeping pills is increasing. Yet how effective are these drugs, really?

Scientific research is able to provide some answers (8). Over-the-counter sleep aids often contain melatonin or diphenhydramine (sold as Benadryl, Tylenol PM, Advil PM, Aleve PM, ZzzQuil, etc.). Based on limited research, these medications reduce the time it takes to fall asleep by a mere 8 to 9 minutes. Moreover, the increase in total sleep time with the use of diphenhydramine is just 12 minutes.

The most commonly prescribed medication for the treatment of insomnia is the hypnotic drug called zolpidem (sold under the brand names Ambien, Ambien CR, and Intermezzo). It affects memory, making someone unaware of being awake, but only modestly enhances sleep. Research suggests that it reduces the time to fall asleep by 5 to 12 minutes, on average. It reduces the time spent awake at night by 25 minutes. As a result, the average increase in total sleep time is about 29 minutes.

Even the newest medication, suvorexant (or Belsomra), is somewhat underwhelming in its effects. Research suggests it only makes it easier to fall asleep by 8 minutes and increases the total sleep time by just 10 minutes.

Unfortunately, most prescription drugs are no better. These medications may affect the memory of wakefulness without substantially adding to sleep quantity or quality. Many times drugs used as sleep aids are incompletely effective, and if they do help, they seem to stop working over time.

Dangers of Using Sleeping Pills to Treat Insomnia

Beyond the lack of efficacy, there are significant side effects associated with these medications. Some effects may be harmless, such as an increase in the incidence of dreams or nightmares that occurs with melatonin use. Others may be more concerning.

All medications have potential side effects, and they may be somewhat unique to the agent used. Broadly speaking, research has demonstrated sleeping pills increase the risk of falls and resultant hip fractures, urinary retention, confusion or delirium, sleep-related behaviors, and morning hangover effects that may affect driving safety (9). More startling, these drugs seem to double the risk of overall mortality and are being linked to the development of dementia (10, 11, 12, 13).

These dangers can—and must—be avoided.

Doctors Recommend Cognitive Behavioral Therapy for Insomnia (CBTI)

Due to the modest improvements associated with sleeping pill use and the potential short- and long-term harms, major medical associations are beginning to recommend a change in the treatment of chronic insomnia through the issuance of national guidelines. In particular, cognitive behavioral therapy for insomnia (CBTI) is being heralded as a preferred treatment choice.

After reviewing the available data regarding the use of sleeping pills, the American Academy of Sleep Medicine offered weak recommendations for many drugs and suggested abstaining from many common agents, including melatonin, diphenhydramine, and trazodone due to the potential harms outweighing the benefits. Instead, CBTI has been recommended as the gold standard treatment for insomnia that lasts a prolonged period (14).

In 2016, the American College of Physicians also recommended that all adult patients receive CBTI as the initial treatment for chronic insomnia. Before sleeping pills are offered, our nation’s primary care providers have been advised to prescribe CBTI (15).

It cannot be overstated how much this represents a major paradigm shift in the recommended treatment of insomnia. Before reaching for a prescription pad, our doctors are now told to offer their patients the opportunity to resolve their insomnia with CBTI. The scientific research strongly supports these national recommendations, and resources exist to make this treatment more accessible.

This should prompt anyone with insomnia to seek out more information on this potential treatment option.

This three-part series entitled, Making the Case for CBTI, continues with the next article “What Is CBTI? The Pros and Cons of Insomnia Therapy” and concludes with “A CBTI Revolution? Making the Case for Online Insomnia Therapy.”

Brandon R. Peters, MD, is the creator of Insomnia Solved, an online CBTI program, the writer on sleep for Verywell.com, a neurology-trained sleep medicine specialist at Virginia Mason in Seattle, and clinical faculty affiliate at the Stanford Center for Sleep Sciences and Medicine. This Center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. To learn more, visit us at: sleep.stanford.edu.

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