From the Editor

It’s one of the most common patient complaints: I can’t sleep.

What many of our patients aspire to…

Insomnia affects 6 to 10% of the population. It’s a common problem – and often chronic. But are we mishandling insomnia?

In a two-part, two-week series, we look at the latest in insomnia research.

This week. Fewer Pills, More Therapy. The new Clinical Practice Guideline.

Next week. Insomnia, Is There an App for That? The GoodNight Study.

This week, we look at the new American College of Physicians Clinical Practice Guideline on insomnia that suggests that CBT-Insomnia should be the first-line treatment.


American College of Physicians Recommendations

“Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians”

Amir Qaseem et al., Annals of Internal Medicine


Insomnia is a major health care problem in the United States. It is defined as dissatisfaction with sleep quantity or quality and is associated with difficulty initiating or maintaining sleep and early-morning waking with inability to return to sleep. Approximately 6% to 10% of adults have insomnia that meets diagnostic criteria. Insomnia is more common in women and older adults and can occur independently or be caused by another disease. People with the disorder often experience fatigue, poor cognitive function, mood disturbance, and distress or interference with personal functioning. An estimated $30 billion to $107 billion is spent on insomnia in the United States each year. Insomnia also takes a toll on the economy in terms of loss of workplace productivity, estimated at $63.2 billion in the United States in 2009.

Chronic insomnia, also referred to as “chronic insomnia disorder” in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is diagnosed according to the DSM-5 and the International Classification of Sleep Disorders, which have similar criteria for making the diagnosis. These criteria specify that symptoms must cause clinically significant functional distress or impairment; be present for at least 3 nights per week for at least 3 months; and not be linked to other sleep, medical, or mental disorders. Symptoms of insomnia differ between older adults and the younger population. Older adults are more likely to report problems with waking after sleep onset (difficulty maintaining sleep) than they are to report problems with sleep onset latency (time to fall asleep).

The goal of treatment for insomnia is to improve sleep and alleviate distress or dysfunction caused by the disorder. Insomnia can be managed with psychological therapy, pharmacologic therapy, or a combination of both.

Dr. Amir Qaseem

So opens a new Clinical Practice Guideline by Dr. Qaseem et al., just published in the Annals of Internal Medicine, for the American College of Physicians – an American body with a membership of more than 150,000 internists.

Here’s what they did:

· Reviewers searched several databases for randomized, controlled trials (RCTs), published between 2004 and September 2015. Papers needed to be in English.

· The study population consisted of adults with chronic insomnia disorder.

· The systematic evidence review evaluated psychological therapies, including CBT-I, multicomponent behavioral therapy for insomnia, stimulus control, relaxation strategies, and sleep restriction; pharmacologic therapies, including tricyclics, benzodiazepines, and new agents, off-label use of drugs (such as antidepressants and antipsychotics), and melatonin; and complementary and alternative approaches, including acupuncture and Chinese herbal medicine.

· Outcomes included global outcomes assessed by questionnaires (such as treatment response), patient-reported and intermediate sleep outcomes, and harms.

Here’s what they found:

· On psychological treatment: “Evidence for most psychological therapies was limited, and there was insufficient evidence to determine the comparative effectiveness of different psychological treatments for chronic insomnia disorder in the general population or in older adults.” That said, CBT-I did have evidence for both adults and the elderly. (See recommendations below.)

· On pharmacologic treatment: “Evidence was insufficient to determine the benefits of pharmacologic therapy with benzodiazepines in the general population or in older adults. Few trials met the inclusion criteria for the evidence review, largely because many assessed short durations of treatment.”

· On complementary medicine: “There was insufficient evidence to determine the safety or efficacy of complementary and alternative treatments for insomnia disorder in the general population or in older adults.”

The authors make two recommendations:

Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)

Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)

They conclude:

Cognitive behavioral therapy for insomnia is an effective therapy for chronic insomnia disorder and can be performed and prescribed in the primary care setting. Evidence showed that CBT-I was effective in treating the general population of adults as well as older adults with chronic insomnia disorder. There is insufficient evidence to directly compare CBT-I and pharmacologic treatment. However, because CBT-I is noninvasive, it is likely to have fewer harms, whereas pharmacologic therapy can be associated with serious adverse events. Thus, CBT-I provides better overall value than pharmacologic treatment.

The Guideline runs with an Editorial by Dr. Roger G. Kathol and J. Todd Arnedt, “Cognitive Behavioral Therapy for Chronic Insomnia: Confronting the Challenges to Implementation.”

You can find it here:

Dr. Roger Kathol

The Editorial champions CBT-I for insomnia – “CBT-I is a relatively brief, highly effective, and safe behavioral health intervention for patients with chronic insomnia, regardless of whether it occurs along with other health conditions.”

But the authors note challenges to the recommendations being implemented. “It is frustrating that an intervention as effective as CBT-I is difficult for many patients to access.”

“The first step in implementing the new ACP guideline is for physicians to recognize that a psychological alternative to pharmacologic therapy will accomplish better and safer patient outcomes.” Kathol and Arnedt see implications for education and service payment.

A few thoughts:

1. This Guideline is smart, thoughtful, and far-reaching in its implications.

2. We all see people with chronic insomnia. How many of us are recommending a psychological intervention – and how many of us still think the solution to chronic insomnia is found with a prescription pad? Many guidelines are published, but this one is very relevant clinically.

3. Of course there are two larger questions that can be asked. First, is this Guideline skewed towards CBT-I? Remember that the Guideline looked at benefits and harms. So, yes and no. The Guideline is – as I’ve said – smart and thoughtful. That said, given the lack of harms with CBT-I, it has a competitive advantage over medication options. Second, is this Guideline practical? CBT-I tends not to be offered in primary care or specialist settings. If we are serious about addressing chronic insomnia, this Guideline requires work – or, really, a build. Kathol and Arnedt speak to changing education and payment; much would need to be done. We can also think outside the box. Is there a role for technicians to deliver more therapies, like CBT-I? Could technology be used to offer a lower-cost model of CBT-I? (Spoiler alert: next week’s Reading considers just that.)

4. There is a larger lesson here: the age of psychopharmacology is clearly over. A couple of decades ago, all psychiatric problems seemed to be solvable with a medication. Not only is this not true, but it ignores the incredible role of evidence-based psychological interventions.

Further Reading

Annals offers two papers with more details on the analysis for psychological and pharmacologic treatments.

You can find these papers here:

And here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.