Michael L. Perlis, PhD
Is targeted treatment for insomnia warranted?
It is a long standing tradition, both within medicine and psychology, to view insomnia as a symptom and not as an independent disease or disorder. As a result, the proper target for treatment has often been viewed as the underlying factors that give rise to the symptoms of disease. Taken together, these considerations have suggested that specific treatment for insomnia is unwarranted. Further, implicit in this point of view, is that successful treatment of the underlying primary disorders will result in an amelioration of the insomnia itself. This point of view has, within the sleep research and sleep medicine communities, been called into question with the publication of the following data:
- Insomnia is a substantial risk factor for the development of new onset mental illness e.g., 1,2
- Insomnia often does not resolve with the successful treatment of the primary mental illness conditions e.g.,3,4
- Insomnia represents a risk factor for non-response to standard treatments for primary mental illness conditions e.g.,5
- Insomnia is a significant risk factor for relapse and recurrence of mental illness e.g.,6,7
- Cognitive behavioral therapy for insomnia (CBT-I) has been found to be as effective with insomnia that occurs co-morbidly with other mental illnesses as it is with primary insomnia e.g.,8,9
- Targeted treatment with CBT-I has been shown to produce improvements in what was previously construed as the primary disorders (depression and chronic pain).
The evidence base for these claims has lead to a paradigmatic shift where insomnia will be classified in the DSM-V as a disorder which, when it occurs with other mental illnesses, will be classified as a co-morbid disorder. This change in the psychiatric nosology has set the stage for the point of view that targeted treatment for insomnia is warranted 10-12.
What is the Ideal Treatment for Insomnia?
The ideal treatment for chronic insomnia is CBT-I. The claim that CBT-I is the treatment of choice for chronic insomnia is based on the following findings:
- Pharmacotherapy and CBT-I produce comparable clinical outcomes on pre-to-post, sleep-diary assessed sleep latency, wake after sleep onset, and number of awakenings13-19;
- CBT-I appears to produce fewer adverse events, though this has not been formally assessed;
- There is preliminary data to suggest that CBT-I, at the end of treatment, has positive effects on sleep macro- and micro-architecture (e.g., produces increases in slow wave sleep and non-rapid eye movement [NREM] delta activity and decreases in NREM alpha and beta activity)20;
- CBT-I produces clinical effects that persist beyond treatment discontinuation21;
- CBT-I provides for continued improvement over time (for follow up intervals up to 24 months)21;
- The costs of CBT-I in treatment responders can be amortized in health care savings in less than six months (i.e., the cost of treatment is typically $800 or less where the six month costs of untreated insomnia have been estimated at between $924 [18-64 year olds] and $1143 [65 and older])22,23.
What is CBT-I?
CBT-I is a form of the acronym “CBT”. The addition of the “I” is intended to elicit the response “I know what CBT is, but what the heck is CBT-I?!” CBT-I stands for Cognitive Behavioral Therapy for Insomnia. This form of CBT is a multi-component treatment that targets specifically sleep continuity disturbance (difficulty initiating sleep, maintaining sleep, or both) and is typically comprised of stimulus control procedures, sleep restriction therapy, and sleep hygiene instructions. While CBT-I often only includes a general form of cognitive therapy which is intended to address adherence issues, there are also a variety of specific cognitive procedures that are used with the above three interventions including paradoxical intention procedures, sleep education, decatastrophization, and behavioral experiments. Some multi-component forms of CBT-I also include relaxation training.
How Efficacious / Effective is it?
Since the 1930s more than two hundred trials have been conducted on either single interventions for insomnia (stimulus control, progressive muscle relaxation, and sleep restriction) or multi-component interventions that may be characterized as CBT-I. This extensive literature has been quantitatively summarized using meta-analytic statistics on at least three occasions24-26 and there is at least one comparative meta-analysis which evaluates the relative efficacy of CBT-I as compared to benzodiazepine receptor agonists (BZRAs)14. The data from these literatures suggest, consistent with the conclusions of the NIH State of the Science Conference27, that 1) CBT-I is highly efficacious, 2) BZRAs and CBT-I produce comparable outcomes in the short-term and 3) CBT-I appears to have more durable effects when active treatment is discontinued.
