The Importance of a
Good Night’s Sleep
More and better quality sleep would make most people happier, healthier, and safer. But getting a good night’s sleep is largely dependent on good psychological and physical health. Stress, anxiety, and depression almost inevitably interfere with sleep, as do pain and a number of other medical conditions. Chronic sleep disturbance can also increase the risk for major depression and other mental illness as well as lower immune function. Research has also shown an association between chronic sleep deprivation and increased body weight and insulin resis-tance leading to Type 2 diabetes as well as high blood pressure and cardiovascular disease. Lack of sleep is also a leading cause of injury and death due to motor vehicle and work-place accidents. Conversely, sleep may play a protective role against infectious diseases and may even speed up recovery from some illnesses.
But getting a good night’s sleep can be an almost insurmontable problem for the estimated 10% to 15% of the population who suffer from chronic insomnia and other sleep disorders. Or the 40% to 60% of adults reporting sleep problems a couple of nights a week or more. Or the majority of teenagers who are chronically sleep deprived.
Current research suggests that a majority of Canadians do not get enough sleep or a quality of sleep adequate for optimum health and well-being. We have become a nation of sleep-deprived insomniacs routinely using prescribed and OTC medications to get to sleep at night and various stimulants to keep ourselves awake during the day.
Despite its high prevalence and negative impact, insomnia remains for the most part untreated. Surveys reveal that less than a quarter of those experiencing serious insomnia have used either a prescribed or over-the-counter sleep aid within the previous year and the average duration of insom-nia before seeking professional help often exceeds 10 years. When individuals with persistent insomnia are asked about the types of methods they have used to cope with insomnia, the majority report passive strategies such as reading, listening to music or watching television, staying up late until they are tired or spending more time in bed.
The first line of active treatment usually involves self-help remedies such as alcohol, over-the-counter products, or herbal/dietary supplements. When all these strategies have failed, some individuals will seek professional help. As for most other health conditions, most individuals with insom-nia typically seek treatment, not from a psychologist, but from their primary care physician first, and treatment almost always involves drug therapy. Over 50% of patients consulting for insomnia in medical practice are prescribed a hypnotic (i.e., sleep medication) and the majority of those continue using their medications almost daily for more than a year. Most of the remaining patients are pre-scribed antidepressant or antianxiety medications.
Sadly, while there is good evidence that most of these hypnotic medications are effective in reducing the amount of time it takes to get to sleep and number of awakenings during the night in the short-term, the long-term efficacy and safety of these drugs remains unknown. As well, many hypnotic drugs have effects on the different stages of sleep that will result in reduced sleep quality and nonrestorative sleep.
Getting a Good Night’s Sleep With
the Help of Psychology
Psychologists can offer a number of effective therapies for insomnia, including sleep hygiene counselling, behavioral and cognitive therapies, relaxation training, and biofeedback.
Cognitive Behavioral Therapy
Should Be First-Line
Medscape Medical News 2006. © 2006 Medscape
November 10, 2006 — Behavioral approaches for the treatment of chronic insomnia are effective, produce longer-lasting effects than medication, and should be used as first-line treatment, a large review suggests.
The results of the study, which included more than 2029 patients from 37 treatment studies conducted between 1998 and 2004, consistently found treatments such as cognitive behavioral therapy (CBT) and relaxation were effective for primary insomnia as well as insomnia associated with some medical conditions and, to a lesser extent, some psychiatric illnesses.
"CBT is an effective therapy [for insomnia], but it is underutilized, largely because there is a misperception by clinicians that it takes too much time to implement. But the fact is, there are some CBT methods that can be efficiently integrated into clinical practice that do not take an undue amount of a practitioner's time," the study's lead author, Charles Morin, PhD, from Université Laval, in Québec, told Medscape.
The study is published in the November 1, 2006 issue of Sleep.
Most Recent Research
In 1999, Dr. Morin's group published a similar literature review to help direct insomnia practice guidelines published by the American Academy of Sleep Medicine.
This current study, said Dr. Morin, is an updated version of the previous review that includes the most recent insomnia research. "It was felt that there has been a significant amount of research conducted since 1999, and it was time to update insomnia practice parameters."
The investigators reviewed 37 studies and assessed study design, sample, diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings.
The main sleep diagnosis was either primary or secondary insomnia, with at least 1 treatment option that was either psychological or behavioral. Study designs were randomized controlled trial, nonrandomized group design, clinical case series, or single-subject experimental design with a minimum of 10 subjects.
Each study included at least 1 of the following dependent variables:
- Sleep-onset latency.
- Number and/or duration of awakenings.
- Total sleep time.
- Sleep efficiency.
- Sleep quality.
One of the review's major findings was strong evidence in support of treating insomnia in patients with comorbid conditions.
"Insomnia rarely comes in isolation, but the direction of the relationship between it and other conditions is often unclear. Previously it was assumed insomnia was always the result of another condition, but there is now evidence showing it may actually be a risk factor for some conditions," Dr. Morin said.
He added that since the last review in 1999, there have been several studies showing behavioral and psychological interventions are effective for both primary and comorbid insomnia.
The other piece of new evidence pertains to treatment of insomnia in older adults. In the past, studies have been conducted predominantly in younger, mainly healthy adults.
