Chronic insomnia best treated with psychotherapy 1st

People with chronic insomnia should try cognitive behavioural therapy before medications, suggests a prominent group of U.S. doctors.

While the American College of Physicians (ACP) can't say cognitive behavioural therapy (CBT) outperforms medications for chronic insomnia, the group does say psychotherapy is less risky than drugs.

"Sometimes we forget that sleep medications have the potential for serious side-effects in some patients, while cognitive behavioural therapy is very low [risk] to patients," said Dr. Wayne J. Riley, ACP president.

"The evidence is clear that CBT and sleep hygiene can be long lasting, life long, durable and delivered at a lower cost," said Riley, who is also affiliated with Vanderbilt University in Nashville.

About 6 to 10 per cent of people in the U.S. have insomnia. Through loss of productivity, the condition is estimated to have cost the country about $63 billion US in 2009, according to the ACP committee that wrote the new guideline, which is published in the Annals of Internal Medicine.

Chronic insomnia is defined as at least three restless nights per week for at least three months.

"We wanted to take a deep dive into the literature for what makes a big difference with insomnia," Riley told Reuters Health.

The ACP commissioned two reviews of insomnia treatments. One focused on medications, and the second focused on psychological and behavioural treatments.

Medication and 'sleep driving' 

Overall, the first review found that some medications may improve sleep over a short period of time, but those come with the potential for changes in thinking and behaviour. Additionally, there is a risk for infrequent but serious harms.

The U.S. Food and Drug Administration says medications for insomnia should only be used for short periods. The agency warns those drugs may impair people during the daytime, lead to "sleep driving," behavioural changes and worsening depression.

The review of psychological and behavioural treatments found that CBT for insomnia improved overall sleep with a low risk of harms, the researchers report.

Evidence collected separately for the two reviews found that "side-effects can be quite severe with the use of insomnia medications in contrast to CBT, where there are minimal side-effects," said Riley.

CBT for insomnia is typically delivered in four to six one-hour weekly sessions. People are taught behavioural techniques such as sleep restriction and stimulus control, and they are also taught sleep hygiene.

When chronic insomnia isn't helped by CBT alone, the ACP advises patients and doctors to consider a short course of medication. That discussion should touch on the potential benefits, harms and costs of medication, the ACP says.

Doctors should encourage patients with insomnia to engage in CBT, according two researchers whose editorial was published with the reviews and the guideline.

'Prescription not the best solution in the long term'

But, they admit, CBT for insomnia might not be covered by insurance and is likely not available at doctors' offices, write Dr. Roger Kathol, of the University of Minnesota in Minneapolis, and J. Todd Arnedt, of the University of Michigan Medical School in Ann Arbor.

"Unless access to and unencumbered payment for value-based behavioural interventions, such as CBT (for insomnia), in medical settings become a reality, patients with chronic insomnia will continue to receive suboptimal treatment and experience suboptimal outcomes," they write.

Alternatives to in-person CBT for insomnia include group therapy session, telephone counseling, online lessons and self-help books, Riley said.

The ACP recommendations are similar to that of the American Academy of Sleep Medicine (AASM), said Dr. Alcibiades Rodriguez, who is medical director of NYU Langone Medical Center's Comprehensive Epilepsy Center-Sleep Center in New York City.

The AASM's 2008 practice guidelines for treating chronic insomnia endorse psychotherapy as a first-line treatment and suggests it be used when medications are prescribed.

"The recommendations made by the ACP will appeal to a broader group of physicians to make them aware of this," said Rodriguez, who was not involved with the new recommendations. "Then the doctors know just giving patients who come to their office with sleep problems a prescription is not the best solution in the long term."