Beyond the issue of efficacy, is the issue of effectiveness. That is, are the clinical outcomes observed in clinical trials comparable to investigations of treatment outcome in 1) patients with insomnia comorbid with other medical and/or psychiatric illnesses (e.g.,8,9,28-31) and/or 2) studies of patients who are treated in clinical care settings. (e.g., 32,33). To date, there have been more than 20 studies in patient samples who suffer such co-morbidities as cancer, chronic pain, depression and PTSD. The data from these studies not only show CBT-I to be effective, the clinical outcomes are, by and large, comparable to those found with patients with primary insomnia. In some cases, the effects are actually larger (e.g.,28,31). As noted above, there also have been a variety of clinical case series studies. The effect sizes for these studies also appear comparable to those obtained in randomized clinical trials.
What Resources are Out There to Learn CBT-I?
One of the major challenges for the field is the problem of how to disseminate and implement CBT-I at the national and international levels. That is, how does one go about 1) making the public aware of the CBT-I treatment option, 2) making the relevant professional disciplines aware of the CBT-I treatment option, and 3) putting into place the requisite training and credentialing processes. These represent truly daunting questions and are currently the major focus of the newly established Society of Behavioral Sleep Medicine (SBSM). This said, significant advances have been made in recent years within this domain, particularly with respect to the issues of training and credentialing.
First, there are at least three published treatment manuals which delineate how to conduct CBT-I34-36.
- Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. Michael L. Perlis, Carla Jungquist, Michael T. Smith, Donn Posner, Springer (April 1, 2008).
- Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach Therapist Guide - Treatments That Work. Jack D. Edinger, Colleen E. Carney, Oxford University Press (March 27, 2008).
- Insomnia: A Clinician’s Guide to Assessment and Treatment. Charles M. Morin and Colin A. Espie, Springer; (June 30, 2003).
Second, there are several multi-day courses that are available on an annual or bi-annual basis. One such course, which is largely an introduction to the variety of interventions that comprise Behavioral Sleep Medicine, has been available through the American Academy of Sleep Medicine (AASM) since 2004 and will continue to be available through the SBSM for the foreseeable future (www.behavioralsleep.org/Course.aspx). Another such course, which is a dedicated training seminar in CBT-I, has been offered annually since 2006 through the University of Rochester, and is currently offered through the University of Pennsylvania: www.med.upenn.edu/cbti/index.html.
Third, in 2005 & 2006 the BSM committee of the AASM established training opportunities via the credentialing of BSM fellowships and mini fellowships. This effort is continuing via the SBSM:www.behavioralsleep.org/Articles.aspx?id=2686.
Fourth, as result of the vision and generosity of the AASM, there is (as of 2004), a credentialing board for BSM that is underwritten and administered by the academy:www.behavioralsleep.org/Certification.aspx.
What are the Barriers to Acess CBT-I?
First, many patients with insomnia are not aware of this treatment option. Second, even if aware, most patients will not receive CBT-I simply because there are too few providers trained in its delivery. At present, only 152 individuals in the US are credentialed by the American Board of Sleep Medicine to provide CBT-I, and there is no evidence that CBT-I has been adopted by the clinical communities that have expertise in, and regularly provide, other forms of cognitive behavioral therapy.
It is hoped that this brief summary serves as a reasonable introduction to the current conceptualization of insomnia and to CBT-I. We hope the information here will prompt the membership of the National Register of Health Service Providers in Psychology to obtain the relevant education and training in this area of practice.
Michael Perlis, PhD, is Associate Professor of Psychiatry and Director of the UPenn Behavioral Sleep Medicine Program at the University of Pennsylvania. He is the principle author of the first text book in this field (Treating Sleep Disorders: The Principles and Practice of Behavioral Sleep Medicine, Wiley & Sons) and is the senior author of two textbooks on behavioral sleep medicine interventions for sleep disorders.
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