In a guideline published in Annals of Internal Medicine, the American College of Physicians recommended all adult patients with chronic insomnia receive cognitive behavioral therapy as a first-line treatment. The group also recommended clinicians use a shared approach in deciding whether to incorporate pharmacological therapy in adults for whom cognitive behavioral therapy did not work.
“There is insufficient evidence to directly compare [cognitive behavioral therapy for insomnia] CBT-I and pharmacologic treatment,” Amir Qaseem, MD, PhD, MHA, vice president of clinical policy at the American College of Physicians (ACP), and colleagues wrote. “However, because CBT-I is noninvasive, it is likely to have fewer harms, whereas pharmacologic therapy can be associated with serious adverse events. Thus, CBT-I provides better overall value than pharmacologic treatment.”
To be diagnosed with chronic insomnia, symptoms must cause clinically significant functional distress; must be present at least 3 nights per week for 3 months; and must not be linked to other disorders, the researchers wrote. Between 6% and 10% of adults in the United States have insomnia that meets this definition. Each year, between $30 billion and $107 billion is spent on insomnia in the United States and an estimated $63.2 billion was lost in 2009 due to decreased workplace productivity stemming from the condition.
To create the recommendations, ACP researchers performed a systematic review of randomized controlled trials published between 2004 and 2015. They used the grading of recommendations assessment, development and evaluation (GRADE) approach to determine the quality of each recommendation.
The first ACP recommendation that all adult patients with chronic insomnia receive CBT-I as initial treatment for the disorder received a “strong” grade with “moderate-quality” evidence. The second recommendation, that clinicians discuss the “benefits, harms and costs” of short-term medications with other clinicians before deciding whether to use pharmacological therapy in adults with chronic insomnia for whom CBT-I did not work, received a “weak” grade with “low-quality” evidence.
In a related editorial, Roger G. Kathol, MD, adjunct professor of internal medicine and psychiatry at the University of Minnesota, and J. Todd Arnedt, PhD, associate professor of psychiatry at the University of Michigan Medical School, wrote that while evidence clearly supports the ACP recommendations, it will be a challenge to implement these guidelines.
“First, some clinicians do not recognize insomnia as a health problem, often considering it merely a symptom secondary to another condition,” Kathol and Arnedt wrote. “Second, many clinicians and their patients harbor biases against and are reluctant to consider ‘psychological’ interventions. Third, the number of practitioners trained to deliver CBT-I in the United States is limited, and most of these practitioners are not located in medical settings.”
Kathol and Arnedt wrote that the first step to implementing the ACP recommendations is to teach that CBT-I works. They noted the therapy it works in 70% to 80% of treated patients. Another step is to use questionnaires, like the Insomnia Severity Index, to identify the best candidates for CBT-I. A score of 14 or greater is considered an appropriate candidate, according to studies.
For a long-term solution, Kathol and Arnedt note CBT-I should be included in insurance coverage.
“The evidence behind the ACP recommendations should motivate all stakeholders to move in unison to advocate for CBT-I payment in medical settings as part of medical insurance benefits,” they wrote.
They added, “Unless access to and unencumbered payment for value-based behavioral interventions, such as CBT-I, in medical settings become a reality, patients with chronic insomnia will continue to receive suboptimal treatment and experience suboptimal outcomes.” – by Will Offit
Disclosures: Barry reports grants, personal fees and non-financial support from the Informed Medical Decisions Foundation and Healthwise outside of the submitted work. Kathol reports being the owner and president of Cartesian Solutions Inc. Please see the full study for a list of all other authors’ relevant financial disclosures.