When the sheep are gone, how do you treat insomnia?

Ms. Rose is a 65-year-old woman with diabetes who is the primary caregiver for her adult son. She has been having difficulty sleeping over the last year and tells you about it for the first time today.

Ms. Rose feels exhausted every day, which she thinks is due to poor sleep. It takes her 5 minutes to fall asleep. She then wakes up 2-3 times per night and stays awake for 30-90 minutes each time. She believes she is asleep for ~6 hours each night, but is in bed for 8-9 hours. These sleep disturbances occur almost nightly. She does not nap, use her cell phone or watch TV in bed, but she does sleep with the door open in case her son needs her. She does not snore, have restless legs, or fall asleep at unexpected times during the day. She does not feel depressed, anxious, or suicidal. She occasionally drinks alcohol, but does not use any unprescribed substances. 

Does Ms. Rose have insomnia disorder?

Insomnia disorder is defined as a sleep continuity disturbance with negative daytime effects. Symptoms are persistent, defined as occurring 3 or more days per week for 3 or more months. There are no defined severity criteria for insomnia disorder, but clinicians often recommend treatment to patients with daytime symptoms including fatigue, somatic symptoms, compromised work or cognitive function, who take 30 minutes or more to fall asleep, or who are awake for 30 minutes or more during the night.

Ms. Rose has insomnia disorder. She has troubles with sleep maintenance but not sleep onset. 

How do you treat insomnia disorder?

The 2 main treatments for insomnia are cognitive behavioral therapy for insomnia (CBTi) and medications. All society guidelines recommend CBTi as the first-line treatment given its efficacy and durability. 

Treatment with CBTi

Compared with no treatment or sleep hygiene advice only, CBTi was found to be superior for people with isolated insomnia as well as those with co-morbid psychiatric and medical conditions. 6-8 sessions of CBTi reduced sleep latency (time to fall asleep) and wake after sleep onset (time awake during the night) by ~50% (from 45-60 minutes pre-treatment to 20-35 minutes post-treatment) (Perlis 2022). CBTi had minimal effect on total sleep time (only 45% of patients exceeded baseline total sleep time at the end of treatment). However, when assessed using the Insomnia Severity Index (ISI), 60-80% of patients had a clinically significant response to CBTi. The ISI evaluates sleep disturbances and daytime impairments, and can be useful clinically to monitor the effectiveness of insomnia treatments. Additionally, the treatment response to CBTi lasts: improvements in decreased sleep latency and wake after sleep onset are stable for up to 2 years.

A brief look at the requirements of CBTi exposes the dedication and time required for this form of treatment. It is available in-person and on digital platforms; in the current landscape, in-person therapy can be challenging to access. Digital platforms were found to be non-inferior to face-to-face CBTi, and may be a reasonable alternative for a motivated patient. Insomnia Coach created by the Veterans Administration, is a free app for CBTi. CBTi Coach, also by the VA, is an app designed to augment provider-led CBTi. 

Given how hard it is to access in-person CBTi, I am going to summarize some of the basic techniques with the goal that you can explain CBTi to your patients and help the motivated patient get started with Insomnia Coach. 

What can your patient expect from CBTi? 

CBTi combines stimulus control, sleep restriction, sleep hygiene, and cognitive therapy. Stimulus control instructs the patient to focus the bedroom on sleep (and sex) only: do not perform other activities in bed, get in and out of bed at the same time each day (regardless of sleep quality), and limit the amount of time spent awake in bed. Sleep hygiene is a set of guidelines to promote sleep, including avoiding naps, caffeine and alcohol before bed, and bright lights and electronics in bed, and exercising (but not too close to bedtime). Cognitive therapy guides exploration and reframing of a patient’s dysfunctional sleep related beliefs. 

Sleep restriction purposefully creates sleep debt in order to improve sleep efficiency (the proportion of time in bed spent asleep, specifically the time asleep in bed/time spent in bed).  It involves determining an assigned duration of time in bed that is limited to the person’s average total sleep time plus 30 minutes. The person chooses their desired wake-up time and must get up at that time every day, even if they are sleepy. If the average sleep efficiency is 85% or more, then the time in bed is increased by 15 minutes. The time in bed is decreased if the opposite is true. Do not use sleep restriction for those who cannot tolerate sleep deprivation. 

Before starting sleep restriction, Ms. Rose would keep a daily sleep diary for a week. If it showed that she sleeps an average of 6 hours per night, she would restrict her time in bed to 6.5 hours. If she chooses to wake up at 6:30 AM, her assigned bedtime would be 12 AM for that week. A CBTi therapist, or the Insomnia Coach app, would calculate these times based on her daily sleep diaries and adjust them weekly.  

What are the next steps for Ms. Rose?

For Ms. Rose, I recommend offering CBTi. I would explore with her the options for in-person v. digital CBTi. I would also provide her with a list of behavioral recommendations derived from CBTi (see below) and have her choose 1-2 to focus on for the next month. If at any time she would like to use medication, in addition to CBTi, I would invite her for another visit to discuss medication treatment options.

We will cover medications for the treatment of insomnia in a future PsychSnap.

Sleep behavior tips

During the day:
1) Get up at the same time every day
2) Early morning exposure to light
3) Daytime physical activity, preferably in the morning
4) No naps
5) Stop caffeine and other stimulants after 4 PM; alcohol also negatively affects quality of sleep
6) Stop screens 1-2 hours before bed or limit blue light

At night:
1) Good sleeping conditions (comfortable, cool, dark, quiet)
2) Bed = sleep (or sex) only. No TV, reading, working.
3) Limit the time in bed to time spent sleeping
4) If can’t sleep, get out of bed and go back to bed when sleepy.

References

  1. Sutton EL. Insomnia. Ann Intern Med. 2021;174(3):ITC33-ITC48. doi:10.7326/AITC202103160
  2. Perlis ML, Posner D, Riemann D, Bastien CH, Teel J, Thase M. Insomnia. The Lancet. 2022;400(10357):1047-1060. doi:10.1016/S0140-6736(22)00879-0
  3. Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: Psychometric Indicators to Detect Insomnia Cases and Evaluate Treatment Response. Sleep. 2011;34(5):601-608. doi:10.1093/sleep/34.5.601
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