Sleeping pills are not the only answer to end sleepless and restless nights. On Monday, 2nd May, the American College of Physicians (ACP) published new guidelines in their journal Annals, which suggest chronic insomnia can be treated with a method known as cognitive behavioral therapy (CBT). According to the guidelines, the body can be conditioned to sleep in case of insomnia without having to pop out the pills, but it will take time and effort.

Currently the US Centers for Disease Control and Prevention (CDC) has estimated more than 50-70 million US adults have one or other kind of sleeping disorder, which has turned it into a major health problem. About 6-10% of adults in the US with insomnia meet the diagnostic criteria and more than $30 billion to $107 billion per year is spent on insomnia related health problems.

Insomnia is defined as a condition in which a person has either a hard time going to sleep, restlessness during sleep i.e., waking up repeatedly, inability to sleep again after waking or poor quality and duration of sleep.

CBT is a brief and safe behavioral health intervention for chronic insomnia. CBT interventions have a 70-80% success rate without aid of medication and does not come with any added side effects which is a given when using sleeping medication.

ACP also published their recommendations for the treatment of sleep deprivation. The clinical recommendations are for the management of chronic insomnia disorder in adults and based on a systematic review trials carried out from 2004 till 2015. The test groups in the trial were clinical patients with chronic insomnia disorder. The first recommendation by ACP is to apply CBT as the initial mode of treatment for all sleeping disorders. The second recommendation is to apply ‘decision-making approach’ before prescribing medication for sleeplessness if only the CBT treatment was unsuccessful.

Cognitive Behavioral Therapy is basically the reconditioning of brain and body from restlessness during the night and leading it towards sleep. CBT engages the patients in their sleep patterns by teaching them cognitive and behavioral skills. In CBT a patient with sleeplessness has to undergo 6 or 8 customized sessions, which encourage the insomniacs to change their daytime and sleeping habits. The guidelines note CBT can be unconformable at first but the continued practice of the non-pharmacologic treatment leads to better sleeping habits and improved focus during the day. The guidelines claim CBT can teach the patients such effective sleep behaviors that patients will themselves are able to detect if insomnia is coming on again.

Recognizing Alternatives

The first step of CBT is to recognize there is a psychological alternative to drug therapy which is safer and will accomplish better outcomes. Physicians also need to make the effort and share the info with their patients. Tools such as the Insomnia Severity Index can be used to determine whether a patient is appropriate for CBT. Primary care studies have shown a candidate receiving a score of 14 or greater is suitable for the treatment.

Patient Participation

The second step is the active participation which is very crucial and the patient needs constant instructions and support for it. The patient is educated with thoughts and behaviors that affect sleep. The guidelines caution it may be why a person going through CBT may first worsen before improving in the early phases of treatment. Regular follow-ups and a support system are extremely crucial and may determine if the intervention will be successful or not.

The guidelines also touched the topic of “virtual” CBT or “eCBT” which is the application of the therapy method through mobile devices. The guidelines declared the basic principle of CBT is time and patient engagement, which may not be possible virtually possible.

“A face-to-face intervention has the greatest evidence of efficacy and should be available in medical settings for those who need it. Unfortunately, that is not the world in which we live,” said Roger G Kathol, MD, the lead author of the study. “The ideal solution would involve having CBT-I available to patients in the setting where they usually receive medical care.”

There are some challenges involved with the approach, since finding trained health workers who can deliver CBT is not easy and the alternative treatment is not always covered by health insurance. As a result, only 1 in 9 affected individuals receive the proper behavioral therapy for sleep deprivation through the general health care sector. The guidelines highlighted how the aim of the editorial is to advocate for the addition of CBT payment in medical settings. The evidence provided by the ACP recommendations should push the participants to ask for CBT coverage by medical insurance providers.

“A long-term solution requires a team effort by policymakers, physicians, health care administrators, sleep medicine specialists, and CBT-I therapists,” said Roger G Kathol. “Unless access to and unencumbered payment for value-based behavioral interventions, such as CBT-I, in medical settings become a reality, patients with chronic insomnia will continue to receive suboptimal treatment and experience suboptimal outcomes.”

The ACP also published a review today which states pharmacotherapies for insomnia treatment can lead to cognitive and behavioral changes which may cause serious harm in the long-term.

“Eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known, ” said Timothy J Wilt, MD, MPH, the lead author of the review.