Shelby Harris on CBT for Sleep Problems – Part 2 of 3

By Lynn Mollick

Insomnia means dissatisfaction with sleep quality or quantity at least 3 nights a week for 3 months. Initially, CBT-I is just as effective as sedative hypnotics, and long-term it is more effective because it makes permanent changes in sleep habits.

Sleep hygiene, stimulus control, and sleep restriction are the best validated components of CBT-I.

Sleep Restriction means reducing time spent in bed in order to increase sleep drive. Aim for sleep efficiency (time asleep divided by total time in bed) of 85 to 90 percent. Never restrict sleep to less than 5 hours. Decide upon a wake-up time and adjust the hour of retiring accordingly. Sleep restriction requires several weeks to effect sleep that is more consolidated into the time available. This is an uncomfortable process, so plan for road blocks and resistance:

1. Gradually push bedtime later while keeping wake up time constant.
2. Plan activities that will facilitate wakefulness until bedtime.
3. Look for ways to increase alertness during the day, e.g. sitting at the front of a class, standing instead of sitting, sitting in bright light, or if all else fails, taking a 15-minute nap.

Cognitive Behavior Therapy: Establish a daytime “worry time.” Disputation — What is the worst thing that will happen if I don’t sleep? Can I cope with that? How likely is it? No clocks should be visible to prevent waking up to check the time, and then worrying about getting back to sleep. Use an alarm clock on the other side of the room to prevent to get patients out of bed and prevent them from shutting off the alarm and going back to sleep.

Relaxation is most useful for sleep onset difficulties. All relaxation techniques are equally effective.

Light Therapy: The jury is still out, but bright light may be helpful to enhance wakefulness until bedtime and/or to establish alertness in the morning. Always consult with the patient’s eye doctor before using bright lights.

Mindfulness: Mindfulness exercises along with emphasis on acceptance of wakefulness show promise.

There is little data supporting the use of acupuncture, over-the counter drugs, or melatonin for insomnia.

Patients may begin CBT-I while they are taking sleep medication. Taper medication with medical consultation after acceptable sleep has been achieved. Avoid adding sleep medication of any sort during CBT-I.

CBT-I can be combined with treatment for other disorders. Combining CBT-I and cognitive behavioral treatment for depression provides better outcome for both disorders than treatment for either problem individually. But be careful using sleep restriction with bipolar patients who are vulnerable to mania when their sleep is diminished.