Managing insomnia: Why CBT is best long-term

Increased availability of online CBT represents a major advance for GPs managing patients with chronic insomnia, an Australian sleep expert says.

Increased availability of online cognitive behaviour therapy represents a major advance for GPs managing patients with chronic insomnia, an Australian sleep expert says.

While basic behavioural counselling about sleep hygiene and stimulus control was standard practice in treating patients with sleep difficulties, for those with chronic insomnia, defined as problem sleeping for at least three nights a week ongoing for three months or more, you really needed to introduce CBT, medication or both, said Dr Anup Desai, senior staff specialist at Sydney’s, Prince of Wales Hospital.

Importantly, CBT is the only therapy that has been proven to provide a sustained benefit in the management of chronic insomnia after the cessation of treatment.

Despite this, CBT was “the bit that often gets lost in general practice, and even in many specialist practices”, Dr Desai said.

Usually because of its ready availability, medication was often initiated before CBT, and because it was easier and was effective, it often took away patients’ motivation to put in the time and effort to work through CBT despite the long-term benefits. 

Ideally both therapies should be commenced together and medication only used short-term, two to three weeks gradually being tapered as the effects of the CBT become established.

The effectiveness of face-to-face CBT in improving both sleep time and quality in insomnia patients is well proven.

“Even doing CBT acutely has equivalent effects to hypnotics in studies,” Dr Desai, who is also Medical Director of the Sydney Sleep Centre, said.

But a major problem for many patients and their treating GPs is access to psychologists who are skilled in this area. 

“There are not many people around,” Dr Desai said.

As with many areas of mental health, CBT for chronic insomnia is moving online and interactive. And while inferior to face-to-face counselling, the online CBT programs have increasing evidence to support their benefit over many non-CBT treatments as well their overall effectiveness.

There are, worldwide, two big groups providing online CBT for chronic insomnia one in the UK and one in the US. Dr Desai’s Sydney Sleep Centre has linked up with the US group, providing access to the SHUTi program through the Centre’s website (www.myshuti.com/ssc/).

Doctors can refer patients to the program which includes six core learning and strategy sessions known as modules. Each module takes the patient about a week to work through and patients are able to submit their daily sleep diaries and have their issues assessed and personalised advice given over the course of the program.

In common with face-to-face CBT for insomnia, the online CBT program covers topics such as resetting circadian rhythm through timed daylight exposure, cognitive therapy to alter negative thoughts that contribute to ongoing insomnia and sleep restriction where patients restrict the time in bed to only those times when they are most likely to sleep.

Population studies suggest that a third to a half elderly Australians experience insomnia. Online CBT represents a safe, effective and accessible option for managing this often distressing and chronic condition.

“It is a powerful strategy to deliver CBT to your patients,” Dr Desai said.

From the presentation Insomnia Management in the Digital aAe, by Dr Anup Desai at the GP Hot Topics evening seminar in Sydney in March 2018