Approximately 5% of persons in the United States suffer from primary persistent insomnia and many are prescribed sedative hypnotics or antidepressant medications. However, prescription medication can also cause side effects or create dependence, and published data on their efficacy for sleep disorders is limited*. Additionally, poor sleep may return once the medication intake stops*. The current study* investigated Cognitive Behavioral Therapy (CBT) for chronic primary insomnia. CBT is a psychological treatment that facilitates change in how one thinks, feels, and acts through various talk therapy and behavioral strategies and techniques.
The current study utilized a randomized, double-blind, placebo-controlled clinical trial design that took place at a university medical center from 1995-1997. 75 adult patients (35 women and 40 men with a mean age of approximately 55 years) with chronic primary insomnia were assigned to receive either: (1) CBT that included sleep education, stimulus control, and time-in-bed instructions, (2) behavioral/relaxation therapy (progressive muscle relaxation training), or a (3) placebo treatment (fake desensitization therapy). Please see the article for a detailed explanation of how CBT, relaxation therapy, and placebo therapies were administered. Participants suffered from chronic primary sleep-maintenance insomnia for am average of over 13 years. Outcome measures were polysomnography (EMG, EEG, etc.), sleep logs with measures of total sleep time and wake periods after sleep onset, estimates of sleep efficiency, self-report measures of global insomnia, sleep related self-efficacy, and mood.
Researchers reported that CBT significantly reduced sleep fragmentation by 54% compared to relaxation therapy (16%) and placebo therapy (12%). Patients in the CBT group showed only modest gains on the polysomnography, an objective outcome measure, including improved short-term sleep efficiency; however, those in the relaxation and placebo groups had almost no changes. Subjective sleep logs showed modest improvements in sleep for the CBT group and none in the other groups. Those that who received CBT gained a vital extra half hour of sleep (went from 5.5 to 6.0 hours) on average each night; and although a small difference, the researchers noted that 5.5 hours is considered pathological (based on current understanding of human sleep needs) whereas 6 hours is considered the minimally necessary amount of “normal” sleep. The researchers acknowledged that although increased sleep times for the CBT group were more modest than reported in other studies that investigated pharmacotherapies, treatment gains from CBT were maintained over 6 months whereas the benefits of pharmacotherapy can cease once the medication is withdrawn.
In summary, CBT for primary insomnia produced modest, but important gains in total hours slept and in the overall quality of sleep. The researchers noted that the small sample size most likely limited the treatment effect size. Nonetheless, CBT for sleep may represent an excellent alternative for those who prefer non-medication based treatments for reasons discussed above. In my opinion, CBT also makes an excellent complimentary treatment to pharmacotherapies that can result in a synergistic treatment characterized by positive short and long term sleep improvements.
*Edinger, J., Wohlgemuth, W., Radtke, R., Marsch, G., & Quillian, R. (2001) Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. JAMA, 285(14), 1856-1864.