Cognitive Behavior Therapy for Insomnia and Hypnotic Deprescribing

Cognitive behavior therapy for insomnia (CBT-I) is the first-line treatment for chronic insomnia with established short- and long-term efficacy, as recommended by the American Academy of Sleep Medicine and the American College of Physicians.^1,2 All adults are recommended to receive CBT-I as the initial treatment for chronic insomnia (of note, although limited, there is also evidence regarding its efficacy on acute insomnia).³ Approximately 70% to 80% of those who complete a CBT-I course, usually provided as 6 to 8 weekly sessions, achieve a therapeutic response, and approximately 40% achieve clinical remission.⁴ Although no prolonged maintenance beyond 6 to 8 weeks is practiced, CBT-I is known for its long-term efficacy, with meta-analytic data evidencing clinically significant effects for 1 year⁵ and a follow-up of a randomized controlled trial (RCT) showing persisting benefits after 10 years.⁶

TABLE. The 3P Model of Insomnia

The Spielman model of insomnia is the principal etiological conceptualization of insomnia and the theoretical backbone of CBT-I.⁷ Often referred to as the 3P model, this model comprises 3 groups of factors: predisposing, precipitating, and perpetuating (Table). Predisposing factors confer the substrate of vulnerability (eg, family history of insomnia). Subsequently, a precipitating factor such as a stressful life event triggers an episode of acute insomnia. Ultimately, perpetuating factors prolong an episode of acute insomnia and lead to chronic insomnia: maladaptive behaviors and cognitions such as extending sleep opportunity to make up for lost sleep (in bed early, out of bed late, napping), worrying about whether sleep will occur, and concern over the adverse health and functional consequences of insufficient sleep. CBT-I focuses on these perpetuating factors, and its key interventions include the following⁸:

Cognitive restructuring. This technique teaches patients how to identify, challenge, and change unhelpful sleep-related thoughts and beliefs. Patients learn to embrace the reality that sleep is out of their control. Thus, the focus is on surrendering to whatever happens regarding sleep but directing the need for control to removing the impediments to sleep, such as managing sleep hygiene, engaging in stimulus control to reduce the time in bed (TIB) when not sleeping, and avoiding time cues. It is essential to acknowledge that sleep is out of our control and that trying harder to sleep only leads to further arousal. We often use the analogy of chasing after (or even stalking) a lover, which makes them run away even further and faster!

FIGURE. Sleep Duration and Prediction of Longevity in Older Adults^11,12

In our clinic, we also provide more realistic information on normal sleep, as most patients with insomnia have a somewhat idealized notion of normal sleep and a high expectation of what normal sleep should be, often leading to heightened sleep anxiety. For example, although the conventional wisdom on the best sleep duration is 8 hours a night, prospective cohort studies and meta-analyses of such studies consistently demonstrate 7 hours to be the best sleep duration for longevity (ie, sleep duration of 7 hours predicts the lowest all-cause mortality).^9,10 Several studies and our unpublished meta-analytic data even show 6 to 7 hours to be the best sleep duration for longevity (Figure).^11,12 Furthermore, the observed average nighttime sleep duration in tribes of hunter-gatherers—who rarely experience insomnia, with only 1% reporting occasional insomnia nights compared with more than 50% of the US population—is 6.4 hours.¹³ Thus, 6.4 hours could be a normal sleep duration in humans living in a natural setting. Additionally, patients learn that normal sleep happens in cycles of approximately 90 minutes with much variation throughout the night and even includes approximately 5 awakenings each night (although only some of them are recalled),^14,15 ultimately realizing that normal sleep is quite imperfect.

Stimulus control. This technique essentially involves using the bed only for sleeping (with the exception of sexual activity) so that the bed becomes a stimulus for sleep rather than for wakefulness. Thus, if a patient has difficulty going to sleep and is becoming agitated, frustrated, or aroused, it is recommended that they get out of bed and reset their emotional and physiologic state by doing a soothing, relaxing activity. They are instructed to return to bed when they feel sleepy. It is also encouraged to eliminate nonsleep activities from the bedroom around bedtime and during the day. Although common nonsleep activities in bed include cell phone use and TV watching, the most common nonsleep activity in bed practiced by patients with insomnia is, in a sense, not sleeping or staying awake, and stimulus control essentially means avoiding this.

Sleep restriction. Lying in bed when awake can become a habit that reduces sleep pressure (also called sleep drive) and strengthens the association between the bed and not sleeping. Sleep restriction works by setting a firm get-up time (not only waking up but also getting up) and initially reducing the amount of time a patient spends in bed to increase their sleep pressure. Once their sleep has improved, TIB gradually increases. Sleep restriction can be challenging, especially at the beginning of the CBT-I course, but it is a powerful intervention that not only increases sleep pressure but also regulates circadian rhythm by establishing a regular sleep schedule. Another reason for the robustness of sleep restriction is that it facilitates stimulus control as patients spend less time in bed and therefore less time awake in bed, and as they get into bed with much stronger sleep pressure and naturally associate it with the bed.

