June 27, 2006 -- A few talk therapy sessions help long-lastingbetter than sleeping pills, Norwegian researchers find.
The simple treatment is a form of cognitive behavioral therapy (CBT). It isn't brain surgery -- or even in-depth psychotherapy. It's all about learning how to change behaviors and thought patterns that interfere with sleep.
Can such a relatively simple treatment work as well as state-of-the-art sleeping pills? Yes, find Børge Sivertsen, PsyD, and colleagues at the University of Bergen in Norway. They randomly treated 46 long-term insomniacs with CBT, Imovane, or inactive placebo pills. Imovane, a sleep drug closely related to Lunesta, is commonly used in Europe but is not available in the U.S.
After six weeks of treatment -- and again six months after treatment – the researchers studied how well the patients were sleeping.
Before treatment, these insomnia sufferers were awake about 20% of the time they were in bed. After six weeks, those who got CBT were awake only about 10% of the night. Six months later, this positive effect was a bit stronger.
Meanwhile, at both time points, those who got the sleeping pill spent just as much sleepless time in bed as they had when the study began.
"We were surprised," Sivertsen tells WebMD. "We expected CBT to be efficient, but we did not expect such strong differences between groups."
But this is no surprise to long-time CBT enthusiast Richard Simon Jr., MD, medical director of the Kathryn Severyns Dement Sleep Disorders Center, in Walla Walla, Wash.
"The main finding of this study is extraordinarily consistent with everything in the medical literature," Simon tells WebMD. "The bottom line is that whenever one compares CBT to sleep medications, CBT is always at least as good if not better -- and, typically, the effect of CBT is longer lasting."
The Sivertsen study appears in the June 28 issue of the Journal of the American Medical Association.
Insomnia, Deep Sleep, and CBT
What surprised both Sivertsen and Simon was the effect of the different treatments on the patients' slow-wave sleep -- what most of us call deep sleep.
CBT raised the patients' average slow-wave sleep 27% by the end of treatment, and had increased it 34% six months later.
On the other hand, patients who took the sleeping pill had a big drop in the amount of slow-wave sleep they got. They had 20% less slow-wave sleep at the end of treatment. Six months later, they had 23% less slow-wave sleep.
"That is scary, when you see that lack of slow-wave sleep is responsible for most daytime sleepiness," Sivertsen says. "And there is an ongoing debate in the American media about traffic-related incidents with sleeping pills."
Simon isn't totally convinced by the finding.
"For most of the newer sleep medications, investigators have found no decrease in [slow-wave] sleep," he says. "But with the older drugs, like Halcion, that is a common finding."
"We were quite surprised to find that [Imovane] decreased slow-wave sleep," Sivertsen says. "The manufacturer says [Imovane] increases slow-wave sleep. We found the opposite. True, we had a relatively small number of patients. But all the patients in the placebo arm were randomized to get one of the two treatments. If we put those additional patients into the final analysis, we get even larger effects. The findings were still there and still significant."
How CBT Cures Insomnia
The CBT used by Sivertsen and colleagues consists of six hour-long sessions one week apart. The sessions incorporate five principles:
- Sleep hygiene. Patients learn how lifestyle habits (such as diet and alcohol use) and environmental factors (such as light, noise, and temperature) affect sleep.
- Sleep restriction. Patients keep to a strict schedule of bed times and wake times that at first increases their sleepiness by depriving them of sleep.
- Stimulus control. Patients learn to associate being in bed with going to sleep. They learn not to do anything in the bedroom that does not help them sleep.
- Cognitive therapy. "The thoughts people with insomnia have about sleep are a bit skewed," Sivertsen says. "Cognitive therapy gives patients control over what is going on. They become their own co-therapists."
- Progressive relaxation technique. Patients learn to recognize and control muscular tension.
"It is not a deep therapy," Sivertsen says. "What is most efficient is sleep restriction and telling the patient not to stay in bed while awake. We think it is not that important for a patient to see a trained therapist in order to get an effect. Even a self-help program based on these principles is almost as efficient."
Simon says many patients don't need the whole six-week program tested by Sivertsen and colleagues. By tailoring the CBT to the needs of individual patients, he is often able to relieve their insomnia after only two sessions.
Staying Awake to Sleep
"I do the sleep hygiene first, and for most patients I do sleep restriction," he says. "They typically have been going to bed for eight or nine hours, and sleeping five hours. If they are driving to work in the morning, I restrict them to six hours in bed. But if not, bedtime is 3 a.m. and wake time is 8 a.m. You may go to bed later, but you can't go to bed earlier. The only bed time they get is time for sleeping. No naps in the daytime." Once patients' sleep diaries show they've slept 90% of their time in bed, Simon increases bed time by 30 minutes -- a bit longer than the 15-minute increments many specialists recommend.
Simon also offers cognitive therapy. "This is the gentle debate between a therapist and a patient to change the patient's conceptions about sleep," he says. "When they wake at night they think, 'Omigod, what if I don't get to sleep.' I try to get them to change it to, 'This is great, I get to fall asleep again.'"
Simon estimates that about half of his patients get over theirwithin two or three sessions -- and he is a sleep specialist who sees only hard cases. Primary care providers, he says, would get much better results.
While CBT is their initial treatment, both Sivertsen and Simon say sleep drugs play a major role in treating.
"Sleep drugs are most useful for good sleepers who have sudden life stress," Simon says. "There is a role for sleep medications in chronic insomnia, and sometimes I do prescribe them long-term. But one does not start there. I believe one starts with CBT."