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Experts discuss changing scope of insomnia treatment

Improving sleep hygiene has long been recommended as a treatment for insomnia, but there is increasing evidence that it is insufficient as standalone therapy. The co-author of a study that showed sleep hygiene was recommended in 75% of cases in a study of the Veterans Affairs health system said that there are little data to support techniques such as avoiding stimulants before going to bed and keeping their sleeping environment comfortable, dark and quiet as monotherapy for the treatment of insomnia disorder.

“We are moving towards a de-implementation of sleep hygiene. I know that sleep hygiene is still on many sleep-focused websites, but as a standalone treatment for insomnia, the data show that sleep hygiene has very little support,” Christi S. Ulmer, PhD, CBSM, of the department of Health Services Research and Development at the Veterans Affairs Clinic in Durham, North Carolina and Duke University Medical Center, told Healio Family Medicine.

Cognitive behavioral therapy for insomnia is much more effective and is now considered the standard of care, she said.

Healio Family Medicine asked Ulmer, and Nathaniel Watson, MD, MS, a past president of the American Academy of Sleep Medicine and codirector of the University of Washington Sleep Center, for suggestions on diagnosing insomnia and the changing scope of its treatment.

Question: How can PCPs tell if a patient has insomnia?

Watson: PCPs should inquire about sleep quality and sleep satisfaction with all of their patients. They can also take a careful sleep history where they ascertain wake times and sleep times on work days and weekends. PCPs can also ask about sleep latency, which is how long it takes them to fall asleep, their satisfaction with their sleep and whether they are sleepy during the day. These are questions that can help identify if a patient has insomnia.

Ulmer: If a patient says he or she has problems falling asleep, staying asleep or waking up too early for at least 3 months and at least three times a week, and also has some kind of daytime impairment that impacts their daily functions, he or she likely has insomnia disorder. That said, studies have shown that patients aren’t likely to report their insomnia to their PCP until they’ve had it for a while or until such time as they’ve tried a few things on their own.

Q: Can you describe cognitive behavioral therapy for insomnia?

Watson: Cognitive behavioral therapy is the best treatment that we have for insomnia. It’s better than any medication. As a general recommendation, it’s best that our patients consult a sleep specialist regarding this therapy to treat insomnia because it works as well or better than their medications long term.

This therapy occurs under the care of a psychologist who has special training or a board-certified sleep specialist. Patients record their sleep hygiene habits, but then they move onto their attitudes and beliefs about sleep that may be counterproductive to getting a good night’s sleep. Patients are also asked to record their habitual sleep pattern to help the psychologist or board-certified sleep specialist come up with a sleep strategy that builds up the patient’s sleep debt or homeopathic sleep drive by reducing the amount of time they spend in bed. The goal is to increase the patient’s sleep efficiency. Following normalization of their sleep efficiency, the time in bed can be increased.

Q: What other ways can a PCP help a patient who has insomnia?

Watson: PCPs should not be dismissive of an insomnia complaint. I would encourage PCPs to think of insomnia as both a symptom and as a disease. For example, insomnia is a common symptom of depression. So sometimes to address insomnia you have to treat the depression and then the insomnia will improve. Vice versa is true as well.

Ulmer: In general, those of us in the field of behavioral sleep medicine haven’t educated PCPs about the process by which insomnia disorder develops, and understanding this process can help PCPs understand why cognitive behavioral therapy for insomnia works better than other approaches. Although insomnia is often related to another condition at the outset (depression, pain, etc), it’s the maladaptive behaviors and beliefs about sleep that ensue following the initial bout of insomnia that serve to precipitate and perpetuate the condition towards insomnia disorder. We used to have certain diagnoses such as “Insomnia secondary to a medical condition”. But, all these prior diagnoses have been collapsed into one diagnosis: insomnia disorder since because there was concern about the term “secondary” promoting undertreatment of insomnia. Insomnia remains a problem after treatment of co-morbid conditions about half the time, because the insomnia developed as a result of learned conditions or unconscious learning. In my survey, we found that primary care physicians tend to view insomnia as a symptom of another issue most of the time, rather than a co-morbid condition warranting separate treatment. Many sleep physicians hold this misperception as well. Cognitive behavioral therapy for insomnia is highly efficacious with co-morbid conditions. So, there’s no need to wait to see if the individual improves after depression treatment, for example. You can refer a patient for treatment of both co-morbid conditions concurrently.

Q: Are we moving more towards approaches to treat insomnia that don’t involve medications?

Watson: The potential of adverse events, medications and interactions, as well as medication costs, has the public desirous of treatments for insomnia other than altering the body chemistry in some way. There’s also an attractiveness to nonpharmaceutical ways to tackle the insomnia problem as technology advances. We’re going to see more of these types of non-pill treatments in the future. All that said, medications can also be very effective for insomnia when taken properly. Many people have taken them, and they are very successful. I would encourage PCPs to try any product that’s FDA approved and see how it goes. Ultimately, our patients teach us so much — they’ll let us know if a recommended treatment isn’t working for them.

Ulmer: Yes, the medical community has recognized the efficacy of cognitive behavioral therapy for insomnia. The ACP recently recommended it as the standard of care for treatment of chronic insomnia. In fact, there is no evidence for sustained resolution of insomnia with sleep medications. Other research suggests that in the average patient with insomnia, sleep medications are likely to only prolong the problem and as soon as patients discontinue the sleep medication, they relapse. Therefore, sleep medications should be reserved for those with very complex sleep difficulties, and then used in conjunction with cognitive behavioral therapy for insomnia.

Reference: Ulmer CS, et al. J Clin Sleep Med. 2017;doi:10.5664/jcsm.6702.

Disclosures: Neither Ulmer nor Watson report any relevant financial disclosures.

Further reading: Watson recommends www.sleepio.com and www.shuteye.com, and Ulmer recommends www.sbsm.org, for PCPs who want to learn more about cognitive behavioral therapy for insomnia.