We often explain the benefits of sleep restriction using the illustration of an elastic band. For example, say that a patient stays in bed for 10 hours a night and sleeps 6 hours a night with sleep onset and maintenance difficulties; they spend 10 hours of TIB interspersed with several fragments of awakenings and experience light, unrefreshing sleep. This patient’s sleep may be compared with an elastic band originally measuring 6 hours long, which is currently stretched thin to 10 hours, thus becoming very light and shallow. Furthermore, this stretched elastic band may become cracked at several points, indicating awakenings and fragmentation. Such a stretched and fragmented elastic band may be compressed back to 6 hours, becoming thick as their sleep does. Eventually, as TIB is gradually increased (usually by 15 minutes a week), this patient may sleep about 6 hours a night within a window of 6.5 hours of TIB within a couple of weeks of CBT-I, which is the same amount of sleep as before but compressed back-to-back with minimal awakenings, making for deeper and more refreshing sleep. Then, by the end of the CBT-I program, they may sleep about 30 minutes more, which is the average sleep duration increase shown by the existing RCTs,⁴ resulting in total sleep time (TST) of 6.5 hours. Despite not sleeping 8 hours a night, the patient may be satisfied with 6.5 hours of restorative sleep that is more consistent with the best sleep duration for longevity, as per the research data.

In addition to the aforementioned interventions, CBT-I may also include relaxation (“winding down”), worry management, daytime management, sleep hygiene, and relapse prevention.

Hypnotic Deprescribing

Although deprescribing hypnotic medications is challenging, with a success rate limited to approximately 40%, hypnotic discontinuation in combination with CBT-I has a success rate of approximately 80%.¹⁶ Therefore, CBT-I is an opportunity for hypnotic deprescribing.¹⁷ It is generally recommended to reduce the initial dose by 25% weekly or every other week until the smallest dose is reached.18 After taking the smallest dose for 1 or 2 weeks, patients may be instructed to take the same dose every other night for 1 or 2 weeks before the complete discontinuation. This last stretch serves as a period when patients realize there are few real effects of the minimal hypnotic dose (“no difference between a tiny piece of the pill and none”) and gain confidence to discontinue it altogether. Some practical considerations are as follows: Patients themselves must be willing and ready to stop; avoid discontinuation during acute stress or major life changes; set realistic goals (not always a complete discontinuation); and consider contraindications to hypnotic withdrawal, such as complex mental health conditions, a history of depression recurrence, and a history of seizure.

Case Vignette

“Ms Tossnturn,” a 33-year-old woman with a personal history of anxiety and a family history of insomnia, had sleep maintenance difficulty most nights and sleep onset difficulty occasionally, which likely started because of work stress approximately 4 years ago. She usually fell asleep fairly well, but it took 1 to 2 hours for her to fall asleep when stressed. Every night, she woke up in the middle of the night with difficulty or inability to fall back asleep, sometimes staying awake until the morning. She reported staying in bed for 9 to 10 hours and sleeping 5 to 6 hours a night. She slept in or tried to sleep in on weekends. She was unable to nap during the day, even when she tried to, as her mind was aroused despite bodily fatigue. She felt anxious at night due to expected sleep difficulty and used her cell phone in bed to relax for at least 30 minutes. She had used multiple prescription hypnotics and was currently taking melatonin and diphenhydramine as needed. Her perpetuating factors of insomnia were identified as: spending a long time in bed, spending a long time awake in bed, sleeping in, irregular sleep schedule, nonsleep activities in bed, trying harder to sleep, worry/anxiety in general and about sleep, ongoing work stress, and chronic sleep aid use. Per her initial sleep diary, her average TIB was 9 hours, with a TST of 6.5 hours and 72% sleep efficiency (SE). Her TIB was thus restricted to 6.5 hours, and she was instructed on stimulus control. In the first week of sleep restriction, she had difficulty reducing her TIB to 6.5 hours, and the actual average TIB was 7 hours, with a TST of 6 hours and 86% SE. Although she slept less than before the treatment, she fell asleep faster and stayed awake for much less time at night. Over the 8 weeks of CBT-I, she gradually increased her TIB, usually by 15 minutes a week, and her sleep quality and quantity improved. By the end of CBT-I, she was staying in bed for 8 hours and sleeping 7 hours and 10 minutes a night on average, with better sleep quality and much less sleep anxiety. She was not taking any sleep aids.

Concluding Thoughts

CBT-I is a widely recognized and consistently proven first-line treatment for chronic insomnia. Despite a relatively brief course of intervention delivered as 6 to 8 weekly sessions, especially compared with the chronic nature of insomnia, CBT-I provides not only a short-term improvement but also a long-term maintenance of benefits with few adverse effects. Its specific components include cognitive restructuring, stimulus control, and sleep restriction, among others, and it targets cognitive and behavioral perpetuating factors of insomnia. Notwithstanding all these wonders, CBT-I has its own Achilles’ heel. The limitations include often challenging adherence issues (dropout rates in clinical settings ranging from 9.7% to 38.8%¹⁹), a shortage of trained CBT-I practitioners, and limited awareness among patients. However, much hope is on the horizon given the continued research and refinement of CBT-I techniques, the expansion of training programs, the technological innovation such as digital CBT-I, and the dissemination of knowledge (eg, by means of articles such as this and media coverage).

Dr Cho is a professor in the Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA. He is also the director of the UCLA Insomnia Clinic.

References

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