TCPR: Dr Morin, you published a landmark paper back in 2009 in JAMA on the use of zolpidem (Ambien) and CBT-I and long-term outcomes for insomnia. Let’s start with a review of that. [See the paper at Morin CM et al, JAMA 2009;281(11):991–999.]
Dr. Morin: In that study, we randomly assigned participants with chronic and primary insomnia to either CBT-I, temazepam, a combination of the two, or placebo. We found that combination therapy was more effective than either treatment alone—in our study, the percentage reduction of time awake after sleep onset was highest for the combined condition (63.5%), followed by CBT (55%), temazepam (46.5%), and placebo (16.9%).
TCPR: Does this imply that combination therapy—cognitive behavioral therapy, plus medication—is the best option for patients with insomnia?
Dr. Morin: There really isn’t a single approach that works best for all patients. We also don’t have good models in terms of sequential therapies. But certainly if we have someone with acute insomnia, drug therapy is probably the best first choice, followed by CBT-I. If we have someone with chronic insomnia who has never used drugs, we would start with CBT because that is least likely to produce adverse effects. Ideally we would combine medication and CBT and after a few weeks gradually discontinue the medication and continue CBT to make sure that they integrate what they have learned during the course of CBT. Sometimes people who have received medication may be tempted to attribute their initial sleep improvement to the medication alone, so when you take it away from them they may be at a higher risk for relapse, hence the need to keep them in CBT for a few more weeks.
TCPR: What are the essential tenets of cognitive behavioral therapy for insomnia (CBT-I)?
Dr. Morin: There are two components: cognitive and behavioral. The cognitive component refers to changing beliefs and attitudes—in this case, thoughts that are detrimental to sleep. While there may be understandable things that keep people awake at night (such as stress), worrying excessively about the insomnia itself or fearing the consequences of it the next day are often enough to perpetuate the problem.
TCPR: How can clinicians target these insomnia-producing thoughts?
Dr. Morin: As an example, many people are convinced that they need eight hours of sleep, and if they don’t get it, they believe that they won’t be able to function well the next day. The fear of this contributes to an anxiety about sleep, thereby making it difficult to fall asleep. It’s a vicious cycle. In fact, sleep requirements vary from individual to individual. Some people don’t need eight hours of sleep. Plus, we have sleep lab data showing that many people sleep longer than the amount of time they think they actually spend sleeping. Confronting them with these data often makes a significant difference. Some people are convinced that if they suffer any kind of daytime complaint, such as sleepiness, headache, or irritability, that it’s due to insomnia. This is certainly possible—these are recognized daytime consequences of insomnia—but sleepiness can also be caused by inactivity and a large lunch with a glass of wine. Headache can be caused by just about anything, and irritability can be a consequence of a variety of things, ranging from stress at work to hormonal fluctuations. Other underlying conditions, of course, such as depression, thyroid malfunction, or a host of others can also contribute.
TCPR: So basically, some people with insomnia keep themselves up at night fretting about having insomnia.
Dr. Morin: Yes. And people with insomnia may also have some erroneous ideas about how to solve their sleep problems, such as spending more time in bed, or engaging in activities that contribute to poor sleep hygiene, such as reading or watching television to fall asleep. Sometimes simply informing the person that not only do these approaches not work, but they contribute to insomnia, helps them reassess their thoughts. Constant rumination over the insomnia, its next-day effects, and the person’s perceived powerlessness to improve his or her own sleep only serves to perpetuate insomnia, making bedtime something to be feared, rather than a time to relax and sleep.
TCPR: And this is where the “behavioral” component of CBT comes in?
Dr. Morin: The behavioral component of CBT-I focuses on maladaptive behavioral habits, such as poor sleep habits and irregular sleep schedules, which contribute to perpetuating insomnia over time. So we also educate people about sleep hygiene, the impact of alcohol on sleep, the effects of a sedentary lifestyle, and behaviors that may be interfering with sleep, such as intake of excessive amounts of caffeine, nicotine, or any other type of stimulants.
TCPR: What do psychiatrists in particular need to know about CBT-I?
Dr. Morin: Well, CBT-I is not psychodynamic therapy. It is brief, it is sleep-focused, and it is problem-focused. We are dealing with the here and now. We try to identify the cognitive or behavioral factors that contribute to the current insomnia. Psychiatrists certainly need to evaluate their patients with insomnia for possible comorbid conditions because it has become clear that insomnia often presents not as a single condition, but as a condition coexisting with major depression, generalized anxiety disorder, or any of a number of other forms of psychopathology.
TCPR: What do you think about the distinction between “primary” and “secondary” insomnia?
Dr. Morin: An important change in paradigm is taking place now; we are no longer talking about “primary” and “secondary” insomnia. Historically, we have often thought insomnia was secondary to something else, and if we treated that other condition, the insomnia would go away. But there is increasing evidence showing that insomnia often persists even after you successfully treat a comorbidity such as major depression or an anxiety disorder. In fact, insomnia is one of the most common residual symptoms of depression, and it may actually contribute to relapse of the underlying depression. So what this is telling us is that when a patient presents with insomnia—whether it is the presenting complaint or it is in association with another psychiatric disorder—we need to treat both conditions at the same time or sequentially, and not assume that if we treat the major depression the insomnia will go away on its own.
TCPR: Are there particular types of psychiatric patients that are good candidates for CBT-I as compared with perhaps pharmacotherapy or combination therapy? For instance, if it is an acute situational insomnia, is that patient a better candidate for pharmacotherapy, or should CBT-I be used for all types of insomnia?
Dr. Morin: I think that people who have acute insomnia probably are better candidates for pharmacotherapy, on a short-term basis at least. We don’t have much data showing that psychotherapy is helpful for these people. But people who have chronic insomnia—regardless of what triggered it initially—are good candidates for CBT-I. When insomnia becomes a chronic problem there are always some behavioral and psychological factors that contribute to maintaining the sleep problem over time, and these are the factors that we can address with CBT-I.
TCPR: Is there any group that just plain doesn’t respond to CBT-I?
Dr. Morin: We don’t have a great deal of evidence that CBT-I works for patients with Axis II personality disorders. We also don’t have much evidence for those with schizophrenia, but sometime we need to educate these patients about good sleep habits and good sleep scheduling. It may be the same for bipolar patients. We know that people with bipolar disorder have very severe sleep problems, but they have also very irregular sleep schedules. So sometime just working on their sleep schedules and sleep environment can help. I am not going to say that this will make them good sleepers, but it can improve their sleep. I think probably the best candidates for CBT-I are those who have comorbid anxiety or affective disorders.
TCPR: What about prognosis?
Dr. Morin: Insomnia is a very persistent condition if you do nothing about it. And we also know that insomnia increases the risk of developing another psychiatric disorder, including major depression. When we treat that insomnia, the long-term outcome is very, very good, because people do maintain their sleep improvement.
TCPR: Thank you, Dr. Morin.