Although behavioral intervention is the recommended first-line treatment for insomnia, high rates of medication (e.g., sedative-hypnotic) prescribing continues.
Behavioral Treatment Works Better
Effective behavioral treatment typically involves four to eight weekly sessions and requires substantial patient motivation. The most efficacious components are considered to be stimulus control and sleep restriction. Sleep hygiene instructions and cognitive therapy may be included as well.
Research studies comparing efficacies of behavioral and medication treatments have found
1) comparable treatment effects
2) more rapid improvement with medications (e.g., sedative hypnotics)
3) more sustained improvement with behavioral treatments
Advantages of behavior interventions are minimal side effects and sustained improvement. Behavioral treatments administered over a period of 4–8 weeks with weekly sessions produce robust and stable improvements in sleep continuity for periods of up to 2 years.
Thus, researchers say that behavioral interventions should be considered as first-line treatment for insomnia.
In comparison, very little is known about the long-term efficacy and safety of medication treatment in patients with chronic insomnia.
Researchers suggest that medications may be selected when immediate symptom reduction is the primary consideration. Behavioral treatment may be indicated when pharmacotherapies are contraindicated (e.g., because of potential drug interactions or history of substance abuse).
Behavioral Treatment Is Under-Utilized
Although Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for insomnia, high rates of medication (e.g., sedative-hypnotic) prescribing continue.
In a 2019 study, researchers examined 5,254 Veterans referred for either CBT-I or prescribed a sedative-hypnotic medication. They found that the majority of Veterans received only a sedative-hypnotic medication (98.0%).
The findings suggest that sedative-hypnotic medications were overwhelmingly the primary treatment recommendation despite evidence to support CBT-I as the recommended first-line treatment.
Underdiagnosis of insomnia seemed to be a contributing factor. Among the 2% of 5,254 Veterans who received a CBT-I referral, a key predictor was a diagnosis of insomnia in the medical record.
But records showed that this cohort of 5,254 Veterans only had a prevalence of insomnia less than 10%, which is much lower than the estimated prevalence in the literature (25–74%).
And an insomnia diagnosis has much to do with the type of health care provider. Mental health and sleep medicine providers may be more likely to document insomnia in the medical record and more likely to refer for CBT-I compared to a primary care provider or a medical specialty provider (e.g., neurology, cardiology, pain).
Researchers say there may also be other reasons for the high rates of medication prescribing for insomnia treatment.
The difference in treatment cost is likely to be a major consideration. Even the most expensive sedative hypnotics, in the short run, do not rival the costs of behavior therapy.
There is also a lack of providers trained in CBT-I. This likely limited both the awareness and the availability of CBT-I.
Sources consulted:
Bramoweth, Adam D., et al. "Identifying the Demographic and Mental Health Factors That Influence Insomnia Treatment Recommendations Within a Veteran Population." Behavioral Sleep Medicine, vol. 17, no. 2, 2019, pp. 181–190.
Smith, Michael T., et al. "Comparative Meta-Analysis of Pharmacotherapy and Behavior Therapy for Persistent Insomnia." The American Journal of Psychiatry, vol. 159, no. 1, 2002, pp. 5-11.
Riemann, Dieter, and Michael L. Perlis. "The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies." Sleep Medicine Reviews, vol. 13, 2009, pp. 205–214.
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