Treating insomnia, but without the medications

Studies show that CBT-I sessions are effective, but most people have never heard of it

December 04, 2013|By Nara Schoenberg, Tribune Newspapers
(Simon Winnall, Getty Images)

She lacked energy, had trouble focusing on the task at hand, and often felt down or depressed.

And no wonder: Dana Albright had been struggling with insomnia for more than a decade.

The Philadelphia teacher would sleep well one night, and then sleep less each night after that, until for a night or two she wasn't sleeping at all. She totaled two cars in fatigue-related accidents, and although no one was seriously injured, she became so concerned she stopped driving for a year. She was prescribed a succession of sleep medications — Lunesta, Ambien, Zaleplon — but the drugs were ineffective or too expensive, or the side effects were too burdensome.

And then a few months ago her doctor suggested something completely different: cognitive behavioral therapy for insomnia (CBT-I), or roughly six to eight talk therapy sessions focused on adopting sleep-promoting attitudes and behaviors.

"It's eight weeks, and it can change everything," Albright, 32, says of CBT-I.

She now sleeps an average of slightly less than eight hours a night, she says. She's much happier and more alert, and she has the energy she needs for her job.

The National Institutes of Health recognizes CBT-I as the preferred treatment for chronic insomnia, and a 2012 review of the medical literature in the journal BMC Family Practice found evidence that CBT-I is more effective in the long run (six months to two years) than sleep medications, with improvements along the lines of 30 to 60 minutes of total sleep time per night.

"What the studies in general show is that in the short run, while people are in treatment, medication and CBT-I are equally effective. But if you look over the long term, CBT-I has much better long-term gains than medication," says University of Pennsylvania assistant professor of psychology Philip Gehrman, a co-author of the 2012 study.

Yet, CBT-I has been slow to catch on, with only about 200 providers certified in the field by the American Board of Sleep Medicine (For a list, go to

Among the reasons: Insomnia traditionally hasn't been taken seriously as a distinct mental health issue; it's been viewed as a symptom of depression or anxiety.

CBT-I involves sleep hygiene practices such as using the bed only for sleep and sex; relaxation exercises to combat sleep-related anxiety; and sleep efficiency training, in which you're asked to limit the amount to time you spend in bed but not sleeping. If, for instance, you're in bed from 10 p.m. to 7 a.m. but only getting an average of six hours of sleep at night, you may be asked to go to bed at 1 a.m. and get up at 7 a.m.

"The theory behind it is that the sleep drive — the need for sleep — builds up and it gets to the point where it overrides the anxiety (about not being able to sleep)," Gehrman says.

The harder you try to fall asleep, the harder it is to do it, Gehrman adds, and sleep efficiency training shifts a patient's focus from trying to fall asleep to trying to stay up: "It takes off some of that pressure, that effort to sleep."

Albright says she lost sleep initially during CBT-I at the University of Pennsylvania Behavioral Sleep Medicine Program but now she's sleeping longer and better than she has in years.

"I don't think a lot of people know that this exists, or where to get it, or how to get it " she says. "I think if there were more places that could offer this, it would be much more popular."