Cognitive behavioural therapy the best way to tackle chronic insomnia

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The findings of a UK study support the effectiveness of multicomponent cognitive behavioural therapy (CBT) for insomnia, in general primary care.

Forget counting sheep and drinking warm milk, an effective way to tackle chronic insomnia is cognitive behavioural therapy, The Guardian reports researchers have confirmed. The authors of a study say that although the therapy is effective, it is not being used widely enough, with doctors having limited knowledge about it and patients lacking access.

“There is a very effective treatment that doesn’t involve medication that should be available through your primary care service. If it’s not, it should be,” said Dr Judith Davidson, co-author of a new study on CBT for insomnia from Queen’s University in Ontario, Canada.

Chronic insomnia, in which individuals have difficulties dropping off or staying asleep at least three nights a week for three months or more, is thought to affect about 10-15% of adults. The condition is linked to health problems including depression, as well as difficulties in functioning and sometimes resulting in accidents.

The report says sleeping pills are not recommended for long-term use and can have side-effects, as well as posing a risk of addiction. Instead, the main treatment for chronic insomnia is CBT – a programme of changes to the way an individual approaches and thinks about sleep. These include staying away from the bed when awake, challenging attitudes about sleep loss and restricting the number of hours spent in bed.

The Guardian says Davidson and colleagues report how they examined the results from 13 previously conducted studies on the provision of CBT for insomnia through primary care. In some studies, participants were also taking medication to help them sleep.
The results showed CBT for insomnia was effective and led to improvements in sleep that lasted during a follow-up many months later.

Looking at results from four randomised control trials, with between 66 and 201 participants of mixed ages, the team found that participants fell asleep on average nine to 30 minutes sooner after completing a course of CBT for insomnia and experienced a reduction of between 22 and 36 minutes in the amount of time spent awake after going to sleep. By contrast, those who were just on a waiting list, or given treatment as usual, only experienced up to four minutes’ improvement in the time it took to drop off and a maximum of eight minutes’ improvement in time spent awake after going to sleep.

The team said it seemed four to eight sessions of CBT were required for such improvements, with an additional trial finding little benefit when only two CBT sessions were offered to insomniacs.

Davidson is quoted in The Guardian as saying that she supported the idea that CBT for insomnia could and should be offered through GPs – patients’ usual first port of call – although, as with most of the studies, the therapy itself could be delivered by others such as nurses, social workers or other primary care services.

Background: Practice guidelines recommend that chronic insomnia be treated first with cognitive behavioural therapy for insomnia (CBT-I), and that hypnotic medication be considered only when CBT-I is unsuccessful. Although there is evidence of CBT-I’s efficacy in research studies, systematic reviews of its effects in primary care are lacking.
Aim: To review the effects on sleep outcomes of CBT-I delivered in primary care.
Design and setting: Systematic review of articles published worldwide.
Method: Medline, PsycINFO, EMBASE, and CINAHL were searched for articles published from January 1987 until August 2018 that reported sleep results and on the use of CBT-I in general primary care settings. Two researchers independently assessed and then reached agreement on the included studies and the extracted data. Cohen’s d was used to measure effects on sleep diary outcomes and the Insomnia Severity Index.
Results: In total, 13 studies were included. Medium-to-large positive effects on self-reported sleep were found for CBT-I provided over 4–6 sessions. Improvements were generally well maintained for 3–12 months post-treatment. Studies of interventions in which the format or content veered substantially from conventional CBT-I were less conclusive. In only three studies was CBT-I delivered by a GP; usually, it was provided by nurses, psychologists, nurse practitioners, social workers, or counsellors. Six studies included advice on withdrawal from hypnotics.
Conclusion: The findings support the effectiveness of multicomponent CBT-I in general primary care. Future studies should use standard sleep measures, examine daytime symptoms, and investigate the impact of hypnotic tapering interventions delivered in conjunction with CBT-I.

Judith R Davidson, Ciara Dickson, Han Han

The Guardian report
British Journal of General Practice abstract

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