The Role of Cognitive Behavioral Therapy and Medication in the Treatment of Insomnia

Whether acute or chronic, many people experience insomnia at some point in their lives.

In this video, Charles Raison, MD, University of Wisconsin at Madison, and Psych Congress Network Depression Section Editor, provides an overview of behavioral and pharmacological interventions that clinicians can recommend to patients working through insomnia episodes. Dr Raison explains some of the strategies of cognitive behavioral therapy for insomnia (CBTI). He also compares the different types of medication options, including benzodiazepines, orexin agonists, and sedating antidepressants.

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Charles Raison, MD: Hey everybody, I'm Dr. Charles Raison. My friends call me Chuck, but when I'm at work, I'm Charles. I am a psychiatrist and a professor of human ecology and psychiatry at the University of Wisconsin, Madison. I also serve as the Director of Clinical and Translational Research for Usona Institute here in the Madison area, and I serve as the Director of the Vale Health Behavioral Health Innovation Center and the Director of Research on Spiritual Health at Emory University in Atlanta, Georgia.

Neurology Learning Network: What is the role of cognitive behavioral therapy in treating insomnia?

Dr Raison: Many of us who are prescribers tend to address mental health conditions often with a medication. Certainly that's the case for depression. Insomnia is a little bit of a different situation. Now I'm talking about insomnia as the primary problem, not people who have secondary insomnia because they're depressed or manic or something like that. How do we think about treating primary insomnia?

Well, if we look at recommendations across the board, the key thing to do and the preferred initial treatment is not a medication. It's actually a form of cognitive behavioral therapy called cognitive behavioral therapy for insomnia (CBTI). The data that it works is really quite compelling and it really looks to be the most effective treatment for insomnia. So let's talk about that a little bit.

There are genetic risk factors for insomnia, insomnia is very much driven by environmental circumstances, right? We know that you're likely to develop sleep problems when you're under stress. I bet every single person listening to me has had at least one time in their life where something bad happened or they were worried about something bad happening, and boom, you either can't fall asleep, you're in there thinking and thinking and thinking, or you fall asleep. If you're like me I always fall asleep but I wake up at 2 AM thinking, “oh my god what am I going to do what am I going to do what am I going to do?” We know that stress is a primary driver of insomnia and then some people are more vulnerable to it than others. Let's just bracket that for a second because then something else happens and this goes along with that old adage about adage about a watched pot never boils.

Because what happens with many people who develop insomnia is that they fall into a pattern of not being able to sleep. They lay down, they're lying there, and they can't sleep. You know what I'm talking about—if you've ever done this, you can't sleep and you can't sleep because you're not just worried about what you're worried about, now you're worried about the fact you can't sleep.

People that have insomnia tend to adjust to it by doing a couple of things. One, they spend more time in bed hoping that they will sleep. And two, they take naps to catch up for what they've missed at night. The core thing about CBTI is to challenge those 2 behaviors and to implement behaviors that actually do quite the opposite.

So, there are some psychoeducational things to CBTI. You learn about what insomnia is, but then the practice is to actually engage in several really interesting behaviors that have been shown repeatedly to benefit sleep, and they're a little bit paradoxical. The first is sleep restriction, and sleep restriction is the opposite of laying in bed for extended periods, right? Sleep restriction means, first off, that if you're struggling with insomnia, you don't take naps because if you sleep during the day, it decreases the pressure to sleep at night and you want to build up that sleep pressure. The second thing you do is you don't just lay in bed. You don't go to bed early. You go to bed at your regular bedtime and you give yourself different things, 30 minutes and if you're not asleep, you get up and you go do something else, and then you try again. If you're still not asleep, you get up and do something else so that you don't get this pattern in your head of “oh my God, the bed is a really stressful place. I'm laying here and I can't sleep and I can't sleep.”

There are other things that CBTI does, in addition to that. You make a commitment to having the bed only be about sleep or sex, not about doing other things. So, you don't bring your computer to bed, you don't bring your iPhone to bed, and you really are diligent about this. You also establish a set wake and sleep time every night.

Now this is a challenge, right? What a lot of people do, especially young people, is they can't sleep during the week, they don't sleep, and then they try to sleep for hours on the weekend. You don't do that. You train yourself to be sort of regimented in when you sleep and when you wake up. That's also very helpful.

Then there are other things that are sort of ancillary practices that are hugely important in terms of behavioral strategies to deal with insomnia. One is the room you sleep in. If you're sleeping in a bright place that is not dark, that really messes up your ability to sort of activate melatonin. This is what helps you fall asleep at night as the light goes down, you get a melatonin surge that sets in motion other things in your brain that help you fall asleep—it turns off the behavioral activating system. Humans also sleep better if they sleep in a cooler space. A warm, well-lit room is a poor place to sleep, right? So, these are things you can do to help your sleep.

Something else that's really crucial for helping sleep is to try to expose yourself to bright light in the morning. It's called a zeitgeber—that bright light in the morning programs your brain, it entrains your chronobiology to be awake during the daytime and then to be sleepy at night. Another thing you can do that's very helpful for inducing deep sort of slow wave sleep, which is so restorative, is to expose yourself to heat a couple of hours before bed. So, it turns out that that your ability to fall asleep and to fall into a deep sleep is very much related to how fast your body temperature falls in the evening because you know your body temperature rises all day and then it falls in the evening and your brain looks at the slope of that fall and the steeper the slope is the faster you fall asleep. If you elevate your body temperature a couple of hours before you go to sleep or an hour and a half before you go to sleep then you go up to a higher peak, you have to fall faster and that falling faster helps you fall into deeper sleep.

