Wednesday June 3 2015
For insomnia, CBT aims to change unhelpful thoughts and behaviours
"Insomnia could be cured with one simple therapy session, new study claims," The Independent reports. UK researchers have been looking at whether cognitive behavioural therapy (CBT) delivered in a single one-hour session can combat acute insomnia.
CBT is a type of talking therapy that uses a problem-solving approach to tackle unhelpful patterns of thinking and behaviour. For example, many people with insomnia develop feelings of anxiety and stress related to not being able to sleep, which can make the problem worse – a vicious circle.
A course of CBT is already an established treatment for insomnia, but this trial aimed to see whether a single one-hour session of CBT could be effective.
Forty adults with short-term insomnia (less than three months) were randomised to a single CBT session or waiting list (no treatment) as a control. Four weeks later, 60% of the CBT group had "remission" of their insomnia (defined as falling below a pre-specified level of insomnia severity on a sleep index) compared with 15% of the control group.
The results show promise, but this was a small sample size who may not be representative of all people with insomnia. The study also had a short follow-up period and it is unknown whether these effects would be sustained beyond a month after the session.
Importantly, brief-form CBT was only compared with no treatment and not with a longer course of CBT or another treatment. A similar trial would be required to see how the brief intervention compares with the alternatives.
Where did the story come from?
The study was carried out by researchers from Northumbria University, Newcastle University and the University of Pittsburgh in the US.
It was not reported to receive any external funding. One of the authors reports receiving educational grants from UCB Pharma and Transport for London, and has consulted for the BBC.
The study was published in the peer-reviewed medical journal, Sleep.
In general, the media has been overoptimistic at this stage. While the results of this small study into the use of a single CBT session for insomnia are promising, questions remain and more study is needed.
Even just going on the results of this study alone, the treatment can't be described as a "cure", despite some media headlines. Not all people showed improvement and we don't know whether the effects lasted longer than a month in those who did improve.
What kind of research was this?
This was a randomised controlled trial (RCT) that aimed to examine the use of a single session of cognitive behavioural therapy (CBT) for insomnia. CBT is a type of talking therapy that examines thought and behaviour patterns and beliefs and attitudes, and helps people find ways to cope with things by looking at them differently.
Up to 15% of the population are reported to suffer from chronic insomnia, though many more report problems with sleeping. Standard CBT for insomnia usually involves sessions delivered over six to eight weeks and has been demonstrated to be effective.
However, people sometimes have difficulties sticking to long treatment courses, and access to qualified therapists can be limited in some parts of the country.
This study aimed to look at the effects of a single session of CBT for insomnia, accompanied by a self-help booklet, compared with a no treatment or waiting list control condition. This treatment was specifically targeted at people who had insomnia for only a relatively short period of time – less than three months.
What did the research involve?
The study recruited people with short-term insomnia, and randomised them to a single session of CBT with the accompanying self-help booklet or waiting list control. Researchers then compared participants' insomnia four weeks later to assess the effect of CBT.
Potential participants were recruited from the north-east of the UK and were assessed to see whether they met diagnostic criteria for acute insomnia (duration of less than three months).
Participants also had to have not previously tried CBT for insomnia and not be taking sleeping medications. A total of 40 adults (average age 32, 55% female) were enrolled who had varying underlying causes for their insomnia.
Most (31 out of 40) reported some form of non-medical stress as a cause (such as family, relationship or work problems) and the rest had insomnia related to health problems such as sleep apnoea or depression.
In the group randomised to treatment, the CBT session lasted for around one hour and was delivered on a one-to-one basis by a single experienced therapist.
The therapy included education on sleep and changes in sleep needs throughout life to challenge any misconceptions, and examination of the person's sleep diary, which they had completed when they enrolled in the study. From this diary, the researchers worked out each individual's "sleep efficiency" – the percentage of the time they spent in bed trying to sleep that they actually spent asleep.
The focus then moved to what was called "sleep-restriction titration", where the person was directed about changing time in bed according to sleep efficiency. This involved reducing time in bed by 15 minutes if a person had less than 85% sleep efficiency, increasing it by 15 minutes if they had more than 90% sleep efficiency, and not changing if sleep efficiency was 85-90%.
