About 1 in 10 Americans has chronic insomnia, and many aren't finding relief from pills.
A form of treatment called cognitive behavioral therapy, which doesn't use drugs, works. But it can be hard to find. So proponents of the treatment are trying new ways to get the treatment to troubled nonsleepers.
Cognitive behavioral therapy is a short-term, pragmatic form of therapy that focuses on changing how a person thinks about and reacts to specific situations. It has been around since the 1960s, and has proven effective for treating a number of problems including depression, eating disorders and insomnia.
But even though it's fairly simple in principle, cognitive behavioral therapy has to be done precisely to work well. It takes some time and effort on the part of both therapist and patient to help with sleepless nights.
"CBT in general isn't enough," says Rachel Manber, a professor of psychiatry at Stanford University Medical Center who studies insomnia. "You need to find CBT for insomnia."
In the therapy, patients usually keep a sleep diary for several weeks, then work with a therapist to identify behaviors that are interfering with getting to sleep and staying there. The therapist gives the patient very specific things to do to change those behaviors, and adjusts the plan week to week based on the patient's sleep diaries.
But this kind of therapy can be hard to find, especially outside big cities. So primary care doctors are more likely to write a prescription for sleeping pills than try to refer a patient to a clinical psychologist with that special training. Proponents of CBT for insomnia are working to make it more accessible.
The Veterans Administration health system has launched a big effort to use cognitive behavioral therapy with veterans. Most people with post-traumatic stress disorder have insomnia, and it can make depression and other health problems worse. PTSD has been a major issue for veterans of Iraq and Afghanistan.
Manber and her colleagues are training hundreds of social workers, nurses and doctors in the VA system on how to do CBT for insomnia. Patients treated by these new trainees had significantly less insomnia, less depression and better quality of life, according to a paper published in the February Behaviour Research and Therapy.
The treatment typically takes six meetings with a therapist, but experiments have shown that it can work in as few as two sessions with phone follow-up. Group sessions developed in the VA work, too, Manber and her colleagues found, and may be one way around the fact that the treatment requires an investment of time from both patient and therapist.
Last year the VA project launched CBT-I Coach, an app that users can customize with alerts on when to get ready for bed, when to go to sleep and when to get out of bed. They can also use it as a sleep diary.
It's not a replacement for therapy, Manber tells Shots. "The app is not treatment," she says, but it can help make it more effective.
People seeking someone trained in cognitive behavioral therapy for insomnia can check a list compiled the American Board of Sleep Medicine, Manber says. Another resource is the Society for Behavioral Sleep Medicine.
Then there's the money angle. Treating insomnia costs the nation at least $10 billion a year, and cost estimates range up to $100 billion once you add in treatment for other medical problems and lost work time and productivity.
To make the economic case for using cognitive behavioral therapy to treat insomnia, researchers looked at the health records of 84 people who were treated at the University of Florida sleep disorders center. Those who completed at least three sessions had less insomnia. They also had lower health-care costs and fewer doctor visits over the next sixth months than they did before the therapy, with costs running about $200 less. People who attended two or fewer sessions didn't see those cost savings.
Psychologist Christina McCrae realizes those numbers don't seem huge, but she says, "I thought it was important to bring attention to the fact that it might save money in the long run." She's on the faculty at the University of Florida and is the lead author of the study, which was published in the current Journal of Clinical Sleep Medicine.
It helps to think of treating insomnia much like people deal with losing weight. Try the simple stuff first. "I'll follow some recommendations," she says. "If that's not successful, I'll go to the next level." In this approach, not everyone is going to need cognitive behavioral therapy to solve their sleep problems. But it should be available for those who do, Manber says.