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 While the American College of Physicians (ACP) can't say cognitive
behavioral therapy (CBT) outperforms medications for chronic
insomnia, the group does say psychotherapy is less risky than drugs.
"Sometimes we forget that sleep medications have the potential for
serious side effects in some patients, while cognitive behavioral
therapy is very low (risk) to patients," said Dr. Wayne J. Riley,
ACP president.
"The evidence is clear that CBT and sleep hygiene can be long
lasting, life long, durable and delivered at a lower cost," said
Riley, who is also affiliated with Vanderbilt University in
Nashville.
About 6 to 10 percent of people in the U.S. have insomnia. Through
loss of productivity, the condition is estimated to have cost the
country about $63 billion in 2009, according to the ACP committee
that wrote the new guideline, which is published in the Annals of
Internal Medicine.
Chronic insomnia is defined as at least three restless nights per
week for at least three months.
"We wanted to take a deep dive into the literature for what makes a
big difference with insomnia," Riley told Reuters Health.
The ACP commissioned two reviews of insomnia treatments. One focused
on medications, and the second focused on psychological and
behavioral treatments.
Overall, the first review found that some medications may improve
sleep over a short period of time, but those come with the potential
for changes in thinking and behavior. Additionally, there is a risk
for infrequent but serious harms.
The U.S. Food and Drug Administration says medications for insomnia
should only be used for short periods. The agency warns those drugs
may impair people during the daytime, lead to "sleep driving,"
behavioral changes and worsening depression.
The review of psychological and behavioral treatments found that CBT
for insomnia improved overall sleep with a low risk of harms, the
researchers report.
Evidence collected separately for the two reviews found that "side
effects can be quite severe with the use of insomnia medications in
contrast to CBT, where there are minimal side effects," said Riley.
CBT for insomnia is typically delivered in four to six one-hour
weekly sessions. People are taught behavioral techniques such as
sleep restriction and stimulus control, and they are also taught
sleep hygiene.
When chronic insomnia isn't helped by CBT alone, the ACP advises
patients and doctors to consider a short course of medication. That
discussion should touch on the potential benefits, harms and costs
of medication, the ACP says.
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Doctors should encourage patients with insomnia to engage in CBT,
according two researchers whose editorial was published with the
reviews and the guideline.
But, they admit, CBT for insomnia might not be covered by insurance
and is likely not available at doctors' offices, write Dr. Roger
Kathol, of the University of Minnesota in Minneapolis, and J. Todd
Arnedt, of the University of Michigan Medical School in Ann Arbor.
"Unless access to and unencumbered payment for value-based
behavioral interventions, such as CBT (for insomnia), in medical
settings become a reality, patients with chronic insomnia will
continue to receive suboptimal treatment and experience suboptimal
outcomes," they write.
Alternatives to in-person CBT for insomnia include group therapy
session, telephone counseling, online lessons and self-help books,
Riley said.
The ACP recommendations are similar to that of the American Academy
of Sleep Medicine (AASM), said Dr. Alcibiades Rodriguez, who is
medical director of NYU Langone Medical Center's Comprehensive
Epilepsy Center—Sleep Center in New York City.
The AASM's 2008 practice guidelines for treating chronic insomnia
endorse psychotherapy as a first-line treatment and suggests it be
used when medications are prescribed.
"The recommendations made by the ACP will appeal to a broader group
of physicians to make them aware of this," said Rodriguez, who was
not involved with the new recommendations. "Then the doctors know
just giving patients who come to their office with sleep problems a
prescription is not the best solution in the long term."
SOURCE: http://bit.ly/Ms1ZbQ Annals of Internal Medicine, online May
2, 2016.
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