In parts of the United Kingdom, if you go to your general practitioner with depression or anxiety or insomnia, you are as likely to be offered cognitive behavioural therapy (CBT), a psychological treatment, as you are a medication. That is because CBT is an effective treatment for these conditions, and the U.K.’s National Health Service has therapists trained in its delivery.
The integration of certain psychological services into primary care makes sense. For the patient, “one-stop” shopping means fewer bounces among professionals, and greater chances of problems being treated sooner. Just as it is important to make CBT for depression and anxiety readily available, it is crucial to provide help for insomnia as soon as it is reported. Left untreated, insomnia reduces quality of life and mood, impairs glucose metabolism, and increases the risk of car crashes. Canada needs a system for early access to effective insomnia treatments.
In the future, you should be able to go to your family doctor or nurse practitioner, report your sleep difficulty and after a brief assessment be offered CBT for Insomnia (CBT-I) or a medication. Both treatments are effective. Whereas sleeping pills are helpful in the short term (two to four weeks), CBT-I is effective for the long term. CBT-I leads to consistently good sleep in about three to six weeks. Many people find this a small and worthy investment to reverse months or years of insomnia.
Few primary care professionals are trained in the delivery of CBT-I. However, change is coming. There are increasing opportunities for Canadian health professionals to learn how to provide CBT-I or to offer advice based on its principles. Family health teams in Ontario and primary care networks in Alberta, because of their inter-professional make-up, are ideally positioned to provide CBT-I.
What is CBT-I?
It is the first-line treatment for chronic insomnia, which is trouble sleeping (difficulty falling asleep and/or staying asleep) that has persisted for at least a month and that is interfering with daytime functioning (typically causing difficulty concentrating, irritability and fatigue).
First, you complete a baseline, week-long sleep diary. You record your bedtime, rise time and what happened in between: how long it took to fall asleep, how many times you woke up and for how long, and how long you were awake in bed before you got up for the day. (These are estimates; you are encouraged not to watch the clock.)
Next, you launch into “sleep scheduling” techniques. First, to strengthen sleep’s circadian (24-hour) rhythm, you pick a rise time that can be maintained seven days a week. Say you choose 7 a.m.: You would then rise each morning at 7 a.m. regardless of how much or little sleep you’ve had and whether or not it is a work day.
Second, you start “sleep restriction therapy” by staying up late. This builds up your sleep drive, making you fall asleep faster and stay asleep longer. How late you stay up depends on your baseline sleep diary. Care must be taken to avoid too much sleep restriction and this is where the guidance of the behavioural sleep professional is key. Sometimes the method involves estimating the amount of actual sleep you got per night at baseline, and assigning this duration plus 30 minutes as your “sleep window.” Your bedtime is calculated accordingly, always keeping your rise time constant. You follow this sleep schedule for four to seven days, tracking your progress with a sleep diary. As sleep consolidates, your bedtime is moved earlier by 15 or 30 minutes for the next week (always keeping the rise time constant), and so on, adjusting each week until sleep is still solid but as long as possible.
Another important CBT-I technique, called “stimulus control therapy,” forms a strong association between your bed and good sleep. It is done concurrently with sleep restriction. It involves reserving the bed for sex and sleep (no electronic devices, no reading) and leaving the bedroom when you are awake for more than 15 minutes. You go to bed, and return to bed, only when sleepy.
The last part of CBT-I works on racing thoughts. Visual imagery is often used to divert the mind from hyperactivity. Also, any troublesome thoughts that pop up at night can be confronted and evaluated during the day. For example, some people worry that their lack of sleep will have major consequences for their daytime performance. These concerns can be calmed by making them more realistic. The middle-of-the-night thought: “I’ll screw up at work tomorrow and the whole day will feel horrible,” could be replaced by the realistic and somewhat boring one: “I may not feel the greatest at some points in the day tomorrow, but I will still function okay.”
It is always easiest to do CBT-I with the close guidance of a professional and this service should – let’s hope soon – be available in family doctors’ offices across Canada.
Dr. Judith R. Davidson is a clinical psychologist and sleep researcher. She works with the Kingston Family Health Team and Queen’s University at Kingston. She is the author of Sink into Sleep: A Step-by-Step Workbook for Reversing Insomnia. You can follow her on Facebook and on Twitter at @JudithRDavidson