CBT-I for Chronic Insomnia


Ads say, "Ask your doctor" for a pill. But, is that the best way to go?

Sleep specialists recommend the best therapies. But, their articles are buried in journals.

Here, healthcare learners will use plain language to share what specialists say.

Recommendation for Sleep

Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion
Nathaniel F. Watson et al
Sleep Research Society | 2015


The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.


The Best Science Based Treatment

Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults
Sharon Schutte-Rodin, MD et al
Journal of Clinical Sleep Medicine | Oct. 15, 2008


Insomnia is the most prevalent sleep disorder in the general population, and is commonly encountered in medical practices. Insomnia is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.1 Insomnia may present with a variety of specific complaints and etiologies, making the evaluation and management of chronic insomnia demanding on a clinician’s time. The purpose of this clinical guideline is to provide clinicians with a practical framework for the assessment and disease management of chronic adult insomnia, using existing evidence-based insomnia practice parameters where available, and consensus-based recommendations to bridge areas where such parameters do not exist. Unless otherwise stated, “insomnia” refers to chronic insomnia, which is present for at least a month, as opposed to acute or transient insomnia, which may last days to weeks.

The American College of Physicians Recommendation

Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians
Amir Qaseem, MD et al
Annals of Internal Medicine | July 19, 2016


Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults.

Methods: This guideline is based on a systematic review of randomized, controlled trials published in English from 2004 through September 2015. Evaluated outcomes included global outcomes assessed by questionnaires, patient-reported sleep outcomes, and harms. The target audience for this guideline includes all clinicians, and the target patient population includes adults with chronic insomnia disorder. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)

Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)

Insomnia is a major health care problem in the United States. It is defined as dissatisfaction with sleep quantity or quality and is associated with difficulty initiating or maintaining sleep and early-morning waking with inability to return to sleep (1). Approximately 6% to 10% of adults have insomnia that meets diagnostic criteria (1–4). Insomnia is more common in women and older adults (5, 6) and can occur independently or be caused by another disease. People with the disorder often experience fatigue, poor cognitive function, mood disturbance, and distress or interference with personal functioning (2, 4). An estimated $30 billion to $107 billion is spent on insomnia in the United States each year (7). Insomnia also takes a toll on the economy in terms of loss of workplace productivity, estimated at $63.2 billion in the United States in 2009 (8).
Chronic insomnia, also referred to as “chronic insomnia disorder” in the American Psychiatric Association’sDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is diagnosed according to the DSM-5 (9) and the International Classification of Sleep Disorders (10), which have similar criteria for making the diagnosis. These criteria specify that symptoms must cause clinically significant functional distress or impairment; be present for at least 3 nights per week for at least 3 months; and not be linked to other sleep, medical, or mental disorders (1). Symptoms of insomnia differ between older adults and the younger population. Older adults are more likely to report problems with waking after sleep onset (difficulty maintaining sleep) than they are to report problems with sleep onset latency (time to fall asleep).
The goal of treatment for insomnia is to improve sleep and alleviate distress or dysfunction caused by the disorder. Insomnia can be managed with psychological therapy, pharmacologic therapy, or a combination of both. Psychological therapy options include cognitive behavioral therapy for insomnia (CBT-I); multicomponent behavioral therapy or brief behavioral therapy (BBT) for insomnia; and other interventions, such as stimulus control, relaxation strategies, and sleep restriction (see Appendix Table 1 for a description of these interventions). Cognitive behavioral therapy for insomnia is multimodal cognitive behavioral therapy targeted specifically to insomnia. It consists of a combination of cognitive therapy, behavioral interventions (such as sleep restriction and stimulus control), and educational interventions (such as sleep hygiene). Various delivery methods are available, including in-person individual or group therapy, telephone- or Web-based modules, and self-help books. Trained clinicians or mental health professionals can administer CBT-I.

