Medication may not be the best way to tackle sleepless nights

Insomnia – difficulty in getting to sleep and staying asleep – is one of the most common complaints brought to GPs. One in four of us have a bout of insomnia lasting at least a week at some point in our lives – and it’s often far longer than a week. The incidence of it increases as we age, and half of us over the age of 65 can expect to experience insomnia at some point. Women are more likely to be affected than men. CBT can provide long lasting improvements in sleep UK doctors are often reluctant to prescribe sleeping pills, except as a very short term measure, because of the risk of side effects: pills can cause drowsiness the following day and some types can induce addiction.

Researchers from Harvard Medical School’s Sleep Disorders Centre and their colleagues wanted to find out if a brief and very focussed course of CBT Cognitive Behavioural Therapy worked in comparison with prescription pills, and tested a group of 63 people aged between 25 and 64.

They divided them into four groups – pills alone, CBT alone, those who had a combination of CBT and pills, and those who had placebo pills only (no CBT). The CBT received by participants in both the ‘CBT only’ and the ‘CBT plus pills” groups consisted of four 30-minute sessions, with a further telephone consultation, over a period of six weeks.

The therapists aimed to enable participants to recognise and then change the thoughts and ideas that interfered with them dropping off to sleep. This was alongside developing a manageable routine, learning how to associate the bed with sleep and sex only, and to go to bed only when actually feeling drowsy. If sleep didn’t come within 20 to 30 minutes, then participants had to go into a different room and do some relaxing activity, returning to the bedroom when drowsy once more. This would be repeated with middle-of-the-night wakings, too. There was to be no tossing and turning and ‘trying’ to get to sleep. The pills used in the trial were Zolpidem, a sedative used in many countries for insomnia, including the UK.

All people taking part were asked to keep a sleep diary which recorded length of time spent asleep, ease of getting to sleep and sleep efficiency (the time spent asleep relative to the time spent in bed). A portable sleep monitor (the ‘Nightcap’) was also used, alongside the diaries.

Results showed that total sleep time was similar in all four groups. But when it came to sleep latency (time taken to fall asleep) and sleep efficiency, highest scores were seen in the CBT groups, with the ‘combination’ group showing no advantages over the CBT-only group.

Even more striking, the improvements in these aspects of sleep were still present when researchers followed up 1, 3, 6 and 12 months after treatment, whereas the smaller improvements experienced by the pills/placebo groups had largely disappeared when the medication ceased.

Further bonus of CBT? It was a very low cost intervention. As the authors state, the improvements came about with only a little more than ‘two hours of treatment time by predoctoral and postdoctoral psychologists, making CBT very cost-effective relative to pharmacotherapy’.

The House Partnership, 1st August 2012