For many sleepless Americans and their doctors, the go-to treatment for insomnia has long been a prescription for sleeping pills. But America may now be waking up to a new era of treatment ushered in by a recent recommendation from the American College of Physicians (ACP) that favors behavioral therapy over meds as the first-line treatment for insomnia. This is welcome news.
Insomnia is a prevalent and debilitating condition that affects over 60 million Americans, and with associated healthcare costs that are estimated in the range of $30 to $107 billion each year. This overall total could double when the additional $60 billion in estimated costs associated with lost work productivity are factored in.
The ACP's recently published guidelines recommend doctors put aside their prescription pads in favor of cognitive behavioral therapy for insomnia (CBT-I) as the most effective and safest treatment. This groundbreaking recommendation was based on a systematic review of randomized controlled trials from 2004 to 2015 that examined the efficacy, safety, and comparative effectiveness of psychological versus pharmacologic treatments for chronic insomnia disorder.
Evidence showa that CBT-I significantly improved insomnia remission, treatment response, and key sleep outcomes, including sleep quality and wakefulness after sleep onset, in the general population and in older adults. Pharmacologic treatments were not nearly as effective. Evidence also shows that commonly used sleep medications including benzodiazepines and the "newer" non-benzodiazepine gabaminergic sleep medications such as eszopiclone (Lunesta) and zolpidem (Ambien) may be associated with increased risk for serious adverse effects, including confusion and disorientation, sleep-related driving, falls, injury, dementia and a wide range of odd sleep-related behaviors.
Recognizing that CBT-I is effective and safer than pharmacologic treatments, the ACP did not mince words when it recommended that "all adult patients receive cognitive behavioral therapy for insomnia as the initial treatment for chronic insomnia disorder."
This recommendation has been welcomed and applauded by the sleep medicine community, including insomnia researchers, clinicians trained in behavioral sleep medicine and professional sleep organizations, including the Society of Behavioral Sleep Medicine, whose members have long been aware of the incongruity between evidence-based practice, which favors CBT-I, and what is actually offered to insomnia patients in most primary care settings.
It is important to recognize, however, that the ACP's recommendation will not in itself raise the level of access to optimal care for insomnia patients. First, there are somewhat mixed messages in the ACP's recommendation regarding who should actually deliver CBT-I. The recommendation said cognitive behavioral "can be performed and prescribed in the primary care setting" while at the same time it noted that "trained clinicians or mental health professionals can administer CBT-I."
As trained and experienced behavioral medicine providers, we would caution against any suggestion that those primary care providers who lack training in therapeutic techniques and may have little training in sleep medicine will have the expertise, time and desire to effectively deliver CBT-I. Effective CBT-I requires specialized provider training, a patient-provider commitment of six-to-eight sessions and the implementation of specific therapeutic techniques. There are also non-trivial concerns regarding insurance provider reimbursement for these services in the primary care setting. An additional reality is that there currently are insufficient numbers of behavioral sleep medicine providers, especially in non-metropolitan areas. This may necessitate partnering between primary care providers and behavior medicine providers to develop a rational "step-wise" treatment model that includes implementation of basic strategies in the primary care setting along with clear indications for referral to more specialized care.
As with many evidence-based treatments, the challenge becomes one of how to implement the recommendation in a way that ensures treatment is made available from well-equipped providers in the settings in which patients are most likely to present. We hope that this important recommendation by the ACP will foster collaboration among primary care providers, nurses, behavioral sleep medicine specialists, and insurers to ensure that CBT-I becomes the go-to treatment for America's sleepless millions.
Wendy M. Troxel is a senior behavioral and social scientist at the nonprofit, nonpartisan RAND Corporation and an adjunct professor of psychiatry and psychology at the University of Pittsburgh.
Judith Owens is an associate in neurology, director of the Center for Pediatric Sleep Disorders and on the faculty at Harvard Medical School. She is on the Board of Directors of the Society of Behavioral Sleep Medicine and editor-in-chief of the journal Behavioral Sleep Medicine.
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