Want to Ditch Your Sleep Meds? Try Cognitive Behavioral Therapy

April 01, 2020

If you use sleeping aids – whether prescription or non-prescription – you've likely heard or read that this is not an ideal long-term solution for insomnia. Nevertheless, some 10 million Americans use prescription medicines, and millions more rely on over-the-counter remedies.

If you have had insomnia for a long time, it might be frightening to contemplate going off those medicines. There is another solution that studies have shown to be effective – Cognitive Behavioral Therapy for insomnia (CBT-I), provided through four to six sessions with a trained therapist.

First, though, you likely have insomnia if you experience:

Struggling to fall asleep, taking longer than 20 minutes at least three times a week to do so.
Waking up frequently through the night and struggling to return to sleep.
Waking up often before your alarm and feeling unrefreshed.
Your sleep difficulties affecting your ability to perform your best at work or to complete daily tasks.

If you have acute insomnia that has recently occurred because of life stressors, a physician might prescribe a temporary prescription of hypnotic medication or other sleep aids. But for chronic insomnia (more than three months of continued sleep difficulties), CBT-I is at least as effective as medication in the short-term and more effective in the long-term.

CBT-I is based on scientific knowledge of sleep. The cognitive part focuses on your thoughts, feelings and expectations about sleep and insomnia, all of which may affect how well you sleep. The behavioral part of CBT-I helps you develop proven sleep habits and reduce problematic behaviors contributing to insomnia. We talked with Samina Ahmed, PsyD, a UH clinical psychologist with specialized training in CBT-I treatment for adults, to learn more about this therapy.

Q. We've all heard a lot about the importance of sleep hygiene. Is that what CBT is about?

A. No, it's much more. Sleep hygiene, in which you adopt habits such as going to bed at the same time each day, keeping your bedroom cool and quiet, and not using electronic devices for a few hours before sleep, is not enough to treat insomnia. But it's a good place to start. I spend perhaps 10 minutes in the first session talking about sleep hygiene. The rest of the time is spent learning about the patient's current sleep behaviors, how the patient is addressing the sleep problems and any stress or life changes that might be contributing to poor sleep. The session concludes with an introduction to CBT-I and the importance of tracking their sleep patterns on a sleep log so I can adapt the treatment to the individual needs of each patient.

Q. What happens at later sessions?

A. After that, each session starts with a review of sleep log data to see what recommendations helped and what continues to be problematic. I typically start with making behavioral changes around sleep, and then cognitive changes – such as challenging negative thoughts around sleep and fear about what will happen if you don't get enough sleep. Cognitive restructuring may sound difficult to practice but is an important component of treatment. Treatment concludes with relapse prevention; the idea is to provide patients with a toolkit of what they can do to address insomnia should it come back.

Q. What is wrong with taking a prescription medicine such as Ambien (zolpidem tartrate) to fall asleep?

A. This is largely dependent on individual cases but overall, hypnotics were created to be taken on a short-term basis. Long-term use of Ambien might promote sleep, but is likely suppressing deep sleep or REM sleep. With time, the medication might lose its effectiveness and you might find yourself needing a higher dose to achieve the same effect. When you get older, there is also a greater fall risk due to side effects of the medication.

Q. Some people takes benzodiazepines to help them sleep. Is that worrisome?

A. Yes, those can be highly addictive and foster a dependence on the medication. Benzodiazepines also are likely to lead to daytime grogginess and present with some of the same concerns as long-term hypnotic use. With that said, it is important to manage anxiety to promote sleep. I find patients function better with daytime use of benzodiazepines or other anxiolytics with emphasis on relaxation at bedtime.

Q. Does anxiety about falling asleep affect the ability to fall asleep?

A. Absolutely, the greater the pressure to fall asleep the harder it is to go to sleep. That's why we work on behavioral and cognitive changes, so a person can identify their problematic behaviors maintaining the insomnia and challenge those faulty beliefs about sleep. Relaxation techniques are also built into this process, such as progressive muscle relaxation and diaphragmatic breathing. People learn to use these to relax before they go to sleep, and if you can focus on anything other than sleep, chances are you will fall asleep!

Q: How do I access this treatment?

A. Adults can ask their primary care provider or other healthcare professional for a referral to Dr. Ahmed at Adult Sleep Psychology at UH. For children, you can ask your child's healthcare provider for a referral to clinical pediatric psychologist Carolyn Landis, PhD, at Rainbow Babies & Children's Pediatric Sleep Center.