Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills

Insomnia is a common sleep disorder that can make it hard to fall asleep or stay asleep. It also can cause you to wake up too early and not be able to get back to sleep. Cognitive behavioral therapy, sometimes called CBT, can effectively treat long-term sleep problems like insomnia. Generally, it's the first treatment recommended.

CBT helps you find out which thoughts and behaviors cause sleep problems or make them worse. You learn how to replace these thoughts and behaviors with habits that support sound sleep. Unlike sleeping pills, CBT helps you overcome the causes of your sleep problems.

To find out how to best treat your insomnia, your sleep specialist may ask you to keep a detailed sleep diary for 1 to 2 weeks.

How does CBT work?

The cognitive part of CBT teaches you to look for and change beliefs that affect your ability to sleep. This type of therapy can help you control or get rid of negative thoughts and worries that keep you awake. The behavioral part of CBT helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.

Depending on your needs, your sleep specialist may recommend that you:

• Change your routine. This can help you sleep better. Set a consistent bedtime and wake time. Avoid naps. Use the bed only for sleep and sex.
• Set sleep limits. Lying in bed when you're awake can become a habit that leads to poor sleep. If you can't fall asleep within 20 minutes, get up and don't go back to bed until you're sleepy. But don't change your wake-up time. This makes you more tired the next night. But once your sleep gets better, your time in bed is slowly increased.
• Change certain lifestyle habits. Change habits that lead to poor sleep, such as smoking, drinking too much caffeine late in the day and drinking too much alcohol. Not getting regular physical activity also can lead to poor sleep. You may learn tips that can help you sleep better, such as ways to wind down an hour or two before bedtime.
• Improve your sleep area. Create a comfortable sleep area. Keep your bedroom quiet, dark and cool. Don't have a TV in the bedroom. Hide the clock from view.
• Learn relaxation techniques. These techniques help you calm your mind and body. Approaches include meditation, imagery and muscle relaxation.
• Remain passively awake. With this method, once you're in bed, you try not to think about falling asleep. That's because worrying that you can't sleep can keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
• Use biofeedback. This technique involves using a device that shows signs such as your heart rate and muscle tension. Then you learn how to help manage them. Your sleep specialist may ask you to take a biofeedback device home to record your daily patterns. This information can show patterns that affect sleep.

The most effective treatment approach may combine several of these methods.

CBT versus pills

It's common for people to try sleeping pills available without a prescription before seeking help for insomnia. Some prescription sleep medicines can be an effective short-term treatment. For example, they can provide relief right away when you're very stressed or grieving. Some newer sleep medicines are approved for longer use. But generally sleeping pills are not the best long-term treatment for insomnia for many people.

It's unlikely that all your insomnia symptoms will go away with medicines alone. Also, some prescriptions come with the risk of serious side effects, including dependence, withdrawal symptoms, amnesia and thoughts about suicide. Most commonly, these medicines can make you tired when you need to be alert, for example, at work or while driving.

CBT may be a good treatment choice if you have long-term sleep problems or you're worried about becoming dependent on sleep medicines. It also can be a good choice if medicines aren't effective or cause bothersome side effects.

Unlike sleep medicines, CBT addresses what's causing your insomnia rather than just relieving symptoms. But it takes time and effort to make it work. In some cases, a blend of sleep medicine and CBT may be best. If CBT is not available where you live, ask your health care provider for sleep tips that are based on CBT.

Insomnia and other disorders

Many medical conditions can disrupt sleep. These include heart disease, asthma, chronic obstructive lung disease (COPD) and arthritis. Mental health conditions also can disrupt sleep. Examples include anxiety, depression, bipolar disorder and post-traumatic stress disorder.

Ongoing lack of sleep increases your risk of health conditions such as anxiety, depression, high blood pressure, heart disease, diabetes and long-term pain. Some medicines, including those available without a prescription, also can cause insomnia.

If your insomnia is related to a medical condition or to a medicine you're taking, talk to your health care provider about how best to manage sleep problems. Insomnia is not likely to get better without treatment.

Finding help

Many types of providers can deliver CBT guidance for insomnia, including behavioral sleep medicine specialists and members of your primary care team. There are a limited number of certified behavioral sleep medicine specialists. You may have to search for a trained practitioner and a treatment schedule to fit your needs.

You can search sleepeducation.org/sleep-center on the web for a sleep center in the U.S. certified by the American Academy of Sleep Medicine, such as Mayo Clinic Center for Sleep Medicine. Or you can search the Society of Behavioral Sleep Medicine website at behavioralsleep.org for a directory of behavioral sleep medicine providers.

The type of treatment, length of treatment and frequency of sessions can vary. You may need as few as one session or as many as eight or more sessions. It depends on your sleep expert, the program and your progress. Most people need 6 to 8 sessions.

When setting up an appointment, ask about the treatment approach and what to expect. Also, check ahead of time to see whether your health insurance will cover the type of treatment you need.

If available in your area, meet with a sleep medicine specialist in person for your sessions. But a phone or video meeting also may help. You also can look for self-help books and online resources for guidance on CBT techniques for insomnia.

Who can benefit from CBT?

CBT can benefit nearly anyone with sleep problems. It can help people who have insomnia due to lifestyle habits, medical issues, physical problems or mental health conditions. The positive effects of CBT seem to last, and there is no evidence that CBT has harmful side effects.

CBT requires steady practice, and some approaches may cause you to lose sleep at first. But stay with it, and you'll likely see lasting results.