"The systematic exclusion of older individuals was somewhat paradoxical, because we know older adults are at greater risk for insomnia than younger individuals. However, in the past 8 to 10 years a number of studies have shown that even though older adults may present with more severe insomnia initially, they respond to behavioral and psychological interventions as well as their younger counterparts," he said.
Better Than Medication
While medication remains first-line therapy, Dr. Morin is optimistic the evidence supporting CBT will help change practice. One of the major barriers to its use, he said, is clinicians' perception that it is unduly time-consuming. However, he said, this is not necessarily the case.
"The evidence supporting [CBT] is there, and as a medical community we can't look away. There are a number of clinical approaches, what we describe in the paper as brief therapy, that can be efficiently integrated into practice. Granted, they may not be brief relative to writing a prescription, but they are effective and have longer-lasting effects than medication."
In addition, said Dr. Morin, CBT offers physicians who are not comfortable prescribing sleep medication an effective alternative therapy.
Source: Sleep. 2006; Vol. 20, pp.1415-1419.
Cognitive Behavioral Therapy
Appears More Effective Than
Sleep Medications for Insomnia
Source: Journal of the American Medical Association, 2006; Vol. 295, pp. 2851-2858.
Newswise — Patients with insomnia who implemented cognitive behavioral therapy interventions such as relaxation techniques had greater improvement in their sleep than patients who received the sleep medication zopiclone, according to a study in the June 28 issue of JAMA.
Insomnia is usually defined as subjective complaints of poor sleep accompanied by impairment in daytime function. It is common in people aged older than 55 years (9 percent-25 percent are affected) and is associated with reduced quality of life, depression, and more physician visits. Despite these links to individuals’ lives and societal costs, most people with chronic insomnia–up to 85 percent–remain untreated, according to background information in the article. Two-thirds of individuals with insomnia report having poor knowledge of available treatment options, and as many as one fifth resort to either untested over-the-counter medications or alcohol in attempts to improve their condition. Among primary care physicians, the treatment of choice for insomnia has commonly been prescription medication. Cognitive behavioral therapy (CBT) is the most widely used psychological intervention for insomnia. No studies have compared the newer non-benzodiazepine sleep medications with nonpharmacological treatments.
Borge Sivertsen, Psy.D., of the University of Bergen, Norway, and colleagues conducted a randomized controlled trial between January 2004 and December 2005 to compare the short- and long-term clinical efficacy of CBT and the non-benzodiazepine sleep medication zopiclone. The trial included 46 adults (average age 60.8 years; 22 women) with chronic primary insomnia. The participants received either the CBT intervention (information on sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation technique; n = 18), sleep medication (7.5 mg zopiclone each night; n = 16), or placebo medication (n = 12). All treatment duration was 6 weeks, and the 2 active treatments were followed up at 6 months. Clinical polysomnographic data and sleep diaries were used to determine total wake time, total sleep time, sleep efficiency, and slow-wave sleep (only assessed using polysomnography [PSG; monitoring of physiological activity during sleep]).
Using PSG testing, the total time spent awake during the night for the CBT group improved significantly more than both the placebo group at 6 weeks and the zopiclone group at both 6 weeks and 6 months. The zopiclone group did not differ significantly from the placebo group. Total wake time at 6 weeks was reduced 52 percent in the CBT group compared with 4 percent and 16 percent in the zopiclone and placebo groups on PSG testing, respectively. On average, participants receiving CBT improved their PSG-registered sleep efficiency by 9 percent at posttreatment, compared with a decline of 1 percent in the zopiclone group, a difference that the authors stated was both statistically and clinically significant.
Total sleep time measured using both PSG and sleep diary increased significantly in the CBT group at 6 months compared with 6 weeks. The zopiclone group showed no significant change at 6 months on PSG, maintaining improvements seen at 6 weeks. Comparing the 2 active treatment conditions, total wake time, sleep efficiency, and slow-wave sleep were all significantly better in the CBT group than in the zopiclone group as assessed using PSG; total sleep time was not significantly different.
“… the present findings have important implications for the clinical management of chronic primary insomnia in older adults. Given the increasing amount of evidence of the lasting clinical effects of CBT and lack of evidence of long-term efficacy of hypnotics, clinicians should consider prescribing hypnotics only for acute insomnia. At present, CBT-based interventions for insomnia are not widely available in clinical practice, and future research should focus on implementing low-threshold treatment options for insomnia in primary care settings. As recently demonstrated by Bastien et al, telephone consultations and CBT-based group therapy for younger patients with insomnia produced equally significant improvements as individual therapy sessions. In another study, CBT delivered via the Internet in a self-help format showed significant improvements in individuals with chronic insomnia,” the authors write. “Finally, future research should seek to identify which single factors in the CBT regimen produce the best results and to what extent booster sessions at 1 to 2 years after initial treatment may be necessary to maintain improvements.”
A previous research study by Dr. Gregg Jacobs and his colleagues at the Sleep Disorders Center, Beth Isreal Deaconess Medical Center and published in the Archives of Internal Medicine (vol. 164, No. 17, September 2004) concluded: ...that young and middle-aged patients with sleep onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia.