According to new research, a combination of cognitive and behavioral strategies, ideally delivered in-person by a therapist, maximizes the benefits of cognitive behavioral therapy forinsomnia (CBT-I). CBT-I is a form of talk therapy, which can be delivered in person or through self-help guides.
The results of the study were published in the journal JAMA Psychiatry.
Chronic insomnia: a combination of cognitive-behavioral strategies comes to the rescue
By analyzing 241 studies, involving over 30,000 adults, researchers identified the most beneficial components of CBT-I. These included: cognitive restructuring, third wave components, sleep restriction, stimulus control, and in-person birth.
Self-help with human encouragement could also be helpful, while waiting for active treatment and applying relaxation procedures appeared to be potentially harmful. Hopefully, understanding which components of CBT-I may offer the most benefit will help practitioners help their patients with insomnia get a better night's sleep.
It's time for bed but your mind is racing. Maybe you wake up multiple times during the night or wake up early in the morning feeling unrested. It is estimated that up to a third of adults suffer from insomnia at some point, and between 4% and 22% chronically.
Chronic insomnia can impact daily life, making it difficult to function when awake or causing distress. More severe cases may require support and treatment, and a drug-free option is cognitive behavioral therapy for insomnia.
CBT-I is a form of therapy that uses educational, cognitive, or behavioral strategies to help patients improve the quality of their sleep. It can be delivered in person or online, via an app or guide, with the support of a therapist, or independently.
Previous studies have shown that CBT-I can be a beneficial, low-risk option for patients with chronic insomnia. However, because it encompasses a wide range of strategies that can be delivered in different ways, it has been difficult to determine which are most successful and whether all are necessary for a patient to experience improvement.
A team led by researchers from Tokyo University Hospital analyzed 241 studies on chronic insomnia from 1980 to 2023, to try to link the different strands of CBT-I with their findings. The studies included 31,452 adult participants, mostly from North America and Europe, with an average age of 45.4 years.
“We expected to find some behavioral components (such as sleep restriction and stimulus control) beneficial, but it was surprising to find that some cognitive components (such as cognitive restructuring and third wave components) were also effective,” Yuki explained Furukawa, lead author and physician at University Hospital.
Using a statistical method called component network meta-analysis, the team classified the effects of different interventions. According to their findings, although following a self-help guide with encouragement from other people was helpful, in-person interaction with a therapist was more beneficial.
Other critical components included: cognitive restructuring (ability to identify, challenge, and change unhelpful beliefs about sleep), sleep restriction (limit time spent in bed), stimulus control (reassociating bed with sleep), and third-wave components (awareness , acceptance and commitment therapy).
On the other hand, sleep hygiene education (explaining the biology of sleep and providing lifestyle and environmental recommendations) did not appear to be essential. Trying to follow relaxation procedures (such as structured physical or cognitive exercises) may be counterproductive, while having to consciously wait for treatment to begin appears to have a detrimental effect.
“Overall, our findings identified several essential components of CBT-I that can lead to an intervention that maximizes treatment effectiveness, minimizes treatment burden, and increases scalability, i.e., makes it easier to offer this treatment to more patients . Further large-scale studies are needed to confirm these contributions,” Furukawa said.
“We hope that our research will encourage practitioners interested in CBT-I to learn simplified CBT-I, so that in turn more people suffering from insomnia can be offered this relatively simple, non-invasive but potentially powerful psychotherapy.” .
In a new Annal “Beyond the guidance,” a clinical psychologist and a sleep doctor discuss the management of a patient with chronic insomnia who has been treated with medications. All “Beyond the Guidelines” features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in the Annals of Internal Medicine.
Insomnia, characterized by persistent sleep difficulties associated with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. Recent guidelines published by the American Academy of Sleep Medicine (AASM) recommend multicomponent cognitive behavioral therapy (CBT) and a limited number of medications that may be helpful for insomnia.
BIDMC Grand Rounds discussants Eric S. Zhou, Ph.D., assistant professor at Harvard Medical School and clinical psychologist at Dana-Farber Cancer Institute, and Eric Heckman, M.D., instructor at Harvard Medical School and cancer specialist sleep and pulmonologist at Beth Israel Deaconess Medical Center, discuss the case of a 64-year-old man who for decades had difficulty falling asleep and woke up early in the morning.
Many years ago the patient was prescribed zolpidem, which was initially taken as needed, but is now a daily necessity for sleep. More recently, trazodone was added to his regimen. The patient was also diagnosed with obstructive sleep apnea (OSA).
In their assessment, both Drs. Zhou and Heckman agree that CBT is the preferred intervention in the situation of the patient with insomnia. Dr. Heckman would first evaluate and treat the patient for OSA and other comorbid conditions such as restless legs syndrome that may affect his or her sl
eep, while Dr. Zhou would dispel the common belief that all patients require 8 hours of sleep per night as part of your treatment.
Dr. Zhou and Mr. F will also work together to identify your individual sleep needs through a structured process that involves sleep restriction and then expansion.
Dr. Heckman would consider a streamlined, clinic-based behavioral intervention focused on sleep restriction and stimulus control if CBT was not accessible or acceptable to the patient with insomnia.
He would not insist on immediate withdrawal of the drugs, but would attempt to discontinue the trazodone followed by a reduction in the zolpidem dose over time, depending on tolerance.
Multicomponent cognitive behavioral therapy is strongly recommended for the treatment of chronic insomnia in adults.
Jack D. Edinger, Ph.D., of National Jewish Health in Denver, and colleagues conducted a systematic literature review to evaluate the relevant literature and quality of evidence to develop recommendations for behavioral and psychological treatments for chronic insomnia disorder in adults.
The authors strongly recommend that clinicians use multicomponent cognitive behavioral therapy to treat chronic insomnia disorder in adults.
Conditional recommendations include the use of stimulus control and sleep restriction therapy and relaxation therapy as single-component therapies for the treatment of chronic insomnia disorder in adults.
Sleep hygiene is not recommended as a one-component therapy for the treatment of chronic insomnia disorder.
“Although sleep hygiene is often suggested and well understood by patients, the [raccomandazioni] on sleep hygiene are not an effective therapy in their own right,” Edinger said in a statement. Several authors have disclosed financial ties to the pharmaceutical and medical technology industries.
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