Waiting for alcohol abstinence before treating insomnia may be ‘missed opportunity’

Key takeaways:

• Cognitive behavioral therapy for insomnia had “a direct effect” on alcohol-related problems while reducing insomnia in AUD.
• The finding counters current guidance to achieve abstinence before beginning CBT-I.

Waiting until patients with insomnia and alcohol use disorder achieve abstinence before treating their insomnia is unnecessary and could be “a missed opportunity” to both improve sleep and reduce alcohol-related harm, according to a study.

The randomized clinical trial, published in JAMA Psychiatry, was “the first” to find that the usual first-line treatment for insomnia, cognitive behavioral therapy for insomnia (CBT-I), also had “a direct effect” on alcohol-related problems, such as damaged relationships and risky behavior, Mary Beth Miller, PhD, of the University of Missouri, and colleagues wrote.

The finding challenges current guidance that patients with alcohol use disorder (AUD) should abstain from alcohol to improve their sleep before undergoing CBT-I, Miller and colleagues wrote.

The study was conducted among 67 U.S. veterans in an addiction treatment program at a Veterans Health Administration hospital who met DSM-5 criteria for insomnia disorder and severe AUD. Participants were randomly assigned to receive either a single session of sleep hygiene instruction (n = 35) or five sessions of CBT-I (n = 32).

Primary outcomes were:

• insomnia severity, as evaluated using the Insomnia Severity Index;
• frequency of drinking and heavy drinking, measured via timeline follow-back; and
• alcohol-related problems, assessed using the Short Inventory of Problems.

Outcomes were tracked with a combination of sleep diaries and self-report measures over 7-day periods at baseline, 6 weeks after baseline (called “post-treatment”) and at another 6 weeks after that point (called “follow-up”).

Compared with the sleep hygiene group, CBT-I participants reported greater decreases in insomnia severity at post-treatment (group x time interaction: –3.70; 95% CI, –6.79 to –0.61) and follow-up (–3.34; 95% CI, –6.46 to –0.23).

There was also a greater decrease in alcohol-related problems in the CBT-I group at follow-up (group x time interaction: –0.84; 95% CI, –1.66 to –0.02). Using two mediation models, researchers found that CBT-I’s effects on alcohol-related problems were mediated by post-treatment change in insomnia severity.

As for the study’s limitations, participants were 91% male and 84% white, and 87% were being monitored in residential addiction treatment. Miller and colleagues noted the single-session sleep hygiene control made it “impossible to know if results are unique to CBT-I or due to non-specific therapy effects (eg, therapist/treatment time).”

Researchers called for replication of the study in outpatient and civilian settings, as well as studies testing transdiagnostic, modular treatments tailored to each patient.