The Insomnia Dilemma: Cognitive Behavioral Therapy or Medication?
Prioritize sleep, and you will optimize your immune system's health. When you do get sick, make sure you listen to your body. It will tell you to slow down and rest.
What is Insomnia?
Insomnia can be acute and transient, often precipitated by a stressful life event, lasting three months or less. Insomnia symptoms typically improve gradually with time. Chronic insomnia impacts daily functioning and is a long-term pattern of difficulty falling asleep, staying asleep, or both, at least three nights per week for three months or longer.
Who is at greatest risk for Chronic Insomnia?
Insomnia can affect anyone of any age, though it is more common the older you are. Women tend to be more affected than men due to hormonal fluctuations, especially during perimenopause. Lifestyle factors such as work schedule, alcohol consumption, smoking, recreational drug use, irregular sleep schedule, lack of physical activity, and excessive napping can further disrupt your ability to sleep well.
How is Insomnia Treated?
The quest for a good night's sleep often leads to a crossroads: Cognitive Behavioral Therapy for Insomnia (CBTi) or medication. This blog post delves into both treatments, comparing their effectiveness, advantages, and drawbacks.
Cognitive Behavioral Therapy for Insomnia (CBTi)
While medication therapy has historically been the most common way to manage insomnia, the most effective treatment to manage insomnia is CBTi, which is a structured program that helps individuals identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. In fact, it is now standard of care that initial approaches to chronic insomnia involve CBTi as the first line. Medication for the management of insomnia may be necessary but should be viewed as a temporary supplement for a short period of time, in addition to CBTi when possible, based on updated guidelines published in 2021.
CBTi is a term referring to multiple components of behavioral therapy addressing the root cause of insomnia.
Key Components of CBTi include:
Sleep Education: Understanding the mechanics of sleep and factors affecting sleep quality.
Stimulus Control Therapy: Associating the bed with sleep, not wakeful activities.
Sleep Restriction Therapy: Limiting the time spent in bed to increase sleep efficiency.
Relaxation Techniques: Methods like mindfulness and deep breathing to reduce anxiety.
Cognitive Therapy: Addressing misconceptions and anxieties about sleep.
Research shows that CBTi is highly effective in treating insomnia. It helps improve sleep quality, reduce the time it takes to fall asleep and decrease wakefulness during the night.
The benefits of CBTi are usually long-lasting, offering a sustainable solution to insomnia.
No dependency issues compared to medication.
Addresses underlying issues causing insomnia.
Improves overall mental health and stress management.
While working directly with a trained therapist may be very beneficial, many online options are now available for CBTi.
Requires commitment and time.
May take several weeks to see results.
Access to trained therapists may be limited.
Medication for Insomnia
Medications are often prescribed for short-term relief from insomnia. These include over-the-counter (OTC) and prescription drugs. The 2017 guidelines on medication therapy for the treatment of chronic insomnia note that pharmacotherapy (using medications to treat insomnia) comes with a WEAK recommendation. The definition of a “WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients, but should not be construed as an indication of ineffectiveness.”
Effectiveness of Medication:
Medications can provide quick relief from insomnia symptoms.
They are effective in acute cases but less suitable for long-term management.
Placebo-effect has been noted in prior medication trials, meaning participants enrolled in randomized trials receiving placebo versus medication experienced improvement in insomnia symptoms, despite not receiving the medication.
Advantages of Medication:
Immediate effect, providing quick relief.
Useful for acute episodes of insomnia.
Easily accessible through prescriptions.
Limitations of Medication:
Risk of dependency and tolerance.
Potential side effects, like daytime drowsiness.
Doesn’t address the root cause of insomnia.
Up to 50% of effectiveness may be placebo-related rather than true medication effect.
When comparing CBTi and medication, several factors come into play:
1. Long-Term Effectiveness:
CBTi has a more sustained impact, with benefits lasting even after therapy ends.
Medication effects are short-lived and not advised for long-term use.
2. Side Effects:
CBTi has virtually no physical side effects.
Medications can have various side effects, including potential addiction.
3. Accessibility:
CBTi may not be readily available to everyone due to a shortage of trained therapists.
Medications are widely accessible but require a prescription.
4. Cost Implication:
CBTi can be cost-effective in the long run despite the initial therapy cost.
Medications may seem cheaper initially but can be costly over time, especially if used regularly.
5. Addressing Root Causes:
CBTi aims to treat the underlying issues of insomnia.
Medication treats the symptoms but not the cause.
Who Should Choose What?
For CBTi:
Individuals with chronic insomnia.
Those who prefer a drug-free approach.
People willing to invest time and effort into therapy.
For Medication:
Those experiencing acute or short-term insomnia.
In cases where immediate relief is needed.
When CBTi is not accessible or feasible.
Conclusion
In the journey to conquer insomnia, both CBTi and medication have their places. CBTi stands out for its long-term effectiveness and lack of physical side effects, making it a preferred choice for chronic insomnia. Medication offers immediate relief and is suitable for short-term use.
Keep in mind that healthcare professionals may suggest medications like trazodone or melatonin on a case-by-case basis. While these medications are not recommended for routine use in clinical practice, they may be effective in the appropriate individual. Guidelines are general roadmaps for medical providers to follow. However, every person has unique sleep issues and ultimately requires a unique approach. If you are concerned about the quality or amount of sleep you need, please consult a board-certified Sleep medicine specialist to discuss what treatment options are right for you.
