Cognitive Behavioural Therapy for Insomnia (CBT-I)

Cognitive Behavioural Therapy for Insomnia (CBT) is a structured, time-limited psychotherapy that treats insomnia disorder. It is an effective and cost-effective treatment for insomnia disorder and should be offered as a first-line treatment.^[1][2] Research evidence has also shown that CBT-I should also be a first-line treatment for insomnia in mid-life women experiencing menopause with hot flashes.^[3] With the advent of the internet, CBT-I has become widely accessible online (see table below), and is of similar efficacy with in-person CBT-I.

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• Insomnia disorder
• Major depressive disorder with comorbid insomnia
• Research evidence has also shown that CBT-I should be a first-line treatment for insomnia in mid-life women experiencing menopause with hot flashes.^[4] With the advent of the internet, CBT-I has become widely accessible online (see table below).

• Patients generally see improvements in sleep within the 2 to 3 weeks of starting CBT-I.
• There is strong and robust evidence that shows the effectiveness of CBT-I for insomnia.^[5]
• Importantly, there is comparable treatment effect with hypnotics, and the effects from CBT-I are more durable than medications.^[6]
• CBT-I can also reduce and eliminate the need for hypnotic use and significantly reduce depression symptoms.^[7]

• The typical duration of a course of CBT-I lasts for about 6 to 12 sessions.

CBT-I is more advantageous than medications for 3 key reasons:

1. CBT-I is equally as effective (or more effective) as any medication used for insomnia
2. There are no side effects from CBT-I (unlike medications)
3. The gains from CBT-I are durable and sustaining (unlike medications)

CBT-I can be delivered in various formats with similar success rates, including through:

• One-on-one in person therapy
• Online CBT-I (via websites)
• Bibliotherapy (self-guided CBT-I books)

Providing the patient education that the beginning of CBT-I helps frame the structure of the therapy. This includes providing education about the role of sleep and the body clock, and the basic principles of CBT-I.

• The body clock is a 24 hour clock, and influences the timing of behaviours of sleep, physiological processes
• Melatonin is a hormone released by the brain that is a:
  • Time-setter and mild sedative
  • Melatonin level rises 3-5 hours before sleep onset (0.1 to 0.5mg is enough to do this)
  • Melatonin levels are typically lower during the day
  • Melatonin is also suppressed by blue light (computer screens)
  • Bright morning light is the most powerful time setter and keeps the body clock on a regular schedule
• The natural sleep window is between 12am to 9am
  • Body has a high level of alertness towards the end of the day
  • Sleeping outside this window is depressogenic and increases the risk for “social jet lag.”
  • Napping is like having a snack before dinner (takes away your appetite)
• Prior to bed, you want to do low arousal activites
• Unhelpful beliefs about sleep can affect our sleep
  • “I need 8 hours to sleep to function tomorrow”
  • “I can’t sleep without medications”
• Conditioned Arousal
  • If you’re used to doing things in bed, like watching TV, or playing on the phone, you can also condition yourself to not sleep in bed.

• The goal of CBT-I is to join your fragmented sleep together
• Waking up late on the weekends = artificial jet lag (e.g. - waking up 3 hours difference between weekday and weekend is like a 3 time zone jet lag!)
• Staying up late is easier than falling asleep earlier, and CBT-I helps “retrain” this
• Physician and patient should work together to find a good wake time that works for the patient
• If sleepy but starting to nod off and doze, stand up, walk, do anything but lie down!
• 2 hours before bedtime no bright lights or phones (to avoid inhibiting your melatonin production)
• Telling a patient to just “relax their minds” at night doesn’t work – they'll end up thinking of everything
• If there are middle of the night awakenings:
  • Go to another room: best to do something very repetitive and boring (e.g.- word searches); crossword puzzles and Sudoku are in fact highly stimulating (since people are searching and thinking of answers or doing math)
  • Also don’t read magazines or books, or you might be motivated to finish it!
• Once you get head-nodding feeling, then go back to sleep!
• Always cover the clock at bedtime, to avoid the mental math of “How many hours do i have until I wake up?”

The principles of CBT-I is to correct unhelpful sleep-related beliefs and anxiety as well as common sleep-disruptive habits that maintain or contribute to insomnia. Patients are advised to adhere to basic rules regarding their sleep, including:

1. Rule 1: Select a standard wake-up time everyday (including the weekends!)
2. Rule 2: Use the bed only for sleeping (or sexual activities)
3. Rule 3: Get up when you can’t sleep
4. Rule 4: Don’t worry, plan, etc., in bed
5. Rule 5: Avoid daytime napping
6. Rule 6: Only go to bed when you are sleepy, but not before the time suggested by your doctor

Treatment during CBT-I involves all or some of the following components:

• Sleep restriction therapy
  • Reduce the time in bed, to match the amount of sleep you produce
• Stimulus control
  • Do low arousal activities to stimulate sleepiness
• Sleep hygiene (on its own not very effective)
• Relaxation training (e.g. - progressive muscle relaxation)
• Cognitive strategies

Sleep restriction involves:

1. Tracking your sleep for 2 weeks using a sleep diary to determine the average nightly total pre-existing sleep time
2. Then calculate a sleep window or “total time allowed in bed.” This is the average nightly total pre-existing sleep time + 50% of the time that the patient is awake in bed (e.g., if it takes 1 hour to fall asleep, and the patient is up for another 1 hour mid-sleep, and they only sleep for 6 hours, then their sleep window is 7 hours in bed).
3. On follow-up, the sleep window is lengthened or reduced based on the calculated sleep efficiency (SE).
   • The patient is told to increase or reduce their time in bed by 15-30 minutes (i.e., pushing bedtime later or earlier) until the SE reaches around 85%. The wake time is kept the same every week.
4. Stimulus control principles are reinforced throughout.

Relaxation therapy involves reducing the somatic and/or mental ruminations that interferes with sleep and include techniques such as:

• Progressive muscle relaxation
• Imagery training
• Autogenic training
• Meditation

Cognitive therapy involves correcting faulty expectations, cognitive distortions, and false beliefs that interfere with sleep by:

• Avoiding blaming insomnia for all daytime impairments or difficulties
• Encouraging the patient to keep realistic expectations of sleep requirements and daytime alertness (“It is okay if you only get 3-4 hours of sleep on one night during the course of CBT-I.”)
• Avoiding catastrophizing after a poor night’s sleep (“Insomnia is unpleasant but not life threatening.”)
• Exploring cognitive experiments:
  • If rumination and anxiety affects sleep initiation, set aside “worry time” earlier in the evening before bed.
  • Trying to keep oneself awake as long as possible (also known as paradoxical intention).

Sleep hygiene involves correction of lifestyle and environmental factors that interfere with sleep. While good sleep hygiene is important for any healthy sleep, chronic insomnia rarely is due to only poor sleep hygiene alone.

• Cognitive Behavioral Therapy for Insomnia in Veterans: Therapist Manual
• Improve Your Sleep: A Self-Guided Approach for Veterans with Insomnia SELF-HELP Workbook