the study's findings support that CBT-I is an effective treatment for insomnia that can also promote a broad range of outcomes for people undergoing psychiatric care.
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How can cognitive behavioural therapy improve your sleep?

Wondering about effective insomnia treatments? While sleep medications have their place, cognitive behavioural therapy might be the solution.

Are you one of the many who struggle with sleep? If so, you’ll likely understand its potential effects, including irritability, anxiety, or low mood. Insomnia, a condition affecting approximately 10% of adults, can exacerbate these emotional states, particularly when paired with psychological symptoms such as anxiety and depression. Moreover, research indicates that insomnia can also act as a risk factor for the onset of mental health conditions, including depression and anxiety.

Insomnia is characterised by persistent dissatisfaction with sleep, often taking the form of difficulties falling asleep or maintaining sleep, leading to daytime distress and impairment. As insomnia gains ground, individuals become increasingly preoccupied with their sleep, often making desperate attempts to rectify the situation, paradoxically exacerbating the condition. It becomes a debilitating cycle.

Insomnia as a missed opportunity in mental health treatments

Insomnia represents the most prevalent symptom among all mental disorders. Historically, it has been regarded merely as a symptom of psychological issues rather than a condition that could potentially instigate them. Such a perspective on insomnia reduced merely to a symptom has led to its frequent neglect in healthcare settings. The dominant assumption has been that resolving the co-occurring issue would naturally alleviate insomnia.

However, a more recent accumulation of research illustrates that insomnia plays a significant role in the development, persistence, severity, and recurrence of psychological difficulties, including depression, anxiety, stress, substance misuse, bipolar disorder, and psychosis. Consequently, the assessment and treatment of insomnia within mental healthcare settings is of paramount importance, particularly given the availability of effective interventions for the condition.

Credit. Sleep Matters

Regarding treatment, sleep medications are frequently used to manage insomnia; however, they often have limited long-term effectiveness and carry risks of dependence and side effects. In contrast, Cognitive Behavioural Therapy for Insomnia (CBT-I) generally outperforms medications in the long run and exhibits a superior side-effect profile. Hence, CBT-I is recommended as the primary line of treatment, even in comorbid conditions.

CBT-I is a brief treatment, typically lasting four to eight sessions, targeting processes causing insomnia, such as hyperarousal (physical tension, anxiety, stress, busy mind), reduced homeostatic sleep drive (not being biologically sleepy enough to sleep well), and misalignment of the circadian rhythm with the sleep-wake cycle (trying to sleep at a time when the body clock is in a wakeful state).

CBT-Insomnia typically involves; 

  1. An exploration of science-based facts about sleep to promote understanding of what constitutes healthy sleep and to learn about sleep regulation.
  2. Adjustments to the daily sleep routine aim to enhance sleep onset, reduce nocturnal awakenings, and foster a healthy association between bed and sound sleep.
  3. Establish a relaxed approach to sleep without anxiety and worry about sleeping well. As Dr Ree notes, “it’s important to remember that healthy sleep isn’t perfect sleep, we all wake up overnight, and we all have a poor night now and then”.
  4. Strategies to calm a busy mind and/or tense body.
  5. Strategies for improving daytime energy and managing tiredness.

So why is insomnia ignored?

Despite CBT-I being cost-effective and enhancing outcomes for sleep and a spectrum of concurrent conditions, it is seldom provided in healthcare settings. This may be partially attributed to how the majority of research in this domain has been undertaken within tightly controlled settings, leaving a void of information about the efficacy of CBT-I in real-world healthcare contexts. As Dr Ree asserts

This all leads to the fact that implementation research is urgently needed to increase the availability of what has been robustly demonstrated scientifically.

Dr. Ree

Real-world evidence for the benefits of treating insomnia

A recent study conducted in Australia, co-authored by Dr Ree, delved into the effectiveness of CBT-I within a psychiatric healthcare environment. This study embraced the complexities inherent in real-world research. It distinguished itself by incorporating patients with extensive psychiatric comorbidities and diverse medication use, offering greater ecological validity and applicability to real-world clinical scenarios.

The study involved 76 patients with various comorbid mental health conditions who participated in a four-session group CBT-I programme. Participants filled out validated questionnaires, both pre-and post-treatment, to assess symptoms of insomnia, depression, anxiety, and stress, in addition to their quality of life and daytime functionality.

Treating insomnia brings about positive change beyond sleep

The results underscored the real-world effectiveness of CBT-I, particularly amongst patients with a range of mental health issues. The effectiveness of the treatment was striking, especially given the employment of an intent-to-treat analysis—a conservative approach to analysing clinical outcome data. The study found substantial improvements in insomnia. Intriguingly, and of critical note, symptoms of depression, anxiety, and stress, along with quality of life and functional impairment, also exhibited improvement. The findings robustly endorse the applicability of CBT-I in routine clinical settings for patients with diverse presentations.

Beliefs about sleep were important to treatment success

Besides evaluating the effectiveness of insomnia treatment, the researchers also explored its underlying mechanisms. They gauged the prevalence of detrimental beliefs about sleep, such as inflated expectations concerning sleep requirements (for example, “I must get 8 hours of sleep every night”) and exaggerated assumptions about the impact of insomnia. Such beliefs are hypothesised to foster anxiety related to insufficient sleep and perpetuate unhelpful behaviours that exacerbate sleep issues (e.g., oversleeping in the morning after a restless night, and consuming extra coffee). Hardman and his team aimed to emulate the findings from controlled research trials in real-world settings by examining whether greater changes in these unhelpful beliefs throughout the treatment period correlated with larger therapeutic gains.

In line with previous, controlled research, change in unhelpful beliefs about sleep was indeed found to predict change in insomnia severity, suggesting that changing these beliefs should be a treatment target. Overall, the study’s results suggest that CBT-I can add benefit to standard care in settings where mental health comorbidity exists. These findings lend support to the argument that insomnia is a transdiagnostic experience whose treatment can optimise mental health outcomes.

In conclusion, the study’s findings support that CBT-I is an effective treatment for insomnia that can promote a broad range of outcomes for people undergoing psychiatric care. Insomnia should be routinely considered in order to optimise care for members of our community with mental health presentations.

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Journal reference

Hardman, J. R., Rees, C. S., Bonnar, D., & Ree, M. J. (2023). Group cognitive behavioural therapy for insomnia: impact on psychiatric symptoms and insomnia severity in a psychiatric outpatient setting. Clinical Psychologist, 1-11. https://doi.org/10.1080/13284207.2022.2155034

Melissa is a senior lecturer at The University of Western Australia (UWA), where she conducts research and teaches in the field of behavioral sleep medicine. Her research focuses on therapies for insomnia, improving sleep health, and the impact of treating insomnia on various domains. In addition to her academic role, Melissa is an experienced clinical psychologist and serves as the director of Sleep Matters, a sleep disorder treatment clinic located in Perth.