If you find yourself lying awake at night staring at the ceiling and feeling restless nearly every night, you’re not alone: Nearly 10 percent of Americans have insomnia, and the CDC considers America’s level of sleep deprivation a “public health problem.” Likely stressed out from other events going on in their lives, insomniacs often turn to sleeping or anxiety pills like Ambien or Xanax, hoping to drug themselves into slumber.
However, pills may not be the best first option for treating insomnia. New guidelines from the American College of Physicians (ACP), published in the Annals of Internal Medicine this week, encourage doctors to embrace cognitive behavioral therapy as “first-line treatment” for insomnia, rather than immediately prescribing pills.
The adverse health effects of sleep deprivation have become much clearer in recent years, and a need exists to remedy a nationwide trend of sleep loss — not only because chronic exhaustion can lead to memory and focusing problems, as well as more dangerous driving, but because lack of sleep can contribute to obesity, heart disease, and mental health problems. Nearly one-third of Americans are sleep-deprived, according to the CDC.
The report’s authors start out by noting the large pool of evidence that exists in support of the efficacy of cognitive behavioral therapy for insomnia (CBT-I). One 2014 study found that just one hour’s worth of talk therapy helped 73 percent of participants improve their sleep quality. Another study from that year found similarly promising results: 86 percent of patients experienced reduced insomnia. In 2015, researchers found that CBT-I was more effective in treating insomnia than typical drugs used to induce sleep, like Valium or Xanax.
It’s not for lack of evidence that patients face barriers to this treatment, then. In their paper, the authors note that access to CBT-I is hard to come by in the medical world, often simply because mental health care is separate from primary care, and there aren’t enough behavioral health practitioners trained in sleep medicine. The authors note that only one in nine general health care patients also receive proper behavioral health treatment.
On top of that, it’s often easier to prescribe pills, which in effect may mask the more complicated issues that likely underlie sleep difficulties. Sticking with cognitive behavioral therapy over the course of months and even years is necessary for it to work.
“CBT-I requires more active patient engagement than taking medication, thus patients need ongoing instruction and support,” the authors write. They also note that patients should be informed that “CBT-I involves learning new approaches to thoughts and behaviors that affect sleep,” and “that persistent effort is critical, and that symptoms may initially worsen before sleep improves.” Cognitive behavioral therapy for insomnia could seem more complicated than medication because of the long-term effort and follow-up it requires. But “support and encouragement to continue, despite initial adversity, can be the difference between CBT-I success and failure,” the authors write.
At the end of the day, however, risking dependency and the potential side effects of medication likely outweigh the inconvenience of sticking with therapy. Of course, that doesn’t mean medications should be entirely ruled out; they can be helpful when other approaches fail to work.
“We looked [at the issue] very broadly,” Dr. Wayne Riley, president of the American College of Physicians, told HealthDay. “[W]e don’t say don’t use a medication, we say, give your patient a trial… and if they come back still having problems sleeping, maybe add short-term use of a medication. We try to counsel against using [medication] longer than 10 to 14 days because we know dependence can be an issue.”
The authors note that CBT-I should be embraced by more physicians and patients, though it will require a large effort from a diverse group of people.
“A long-term solution requires a team effort by policymakers, physicians, health care administrators, sleep medicine specialists, and CBT-I therapists,” the authors conclude. “The evidence behind the ACP recommendations should motivate all stakeholders to move in unison to advocate for CBT-I payment in medical settings as part of medical insurance benefits. ”