For Insomnia, Consider Cognitive Behavioral Therapy Before Medication

Although many patients with insomnia may leave the doctor’s office with a prescription, new guidelines recommend psychotherapy as the first-line treatment.

7:00 AM

Author | Haley Otman

Insomnia is a debilitating condition. According to the American Academy of Sleep Medicine, it affects up to 35 percent of adults. And about 10 percent of people deal with chronic insomnia disorder, meaning they have difficulties falling or staying asleep at least three nights per week (over a period of at least three months) and the sleep disturbance causes daytime impairment.

SEE ALSO: How Research Brightens the Bipolar Treatment Outlook

In fact, the U.S. spends billions of dollars treating insomnia annually, in addition to an estimated $60 billion in lost productivity alone. Poor sleep affects all aspects of a person's day, from efficiency at work to the ability to safely drive a car to athletic performance, and it is the second most common complaint behind pain reported to primary care doctors.

Prescription sleep aids are a common recommendation from many physicians. But recent guidelines from the American College of Physicians, in the Annals of Internal Medicine, recommend psychotherapy as a first-line treatment for chronic patients instead of medications.

J. Todd Arnedt, Ph.D., associate professor of psychiatry and neurology who specializes in insomnia, co-wrote an accompanying editorial. Arnedt, also director of the University of Michigan's Behavioral Sleep Medicine Program, explains why the recommendations have merit for health care providers, though they may not be widely implemented anytime soon.

What can a patient expect from CBT treatment for chronic insomnia disorder?

Arnedt: First, the provider determines if a CBT approach is appropriate for a particular patient. That first visit includes conversations about what symptoms the patient has, how the insomnia affects daytime functioning and what could be causing or contributing to the insomnia, from other sleep disorders to depression to chronic pain or cognitive factors. Patients who report engaging in behaviors and thought patterns that are thought to perpetuate insomnia are particularly good candidates for this type of treatment.

Once treatment begins, there are usually only four to six CBT visits for insomnia, so it's a shorter course of treatment than CBT for other conditions. CBT for insomnia is a highly structured treatment, with each session focusing on specific cognitive or behavioral techniques that have been demonstrated to improve sleep quality. Patients are then given specific sleep-related recommendations to "practice" at home in between sessions. Over the four to six visits, patients can expect an improvement in both the quality of their sleep at night and the quality of their functioning during the day.

An important element of treatment is the daily sleep/wake diary. We ask patients to record when they go to bed, when they wake up, how long they estimate it took to fall asleep, whether they woke up in the middle of the night and sleep quality. We then use this information to guide recommendations and to evaluate treatment progress. Patients have to be engaged in treatment and be willing to put in some work during the course of treatment in order for their sleep to improve.

The research didn't prove CBT is better than medications, so why should providers consider recommending it on the first try?

Arnedt: We recommend CBT as the first-line choice because the treatment has been shown to be as effective as sleep medicines and the risks are generally lower. CBT has fewer side effects than most of the first-line medications. It's not without side effects, but it's generally a well-tolerated treatment. Some CBT techniques increase sleepiness during the early stages of treatment, which patients find uncomfortable and which can reduce daytime productivity, but it is otherwise a well-tolerated approach.

With sleep medications, patients can build up a tolerance, so the dose becomes less effective over time. That leads to increasing the dose or switching medications to continue treating symptoms effectively. Daytime sedation can also be an issue with some medications. Some patients may also experience changes in thinking and behavior. In elderly patients, there is a concern about increased risk for falls during the night after taking sleep medication.

However, treatment for insomnia does not have to involve only medication or only CBT. There is also emerging evidence to support combination therapy, incorporating CBT strategies into treatment with medication. While this approach has some appeal, the bulk of the evidence indicates that, while medications work more quickly, CBT is equally effective over six to eight weeks and shows superior outcomes to medication in the long term.

If CBT has so many advantages in insomnia treatment, why isn't it more widely used?

Arnedt: The main reason that CBT for insomnia isn't used more widely is that there are too few trained providers to deliver the treatment. 

SEE ALSO: Why U.S. Doctors Love Opioids and Hate Marijuana for Chronic Pain

There are only about 200 providers nationwide with the necessary expertise to adequately deliver CBT for insomnia. Most, like the three of us at U-M, practice at academic medical centers or in specialty clinics. Very few trained CBT for insomnia providers are located in primary care settings, which is where most patients with insomnia are seen initially.

The good news is that there is a movement to expand access by increasing the number of trained providers and delivering interventions through different formats, such as over the phone or online. This opens up an opportunity for untrained providers to undergo additional training in order to deliver CBT for insomnia. However, these models are still likely to fall short of meeting the demand for CBT for insomnia services. We need to continue to devise innovative strategies for improving access to this effective treatment.

Once a patient finds a provider who is equipped to deliver CBT for insomnia, insurance coverage for services can be an issue. In our clinic, however, we find that most behavioral health plans we work with do cover it.

More Articles About: Rounds Sleep Disorders Treatment Insomnia Sleep Disorders
Health Lab word mark overlaying blue cells
Health Lab

Explore a variety of healthcare news & stories by visiting the Health Lab home page for more articles.

Media Contact Public Relations

Department of Communication at Michigan Medicine

[email protected]


Stay Informed

Want top health & research news weekly? Sign up for Health Lab’s newsletters today!

Featured News & Stories couple with kid and medical bill with doctor
Health Lab
Even with private insurance, your child's hospitalization could cost $1,300
Study reveals privately insured families may spend $1,300 out-of-pocket for child hospitalization. High costs impact family wellbeing warns pediatric expert.
brain drawing
Health Lab
Insomnia, sleep apnea contribute to reports of cognitive decline in women with multiple sclerosis
New multiple sclerosis research finds insomnia, sleep apnea contribute to reports of cognitive decline in women.
Hot dog, pizza, hamburgers and fries
Health Lab
1 in 8 Americans over 50 show signs of food addiction
Highly processed foods can act on the brain in ways that spark cravings, emotional reactions and signs of addiction, and a new poll shows how many older adults experience this.
Health Lab Podcast in brackets with a background with a dark blue translucent layers over cells
Health Lab Podcast
Gender-Affirming Therapy May Help Protect Trans Youth From Sleep Disorders
A study finds those who had gender-affirming therapies were less likely to have sleep disorders, suggesting a possible protective effect.
Nurses looking at clipboard with goggles and masks on in clinic
Health Lab
A dual approach to nursing shortages
An education and employment partnership seeks to fill a need for more nurses while also supporting a diverse workforce.
substance use treatment map usa substance use treatment facilities not providing services in sign language <20.0% 20.0%-29.9% 30.0%-39.9% 40%-49.9%
Health Lab
Mental health, substance abuse treatment facilities don't provide communication access to Deaf, Hard of Hearing patients
These services, researchers found, were largely inaccessible to people who use sign language, discriminating against already ‘severely marginalized’ population in the United States.