Managing Insomnia With Behavioral Therapy: Is Shorter Better?

Although many patients find cognitive-behavioral therapy (CBT) effective for management of their insomnia in both the short and long term, there aren’t enough clinical psychologists trained in the area. In addition, the initial treatment is lengthy, lasting 6 to 8 sessions.

These are some of the barriers to such therapy that my colleagues and I identified in our research at the University of Pittsburgh and led us to develop a clinical manual for the conduct of a shorter Brief Behavioral Treatment for Insomnia (BBTI) program.¹ BBTI has an explicit behavioral focus, is overtly linked to a physiological model of sleep regulation, and uses a hardcopy workbook that facilitates its concise delivery format and ease of training clinicians.

Rationale
The rationale behind BBTI is that insomnia often is characterized by sleep-related behaviors that interfere with the underlying physiological mechanisms that regulate sleep (homeostatic and circadian processes). Therefore, treatment involves modifying waking behaviors to increase and regulate the duration of wakefulness, thereby increasing the homeostatic sleep drive (sleep pressure) and identifying an individualized prescription for sleep and wake time that optimizes and reinforces the circadian (internal biological clock) drive for sleep. Optimizing these processes facilitates the ability to fall asleep and stay asleep and promotes improved sleep quality and daytime functioning and alertness.

How the Program Works
CBT is used to manage a variety of behaviors and cognitive processes, including insomnia. Behavioral therapy for insomnia has several components, including sleep education, sleep restriction, stimulus control, and addressing anxiety-provoking beliefs about sleep. As the name suggests, BBTI is a brief (4-session) intervention that focuses on modifying specific behaviors that may perpetuate insomnia.

BBTI was designed to be administered via 2 in-person sessions and 2 telephone sessions as part of a clinical research study published in Archives of Internal Medicine in 2011.² In our clinic setting, however, we have used various combinations of in-person and telephone sessions.

In the original research study, BBTI was targeted toward older adults with comorbid conditions,² because the prevalence of insomnia is particularly high in this patient population, which often is under-represented in controlled research trials. However, beyond this clinical trial, we have used BBTI in the clinic setting for diverse populations, including older and younger adults with and without other co-occurring medical or psychiatric conditions.

Advantages vs Sleep Medications
Behavioral sleep interventions are as effective as sleep medications and typically have more lasting effects. Also, behavioral sleep interventions have fewer adverse effects than medications.

Many patients prefer behavioral interventions over pharmacological ones because of concerns about becoming dependent on medications or potential consequences associated with long-term use. Use of sleep medications in older adults is a particular concern because of the increased risks of falls among those taking them.

Many of our patients continue to take sleep medications as adjunct therapy along with BBTI. For patients who choose to use medication as an adjunct therapy, we recommend the following:

• Take your medication proactively at the beginning of the night, rather than reactively, after frustrated attempts to fall asleep without medication.

• Take the medication at the right time, when you begin to feel naturally sleepy, rather than far too early in the night, hoping that it will “knock you out” before the natural drive for sleep is at its peak.

• When ready to discontinue the medication, do so gradually, rather than abruptly, to minimize rebound insomnia and withdrawal effects.
 
Use in the Primary Care Setting?
BBTI was designed as an intervention that could be more widely disseminated, including to primary care practices. In the research trial, BBTI was administered by a psychiatric nurse who did not have previous training in sleep medicine or behavioral interventions, suggesting that it could be a viable intervention with wider dissemination beyond specialty clinics. To date, however, there has not been a systematic effectiveness trial of BBTI in the primary care setting.

The clinical manual provides a detailed description of the program and is published in the journal article.¹ Also, we offer training sessions through the University of Pittsburgh Sleep Medicine Institute as well as at national conferences and local meetings.

References
1. Troxel WM, Germain A, Buysse DJ. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med.2012;10:266-279.

2. Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171:887-895.