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But First, Sleep

Cognitive behavioral therapy is prescribed as a psychotherapy treatment for anxiety, depression, chronic pain, and other conditions. It is also the first line of treatment for insomnia. When conditions present simultaneously with insomnia, it has typically been thought that treating the other condition(s) – such as chronic pain or depression --would result in improvement in sleep problems.

Now, a new JAMA Internal Medicine study looking at the effectiveness of cognitive behavioral therapy for insomnia (CBT-I) in patients who also have depression, chronic pain, and/or other health issues, suggests that treating sleep problems either first or concurrently can result in benefits in treating the other conditions.

CBT-I targets the underlying thoughts and behaviors that inhibit quality sleep and works to eliminate them while leading the patient towards actions and thoughts that foster better sleep. Depending on the individual, this therapy can include a range of techniques, including sleep restriction, stimulus control, changing the sleep environment, employing relaxation methods, and improving lifestyle habits, among other strategies.

“For a long time, it was thought that insomnia was a symptom of depression or a symptom of anxiety, so if you treat the depression, the sleep is going to get better,” said James Findley, PhD, CBSM, FAASM, clinical director of Penn’s Behavioral Sleep Medicine Program, who was not involved with the study but regularly treats insomnia patients using CBT-I. “Other symptoms of depression can improve and someone can still have poor sleep. If their sleep doesn’t improve, they’re at higher risk to relapse to depression. People can also have sleep problems for years before they develop depression.”

The meta-analysis of 37 randomized clinical trials with data on 2,189 patients with insomnia and other psychiatric and medical conditions shows that the body of knowledge in the field has advanced past simply showing that CBT-I can work for insomnia and shows that CBT-I can also help with other conditions that are often present in these patients.

The idea that CBT-I can be effective to address sleep problems in insomnia patients who present other conditions is not new, said Findley, adding that reviews have been done, but this is the first time researchers looked at patterns in the effects in such a broad analysis of studies and included the effects of improved sleep on the co-morbid condition.

Findley says this study could have implications as to how clinicians treat patients.

“CBT-I has been shown to be effective in improving insomnia in populations with co-morbid conditions,” said Findley. “And it may be that treatment for insomnia should implemented in conjunction with treatment for the co-morbid condition to achieve maximum clinical improvement. For example, someone newly diagnosed with depression who has insomnia issues may see more improvement in both conditions if CBT-I is initiated in conjunction with treatment targeting depressive symptoms.”

For chronic insomnia patients who rely on prescription sleeping pills – approximately nine million Americans – a Penn Medicine study published earlier this week in the journal Sleep Medicine found that they may be able to get relief from as little as half of the drugs, and may even be helped by taking placebos in the treatment plan. 

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