Russell Rosenberg, PhD, spends much of his work in researching new drugs that can help people get to sleep, but the sleep specialist who runs the consulting organization NeuroTrials Research in Atlanta is an advocate of cognitive behavioral therapy for people diagnosed with insomnia.
“Right now, the American Academy of Sleep Medicine says that, if it is available, cognitive behavioral therapy should be strongly considered as an initial sort of treatment for insomnia,” Dr. Rosenberg says.
But there the rub: Availability.
“Cognitive behavioral therapy for insomnia always wins in head-to-head studies with sleeping pills, or are at least as good,” said Steven Feinsilver, MD, director of the Center for Sleep Medicine at Lenox Hill Hospital and professor of medicine at Hofstra Northwell School of Medicine in New York City.
“The reason more doctors don’t use cognitive behavioral therapy is that it takes me about 30 seconds to write a prescription for Ambien and help them,” he says. “Cognitive behavioral therapy requires several half-hour sessions. Psychologists sometimes do it, but most people don’t have insurance to pay for psychologists. Psychiatrists rarely do it.”
“There is strong evidence-based data for cognitive behavioral therapy,” said Jennifer Martin, PhD, a clinical psychologist a professor of medicine at the David Geffen School of Medicine at the University of California at Los Angeles, who also serves on the board of directors for the American Academy of Sleep Medicine.
“The American College of Physicians, a couple of years ago, recommended cognitive behavioral therapy for first-line treatment over and above medication for insomnia,” Dr. Martin says. “For the most part, I help people get off sleeping pills.”
How she does it is with a short course of psychotherapy. “Usually it involves seeing a mental health provider five or six times,” Dr. Martin says, “focusing on the stress and anxiety that goes with not being able to sleep and working hard on some of the behavioral habits that people who haven’t slept for a long time tend to develop, and coming up with a structured plan and working on getting better quality sleep. That treatment is highly effective. It works in terms of significant treatment response in two-thirds to three-quarters of patients.”
As with any medical treatment, Dr. Martin says that the first step in cognitive behavioral therapy is getting a good patient history. “We try to figure out if this is something that is newly developed; has it been going on for a long time; what are the factors that might have triggered the insomnia problem; are they still going on or have they resolved — really trying to understand the real causes, and then the factors that are maybe keeping the problem going over time,” she says. “That’s the beginning.”
Then people are asked to track their sleep, she says. “Most people do it with a sleep diary, either on an app or something like that or just paper and pencil. There are some issues with some of the consumer wearables such as a FitBit in terms of measuring when someone wakes up in the middle of the night and things like that. We still rely on patient report,” Dr. Martin says.
Using the patient diary, providers make recommendations based on the patient’s individual sleep habits, she says. “An example I like to use is: If you live in the suburbs far away from Los Angeles and you have to commute downtown every day for work, you have to get up at 5 a.m.,” she explains. “I’m not going to tell you that you should get up at 7 because that’s not going to work for you. So, we are going to have to come up with a plan to treat your insomnia that includes getting up at 5 a.m. so you can go to work.
“Whereas if you are a freelance writer and you set your own schedule and you feel better if you can sleep until 9, well, our treatment plan would involve getting you good sleep and allow you to get up at 9,” Dr. Martin says.
“It is individualized, but it is based on underlying principles which is that people need to be in bed for the right amount of time, not too long and not too short,” she says. “Some people may need 8 hours of sleep to feel rested, so they should be in bed for 8 hours and 15 minutes. Someone else might feel well rested if they get 6 and a half good hours and they might need to be in bed only for 6 hours and 45 minutes.
“We start by trying to figure that out and make our best guess in the beginning,” Dr. Martin says. “Most people need at least 7 hours, but there are exceptions to that as well. How you feel during the day is the best way to decide if you are getting enough sleep. There is no good one size fits all answer. But there is a number for each person.”
“When I am trying to get someone to sleep again,” says Dr. Feinsilver, “I start with the wake-up times and go backwards. Rule Number 1 is: Pick a wake-up time, and I don’t particularly care what it is. Choose one and stick to it. Pretty much, 7 days a week. You can adjust it a little bit, but is should be pretty close to 7 days a week.
“In the morning, if you want to turn your brain on, go outside — depending on the time of the year — but getting exposed to light is really important,” he says. “Light is what turns the brain on. It’s what sets your body clock. Exercise and food are also important. But mostly in the morning pick a time. Get up. Go outside. Then, we work backwards from the wake-up time.”
Dr. Feinsilver and his patients determine how much sleep is needed for that person. “If you decide you need 7 hours of sleep, then if you are getting up at 7, no matter what else is going on, do not go to bed any earlier than about midnight. Later is okay, but no earlier.
“We are only allowing you to be in bed for about the number of hours you are going to sleep,” he says. “The behavioral trick is to try to associate that going to bed means going to sleep. What annoys people with insomnia is the time in bed and not sleeping.”
Sometimes that takes a few days. “Your first few nights could be terrible,” Dr. Feinsilver says. “You go to bed at midnight and still don’t sleep and only get about 4 hours of sleep, and you still have to get up at 7 when the alarm goes off. If you keep yourself awake until midnight the second, third and fourth nights, you are going to sleep most of those hours.
“And that, in a nutshell is the behavioral treatment of sleep. It works, if you can get people to do it,” he says.
If you can’t find a clinician to help you, or you can’t afford one, Dr. Martin suggests another way to get help. “There are multiple ways to get the treatment – most people will see a provider, but there are some really good self-guided treatments,” Dr. Martin says.
“One is called Insomnia Coach. It is a free app developed through a partnership between the Department of Defense and the Department of Veterans Affairs, which is a self-guided cognitive behavioral therapy,” she says. “It is a great resource for people who either want to do a self-guided treatment or who don’t have access to a mental health provider who knows how to treat insomnia. That is the safest and most effective available treatment for somebody who has insomnia.”
Next: Sleep Hygiene
Source: Various telephone interviews.
Disclosure: Rosenberg disclosed that he and his research organization consult for all the companies that work on insomnia issues. Martin and Feinsilver disclosed no relevant relationships with industry.