Insomniacs Helped by Cognitive Therapy

Veterans Affairs - April 10, 2001

Department of Veterans Affairs and Duke University researchers have made significant inroads toward the treatment of insomnia without the use of drugs.

Called cognitive behavioral therapy (CBT), the treatment combines cognitive therapy with strategies to improve sleep habits and limit time in bed.

The results of this study -- published in the April 11, 2001 issue of The Journal of the American Medical Association -- indicate that CBT is long-lasting and effective in combating insomnia. By the time therapy was complete, recipients reported, on average, a 54 percent reduction in wake time after having fallen asleep.

Researchers tested a group of men and women who were suffering from a form of insomnia causing at least 60 minutes of wake time after they fall asleep, not attributed to psychiatric, medical, or substance abuse problems. Known as persistent primary insomnia (PPI), this sleep disorder affects about 5% of the general population. This translates into approximately 14 million Americans, most above the age of 40.

According to Jack D. Edinger, Ph.D. of the Durham VA Medical Center, about one-third of the adult population is bothered by insomnia at least occasionally. A disproportionate number of insomnia treatment studies have focused on difficulty getting to sleep. However, a small number of studies, including the VA/Duke study, deal with effective ways of treating the many individuals who have trouble staying asleep through the night.

Individuals who are unable to get a minimum amount of uninterrupted sleep -- a little more than six hours on average - run the risk of functioning during the day without optimum alertness. People suffering from PPI are at a significantly higher risk of depression, anxiety and substance abuse. They are also at greater risk of incurring fatigue-related injuries such as work-site and traffic accidents.

Currently, drug therapy including sedatives and antidepressants are the most common treatments offered for PPI. These treatments not only harbor many uncertainties regarding possible adverse effects, but their effectiveness is short-lived - limited largely to the duration of the medication. Patients commonly experience a full return of their insomnia once they stop taking the drugs. However, CBT appears to be a promising, more universally effective treatment with a better long-term outcome.

The cognitive end of CBT tries to correct the misconceptions people have about their own sleep needs and habits. Most of the common misperceptions are addressed right away through a prepared information packet provided to patients. Any unique cognitive problems are then addressed individually.

The behavioral aspect of CBT addresses disruptive habits that can aggravate or even perpetuate PPI, such as failing to relax mentally at bedtime, permitting bedtime distractions such as reading or television, and even spending too much time in bed.

"These people can have a lot of sleep-disruptive habits that they think are compensating for the insomnia, but actually perpetuate it," said Dr. Edinger, further citing daytime napping as a prime example of patients contributing to disrupted sleep at night.

Dr. Edinger said he sometimes explains it to patients as having "a certain 'sleep budget' that you can spend in 24 hours. You can spend it all on one shot, or you can spend it in little increments."

Sleeping during the day can often cause the body to think that it does not need as much sleep at night, and so the pattern of disruption is self-perpetuated. Other disruptive habits include sleeping late on weekends. Late mornings can result in longer evenings, which ultimately disrupts the regularity of one's sleep pattern. Dr. Edinger describes this as being similar to jet lag - an unusual experience to which humans do not easily adjust.

Upon completing the study, the average CBT recipient reported a middle-of-the-night wake time of less than 30 minutes. This signifies a 50 percent (or greater) reduction in wake time among almost 2/3 of the CBT group. Less than 30 minutes of sleeplessness is considered normal. After a six-month follow-up period, treatment recipients reported similar positive results.

This research was funded by a grant from the National Institute of Mental Health.