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University of Pennsylvania

If you have insomnia, pills may not be the answer

Kim Painter
Special to USA TODAY

Like many insomniacs, Crystal Blount tried sleeping pills. They put her to sleep, she says, but left her feeling groggy the next day. So she went back to tossing and turning, spending eight hours in bed each night but rarely sleeping more than four.

"One of the reasons I wouldn't sleep was that I was really worried that I wouldn't sleep," she says.

Then the 49-year-old college psychology instructor tried something called cognitive behavioral therapy. It's a brief form of psychotherapy, used for a variety of conditions. When used for insomnia, it aims to break patterns in thinking and behavior that feed chronic sleeplessness.

Blount quickly learned that she had been sabotaging herself by spending so many wakeful, worrying hours in bed. So, at the advice of her therapist, she set a new, shorter sleep schedule and starting getting out of bed any time she could not quickly fall asleep. She also learned a new, relaxing bedtime routine.

Within a few weeks, she was sleeping at least six hours a night, enough to "make a world of difference," she says.

Blount's experience is common, sleep experts say. But cognitive behavioral therapy for insomnia remains underused, says Michael Grandner, a University of Pennsylvania psychologist specializing in sleep.

"There are millions and millions of prescriptions for sleeping pills written each year," he says. "But most people don't even know this exists."

That's despite the fact that the American Academy of Sleep Medicine, a professional group for sleep doctors, says the therapy should be the first treatment prescribed for chronic insomnia (defined as persistent trouble falling or staying asleep, along with daytime sleepiness or other problems). The academy says cognitive behavioral therapy works as well, or better, than pills, with fewer side effects.

But most insomniacs never see a sleep specialist. They talk to primary care doctors who may not be aware of such recommendations, says psychologist Jason Ong, a sleep researcher at Rush University Medical Center in Chicago.

Two recent studies, published in journals for primary care physicians, may help change that.

The first, published in June in the Annals of Internal Medicine, combined data from 20 previous studies on more than 1,100 people with chronic insomnia and found that those who used the therapy fell asleep an average of 20 minutes sooner and stayed asleep for more of the night than those getting no treatment.

The second, led by Ong and published in July in JAMA Internal Medicine, combined data from 37 studies on nearly 2,200 people who had chronic insomnia along with other medical or psychological problems, such as chronic pain, depression or post-traumatic stress disorder. It found that 36% lost all signs of insomnia after cognitive behavioral therapy vs. 17% after other treatments (including pills) or no treatment.

"This works," Grandner says, but lack of awareness is just one problem. Another is that just a few hundred health professionals in the USA — medical doctors, psychologists, nurses and others — are trained to provide it, he says. (Partial lists of providers are at the websites of the American Board of Sleep Medicine and the Society for Behavioral Sleep Medicine).

To make the therapy more widely available, some providers have set up online versions. Among the oldest is CBTforInsomnia.com, run by Gregg Jacobs, an insomnia specialist at UMass Memorial Medical Center in Worcester, Mass. Jacobs says tens of thousands of people have used the program over the past decade, and studies show it is effective.

While people who use Jacob's service and similar online programs do not see a therapist in person, they are guided through the same steps as someone getting in-person therapy. Jacobs also provides participants with emailed feedback. Another online program, SHUTi, lets you share your progress with your doctor.

Here's what to expect if you try cognitive behavioral therapy for your insomnia, online or in person:

• Sleep diary. To help detect the patterns feeding your insomnia, you will keep a diary for a week or two.

• Sleep restriction. While it might seem "barbaric," most insomniacs need to start by spending less time in bed, Grandner says. The idea is to break the mental link between wakefulness and the bed — by going to bed only when you are very sleepy. You also will get up (until you are sleepy again) any time you can't sleep. Sleep times increase as insomnia improves.

• Sleep hygiene. These are the good habits that can help anyone sleep better: Go to bed and get up at the same time each day, avoid caffeine and bright lights late in the day, and set a relaxing, consistent bedtime routine.

• Relaxation techniques. You may learn some breathing or muscle-relaxation exercises to help you prepare for bed.

• Rethinking insomnia. "People will be lying in bed, absolutely certain that if they don't get enough sleep, something terrible is going to happen the next day," Grandner says. "So we may ask them, 'Of all of the times you have had insomnia, how many times have you lost your job?'"

• Varying costs. In-person therapy, in six to eight sessions, is the most expensive, but it may be covered by insurers. One 20-minute sleep clinic visit can cost $120, Jacobs says. His five-week online program costs $35; another program, called Sleepio, costs $80 for 12 weeks of access; SHUTi costs $135 for 16 weeks of access.

• Possible side effects. Sleep restriction induces temporary sleep deprivation, so it's best to avoid long car trips and major work projects during initial therapy, Grandner says. People with bipolar disorder could become manic, he says.

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