The best treatment for insomnia is a well-kept secret. It's not that anyone is purposely hiding it. It's just that it has yet to find its way from the research world to the clinic and to the people who need it. Unlike sleeping pills that have huge sales potential and marketing budgets, effective non-drug interventions are not rapidly disseminated. So cognitive behavioural therapy for insomnia, or "CBT-I," is not yet a household word.
Decades of research, including randomized controlled trials and meta-analyses, have shown that CBT-I is effective at reversing insomnia. In fact, it is the first-line treatment in Canadian, American and British medical guidelines. It is recommended for chronic insomnia, ahead of sleeping pills. However, as yet, access to this excellent treatment is very limited.
What is it?
Not to be confused with "sleep hygiene," which is wise advice for sleep – things your grandmother might have told you – CBT-I is a structured treatment program for people with insomnia. In my experience, people with full-blown insomnia already have near-perfect sleep hygiene: they avoid caffeine, minimize alcohol, they don't exercise or dine heavily prior to hitting the sack. Rather, they take time to relax before bed, they make sure that their bedroom is dark and their bed is comfortable. Still, they don't sleep.
You may have heard of cognitive behavioural therapy (CBT) for other things, like depression or anxiety. Although CBT and CBT-I have similar names – both involve methods to calm overactive thinking (cognitive components) and actions to improve symptoms and feel better (behavioural components) – they are quite different.
CBT-I is a set of techniques that allow the biological processes of sleep regulation to operate without interference from racing thoughts, hyperarousal, and entrenched, unsatisfactory sleep-wake patterns. In practical terms, it involves restricting your time in bed, getting out of bed when you're not sleeping and getting up at a constant rise time. It also involves learning what to do with racing thoughts. People who follow CBT-I techniques typically start sleeping well in three to four weeks.
A six-week workshop I am involved in with the Kingston Family Health Team is showing promise. Of the first 53 people through the program, 89 per cent no longer reported insomnia by the last session.
Who's it for?
CBT-I works for insomnia. Insomnia is not just any trouble sleeping, it is trouble falling asleep and/or staying asleep that persists for at least one month and interferes with your functioning (for example, your mood, work, concentration) or that causes you distress. Other things can mimic insomnia, so it is best to make sure that your sleep problem is not due to other things such as sleep apnea, periodic limb movements, narcolepsy or thyroid hormone imbalance – disorders that require different treatments.
How does it compare with relaxation?
Relaxation techniques like progressive muscle relaxation and visualization can be helpful for sleep. Meditation can also help. These are essential skills for our rush-rush lives. However, for sleep specifically, these techniques may not be enough for many people with insomnia. CBT-I has been shown to be more effective than relaxation alone for insomnia.
How does it compare with sleeping pills?
Prescribed sleeping pills (known as benzodiazepine receptor agonists) work right away and can provide a better sleep for a number of weeks, but then the benefits subside. By comparison, CBT-I takes at least two weeks to start working, but then it keeps working. Follow-up studies of people who learn CBT-I have shown that they continue to enjoy good sleep two years later. Once people learn the techniques they continue to use them as needed. Although CBT-I takes some time and effort to carry out initially, it avoids the problems of long-term sleeping pill use, such as tolerance (the dose has less effect,) drug-related side effects (mental fogginess, memory problems, risk of falls) and withdrawal effects ("rebound insomnia" is severe insomnia that can occur when the drug is suddenly stopped.)
Although CBT-I works remarkably well to improve sleep, it's not as simple as taking a sleeping pill. It takes some motivation and time. It also comes with side effects of its own. A study led by Dr. Simon Kyle of the University of Manchester, just published in the journal Sleep, found that restriction of time in bed (a primary component of CBT-I) led to sleepiness, reduced vigilance and slowed reaction time. So CBT-I is not a treatment to be using when you need to be alert, quick and accurate; and precautions must be taken to avoid driving while sleepy.
Several behavioural sleep medicine professionals are working to make CBT-I more available to Canadians. Try first to access CBT-I through your family physician's office. If it is not yet available, one option is to try the online six-week CBT-I program developed by Dr. Norah Vincent of the University of Manitoba. (To find out how to access it in your area, you can e-mail her at NVincent@exchange.hsc.mb.ca.)
Dr. Judith 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.