Treating chronic insomnia with cognitive behavior therapy for insomnia (CBT-i) could be
more cost-effective than current pharmacological treatment. Sleeping
tablets can become very expensive if the medication changes from generic to brand
name or as dose and frequency abuse increases.
Unfortunately, hypnotics or sleeping tablets are not usually effective for
chronic insomnia. They can also cause unpleasant side effects, such as daytime
drowsiness or a feeling of having a hangover. Cbt-i therapy includes a range
of strategies to help insomniacs associate night time with sleep time.
Stimulus control therapy aims to associate the bedroom with restful sleep.
Using soft colors in the bedroom and removing clutter, a calming space is
created. Ideally the bedroom should only contain bedroom furniture, so no TV or
computer to distract the sleeper. Sleep restriction therapy limits time spent in
bed to actual sleeping time. This means getting out of bed when awake, whatever
the time. Whilst this creates mild sleep deprivation, it also ensures a connection
in the mind between the bedroom and sleep. Paradoxical intention
can be used to manage situations where it is difficult to get to sleep rather
than to stay asleep. It involves forcing an awake state without trying to go to
sleep.
Finally, biofeedback uses senses on the body to measure the body's physical
responses. The biofeedback machine indicates changes in muscle tension and
heart rate.
This helps the subject to control breathing and body responses more
effectively. A US randomised controlled trial of the effects of CBT-i tested the
effectiveness of the therapy for insomnia and daytime functioning. 34
randomly selected college students completed either 6 sessions of CBT-i
or a 6-week wait list control. All participants completed a week-long sleep
diary and underwent actigraphy. Actigraphy is a non-invasive method of
monitoring human rest and activity cycles using the sensor which is worn by
the patient at all times. The subjects also completed
questionnaires about sleep and daytime functioning both before and after
treatment. The treatment group repeated all measures during a 3-month
follow-up. The subjects who underwent CBT-i showed greater improvements in sleep
efficiency, sleep onset and the number of awakenings. They spent less time awake
after sleep onset and had better sleep quality. They also reported
reduction in insomnia severity in general fatigue than the WLC group. These
improvements were still in evidence at the 3-month follow-up. iI was also
noted that the results were even better after following the recommendations to
go to bed only when sleepy. They were also advised to keep regular hours and to get
out of bed if getting to sleep was proving impossible. A New Zealand review
of the cost-effectiveness of CBT-i backed up these results. 21 insomnia
treatment providers were recruited using snowballing sampling. Snowball sampling
is also called referral sampling as future subjects in a study are recruited
from acquaintances of existing subjects.
Information gathered from the interviews was used to estimate treatment uptake
and costs as the basis for a decision analytic model. The results highlighted
the fact that insomnia treatment in New Zealand is quite unstructured.
Despite this, the net annual benefit for treating insomniacs was judged to be
reasonable compared with the cost of using drug therapy. Cognitive
havior therapy for insomnia is not in widespread use, however, it does provide
an alternative for treating chronic insomnia. The uptake of CBT-i is sometimes
influenced by the scarcity of clinicians who are trained in providing CBT
specifically for insomnia. Another issue for its use in primary care is the
length of treatment. Generally speaking, 6 sessions is usually considered to be too
long for inpatient care.
Perhaps for these reasons insomnia remains an undertreated disorder and a
considerable burden to those who suffer from it.