Sleep diaries were again assessed at one week and four weeks after the session, and at four weeks participants also completed the Insomnia Severity Index (ISI).
This index measures the nature, severity and effects of insomnia on a scale, with each question response ranging from 0 (not a problem) to 4 (a severe problem).
The total possible test score is 28, with a higher score showing more severe insomnia. People whose scores reduced to 10 or less were considered to be in "remission" from insomnia.
People in the "waiting list" control group received no treatment during the study. At the end of the four-week study, participants in both groups were offered a full course of CBT for insomnia.
What were the basic results?
At the start of the study, there was no difference between the two groups on any characteristics or their ISI scores (average score 14.6 points).
At four-week follow-up, there was a significant difference in ISI scores between the groups. Average ISI score was 9.6 points in the CBT group and 12.7 points in the control group. Remission of insomnia according to the ISI score was achieved by 60% of the treatment group (12/20) compared with 15% of the control group (3/20).
When examining the sleep diaries, outcomes were also better for the CBT group compared with the control group. The CBT group had significant improvements in how long it took for them to get to sleep (sleep latency), how often they woke after falling asleep, and sleep efficiency.
After the study, 70% of people in the control group (14/20) requested a full course of CBT, compared with only 5% in the treatment group (1/20). Forty percent of the treatment group (8/20) requested a single booster CBT session, mainly so they could talk about ways to prevent relapsing.
How did the researchers interpret the results?
The researchers concluded that, "This single session of cognitive behavioural therapy for insomnia is sufficiently efficacious for a significant proportion of those with insomnia."
They say there may be the possibility of introducing this brief form of CBT into the "stepped care model" for insomnia, where people start with lower-intensity treatments and move on to more intense treatments if these don't work.
This RCT demonstrates that a single one-hour session of CBT led to remission at one-month follow-up for 60% of people with acute insomnia, compared with 15% with a waiting list control.
A course of six to eight weeks of CBT is already a recommended treatment for insomnia, and the results of this study suggest promise for a briefer intervention. This may be better if it makes it more likely people will accept treatment and stick with it. Shorter sessions would also be easier to provide, as they need fewer resources.
However, there are important points to bear in mind before taking this study as conclusive proof of the effectiveness of a single CBT session for insomnia:
- The study was small, involving only 20 people in each of the treatment and waiting list control groups. The results need to be confirmed in a much larger trial.
- These were a specific group of people: young adults (average age 32) who had insomnia lasting for less than three months (mostly as the result of work or relationship stress) who were all willing to take part in the study and try CBT. They were also not taking any sleep medications. Results in this group may not apply to other types of people who have insomnia, so care should be taken when generalising to populations, such as those with chronic sleep problems and the elderly.
- Follow-up was only for one month. We don't know if there would be a lasting effect or whether further booster sessions would be needed to maintain effectiveness.
- Comparison was made to a waiting list control – people who received no insomnia treatment and knew this. These people may not have been happy with the fact they were not receiving treatment and this could affect their rating of their insomnia. Also, we can't say how single-session CBT performs compared with alternatives. Ideally, a trial would need to compare the short version of CBT with the full course or other alternatives to compare their effects.
- The researchers say the number of requests for a full course of CBT at the end of the study was "used as a gross indicator of treatment acceptability". The majority of people in the control group wished to have a full CBT course, but only one of the treatment group wanted a full course. It is difficult to know what to interpret from this – for example, whether people in the CBT group didn't find it acceptable to be treated for longer and wanted no further CBT, or whether they felt they'd already gained enough benefit. However, the fact 8 out of 20 wanted a booster session may suggest they didn't feel the need for a full course and preferred to have another brief session.
Overall, the research suggests promise for brief CBT interventions for insomnia, which may well have a place in the treatment of the condition.
However, at this stage questions remain and larger studies are needed, particularly in comparison with other treatments, such as a full treatment course of CBT.
If you are affected by persistent insomnia, self-help techniques, such as not drinking tea, coffee or alcohol in the evening and taking daily exercise of at least 30 minutes a day, may help.
If the problem persists, see your GP. There may be an underlying medical condition contributing towards your sleep problems. Your GP can also refer you to a CBT therapist.