By Andrew Joseph
Put down the sleeping pills and pick up that sleep diary.
According to new guidelines released Monday from the American College of Physicians, chronic insomnia should not be treated with drugs like Ambien or Lunesta, but instead with a specially designed form of psychotherapy known as CBT-I, which blends talk therapy and sleep tutorials, and has been shown to help a majority of patients recover some normalcy in their sleep quality and duration.
Both meds and psychotherapy can improve sleep, the ACP said, but drugs come with a range of side effects -- including next-day drowsiness and other problems that send tens of thousands of Americans to the emergency room each year. Drugs also aren't recommended for long-term use.
But drugs are easy to come by since any physician can write a prescription for a sleeping aid. CBT-I, by comparison, typically requires a trained clinician, of which there are few in even the country's biggest cities -- which could make it hard for the nation to wean itself off prescription sleeping pills and adopt psychotherapy.
The ACP recommendation, which was published in the journal Annals of Internal Medicine, applies only to adults with chronic insomnia, defined as sleep problems that cause distress or impairment, and that occur at least three times a week for at least three months. The physician group also issued a second, "weak" recommendation that doctors should talk with patients about incorporating drugs into their treatment if CBT-I doesn't work alone.
CBT-I, which is short for cognitive behavioral therapy for insomnia, works by changing insomniacs' behaviors and thoughts about sleep and what they do during their waking hours, with a treatment plan tailor made for each patient.
Some of the steps at first seem counterintuitive. If you're exhausted from months of bad sleeping, for example, don't try to go to bed earlier. Instead, if you can only sleep for five hours and want to get up at 6 a.m., avoid your bed until 1 a.m.
Patients also keep sleep logs and will typically become more fatigued in the initial steps of the treatment. Some patients and even doctors are also resistant to the idea of going to therapy for a sleep problem.
"We're still on the cusp of getting people to understand that, 'Hey, the proper treatment for you might be seeing a psychologist,'" said Mark Gorman, director of behavioral sleep medicine at Massachusetts General Hospital.
The treatment can take weeks, but, experts said, it provides lessons and techniques that patients can apply after they stop going to sessions to address future sleep problems.
"No medication on this planet can do that," said Michael Perlis, director of the behavioral sleep medicine program at the University of Pennsylvania Perelman School of Medicine.
John Cormier, 56, started receiving CBT-I last year after 25 years of sleeping problems and a desire to give up medications. During the treatment, he would give himself 30 minutes to fall asleep. If he was still awake, he made himself get up and go do something else for 30 minutes before trying again. He repeated the pattern if sleep didn't come.
"I had a few nights of almost sleepless nights," he said. "It brought me back to my days in college."
After some time, however, Cormier started to see progress. He can now typically get more than 6 1/2 hours of quality sleep and hasn't taken sleep medication since last summer.
But Cormier also spent about five months going to sessions with a sleep psychologist.
"It's not easy, and it's not an instant fix," he said. "It requires a huge time commitment."
Cormier lives in Boston, so he was able to find a therapist trained specifically in CBT-I. But according to Perlis, even many large cities don't have clinicians trained in behavioral sleep medicine and four states -- New Hampshire, Hawaii, South Dakota, and Wyoming -- have no such providers at all.
The ACP guidelines say that CBT-I can be offered in a primary care setting and that patients can use online and phone-based methods, as well as self-help books. Some studies have found that these other strategies can be somewhat helpful, but some apps, including one designed by the Department of Veterans Affairs and Stanford University researchers, are meant to be used by patients working with a clinician.
"Anything is better than nothing," said Dr. Josna Adusumilli, a neurologist at MGH focused on sleep disorders. "Obviously, having a meeting with a sleep psychologist in person is the gold standard, but if that's not possible, an online program would be a good choice."