Something else that has been studied and there's some evidence for around this idea of not exposing yourself to bright blue light in the evening is to get yourself orange amber glasses that block out blue light. I found that beneficial. People sometimes swear by that. So these are all behavioral strategies. Exercise early in the day also helps tremendously with sleep at night. Not drinking alcohol, as sad as that could be for people who like to have a drink at night, will also greatly help your sleep. Alcohol really disrupts sleep. Caffeine disrupts sleep for some people. If it disrupts your sleep, you really don't want to be doing caffeine after 2PM if you're serious about sleeping.

So, these are all things that require effort and require changing our lifestyle—that’s why I think a lot of times people want to reach for a pill. But we know that you don't want to be taking a benzodiazepine or a benzodiazepine receptor agent for prolonged periods of time. There are orexin antagonists, don't seem to have some of the same risks, but in general for something like insomnia, which we really want to deal with, if we can avoid taking a medicine every day, we're getting way ahead of the game, and these are all things that are actually more effective over time than taking a medication every day.

I really want to encourage us in this context when we're thinking about how do we treat insomnia as a freestanding problem that we first look to these behavioral interventions because they are more effective actually than having to chronically take a medication.

Neurology Learning Network: When is it appropriate to incorporate medications into an insomnia treatment plan?

Dr Raison: Behavioral strategies like cognitive behavioral therapy for insomnia are really the recommended first line treatments for insomnia when people are just struggling with insomnia. We're not talking about people that are having trouble sleeping because they're horribly depressed or because they're manic, something like that. But just people with insomnia. We want to deal with the insomnia.

Behavioral measures don't always work, obviously, and then there's some people that just cannot do them. What do we do then? We don't want to leave people with insomnia because insomnia is a risk factor for developing things like depression and also because it fouls up people's lives. It is a disorder now in DSM-5-TR in its own right and rightly so. People that struggle with insomnia struggle during the daytime. They're sleepy, their attention is damaged, their ability to do things is curtailed. So, we want to deal with it. And when behavioral measures fail, you know, thank goodness we have medications.

Let's talk about how we think about medications for insomnia and think about like how would we use them. The first question is how long should a medication be used? Now interestingly in Europe, medications that are used for insomnia, benzodiazepines, benzodiazepine receptor agents like zolpidem or something like, these are only recommended for 3 to 4 weeks. The FDA has backed away from that in the United States. I think recognizing that in the context of our country, there are people who will take or who need to take hypnotic agents for protracted periods. But clearly here, if we can get people to use hypnotic agents for more time-limited periods, that is optimal strategy.

So, when would I think about this? If people are having an acute bout of insomnia because they're under a great deal of stress or something's happened, those are circumstances where a couple of weeks or a month of something like a benzodiazepine receptor agonist or something similar is a very appropriate thing to do. Some of these other agents like melatonergic agonists or agents that work on the orexin system like suvorexant and similar agents may have advantages over benzodiazepine focused agents for longer term use.

In general, we don't want to withhold medications for people that are struggling with an acute problem. I think that's the first really important thing to say. Remember, behavioral strategies, if you're going to do something like cognitive behavioral therapy for insomnia, these take a while. You got to practice them. You got to do the therapy. These are things for people that have chronic insomnia.

Certainly medications are very appropriate for people that are struggling with specific problems. They're certainly appropriate for people that have jet lag, things like this, and they are appropriate for some people that have chronic insomnia, that have failed other agents. Then if you ask, “Well, what's the best agent to reach for?” The answer is a lot of it depends on the individual person. When you're doing things chronically, if you can, you want to avoid agents that have disproportionate side effects over a long period of time. So, for instance, you know, if you can avoid using benzodiazepine agents for long periods, that's preferable because over time, benzodiazepines induce physiologic dependence. If you stop them suddenly, you can have really, really dangerous withdrawal reactions. There's evidence, especially in older people that they impair coordination. They increase the risk of falls, they dull mental acuity. So, if we can avoid those agents for chronic use, that's optimal. But at the end of the day, insomnia, when it's chronic, can be so devastating that you make your way through things and you come to the agent that works. There are a wide range of agents. There are benzodiazepines, there are benzodiazepine receptor agonists, again, for instance, opidum being a classic one, but agents that interact with the benzodiazepine receptor but that are not benzodiazepines, those agents tend to have a more favorable profile in many ways. There are a melatonergic agents and there are agents that are antagonists of orexin.

Then, of course there are sedating antidepressants like mirtazapine or trazodone. They have certain advantages. They don't have risk of withdrawal and direct physiologic dependence like the benzodiazepines do, but of course they have their also have their risks, you know, things like metasamine can increase, can cause weight gain. Then there's atypical antipsychotics and things like Seroquel, which induces sleepiness are often used, but they also come with their own sort of risks in addition to benefits.

So again, there are a range of medications that can be used. Medications are especially appropriate when people are struggling with a short-term source of insomnia. They're appropriate for chronic insomnia when behavioral strategies have been ineffective.

Charles Raison, MD, is the Mary Sue and Mike Shannon Distinguished Chair for Healthy Minds, Children & Families and Professor at the University of Wisconsin-Madison. Dr Raison also serves as Director of Clinical and Translational Research for Usona Institute and as Director of Research on Spiritual Health for Emory Healthcare in Atlanta, GA. Dr. Raison is internationally recognized for his studies examining novel mechanisms involved in the development and treatment of major depression and other stress-related emotional and physical conditions, as well as for his work examining the physical and behavioral effects of compassion training. More recently, Dr. Raison has taken a leadership role in the development of psychedelic medicines as potential treatments for major depression.