The best way to measure sleep

Practice Parameters for the Use of Actigraphy in the Assessment of Sleep and Sleep Disorders: An Update for 2007
American Academy of Sleep Medicine | April 2007


Measure the Quality of your Care

Measurement of Quality to Improve Care in Sleep Medicine
Timothy Morgenthaler, MD et al
Journal of Clinical Sleep Medicine | Volume 12 Number 8


The Board of Directors of the American Academy of Sleep Medicine (AASM) commissioned a Task Force to develop quality measures as part of its strategic plan to promote high quality patient-centered care. Among many potential dimensions of quality, the AASM requested Workgroups to develop outcome and process measures to aid in evaluating the quality of care of five common sleep disorders: restless legs syndrome, insomnia, narcolepsy, obstructive sleep apnea in adults, and obstructive sleep apnea in children. This paper describes the rationale, background, general methods development, and considerations in implementation for these sleep disorder quality measures.

The Workgroup papers are published in this issue under the following titles: Quality Measures for the Care of Adult Patients with Restless Legs Syndrome, Quality Measures for the Care of Patients with Insomnia, Quality Measures for the Care of Patients with Narcolepsy, Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea, and Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea.


Computer-based CBT-I

Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis
Cheng, SK and Dizon, J
Psychotherapy and Psychomatics | June 2012


Background: Computerised cognitive behavioural therapy (CCBT) is an innovative mode of delivering services to patients with psychological disorders. The present paper uses a meta-analysis to systematically review and evaluate the effectiveness of CCBT for insomnia (CCBT-I).

Method: A comprehensive search was conducted on 7 databases including MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Library, Social Sciences Citation Index and PubMed (up to March 2011). Search terms covered 3 concepts: (1) [internet, web, online, computer-aided, computer-assisted, computer-guided, computerized OR computerised] AND (2) [CBT, cognitive therapy, behavio(u)ral therapy OR behavio(u)r therapy] AND (3) [insomnia, sleep disorders OR sleeping problem].

Results: 533 potentially relevant papers were identified, and 6 randomised controlled trials (RCTs) that met the selection criteria were included in the review and analysis. Two RCTs were done by the same group of investigators (Ritterband and colleagues) using the same internet programmes. Post-treatment mean differences between groups showed that the effects of CCBT-I on sleep quality, sleep efficiency, the number of awakenings, sleep onset latency and the Insomnia Severity Index were significant, ranging from small to large effect sizes. However, effects on wake time after sleep onset, total sleep time and time in bed were non-significant. On average, the number needed to treat was 3.59. The treatment adherence rate for CCBT-I was high (78%).

Conclusion: The results lend support to CCBT as a mildly to moderately effective self-help therapy in the short run for insomnia. CCBT-I can be an acceptable form of low-intensity treatment in the stepped care model for insomnia.


Best Sleep Diary

The consensus sleep diary: standardizing prospective sleep self-monitoring
Carney, CE et al
Sleep | Sleep Research Society | Volume 35 Issue 02


Study Objectives:
To present an expert consensus, standardized, patient-informed sleep diary.
Methods and Results:
Sleep diaries from the original expert panel of 25 attendees of the Pittsburgh Assessment Conference 1were collected and reviewed. A smaller subset of experts formed a committee and reviewed the compiled diaries. Items deemed essential were included in a Core sleep diary, and those deemed optional were retained for an expanded diary. Secondly, optional items would be available in other versions. A draft of the Core and optional versions along with a feedback questionnaire were sent to members of the Pittsburgh Assessment Conference. The feedback from the group was integrated and the diary drafts were subjected to 6 focus groups composed of good sleepers, people with insomnia, and people with sleep apnea. The data were summarized into themes and changes to the drafts were made in response to the focus groups. The resultant draft was evaluated by another focus group and subjected to lexile analyses. The lexile analyses suggested that the Core diary instructions are at a sixth-grade reading level and the Core diary was written at a third-grade reading level.
The Consensus Sleep Diary was the result of collaborations with insomnia experts and potential users. The adoption of a standard sleep diary for insomnia will facilitate comparisons across studies and advance the field. The proposed diary is intended as a living document which still needs to be tested, refined, and validated.

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