cognitive behavioral therapy for insomniainsomniaSleep Medication

Why so few insomniacs have tried CBTi, and one way we can change that

By September 16, 2019 No Comments
As you’ve heard my say several times I continue to be confused by:

How very common insomnia is,

and

How few of have try CBTi which is a very effective treatment option.

I may be biased because I am in the medical field but I believe a root problem is medical education. I know litte about nursing school and PA school but I can tell you how much of the curicculum was spent on CBTi:

0 credits.

I bet it is very similar in other areas of medical education. The one thing I remember from medical school is going over onset of action and half-lives for various drugs in my pharmacology course. Even in my psychiatric rotation I don’t recall hearing a word on CBTi and neither did I come across this technique in residency. Finally, during my 1 year as a sleep fellow I learned what CBTi was and how to use the various techniques involved.

Although internet has given most people and everyone in the developed world access to health care, information most people with chronic insomnia at some point seem to talk to their primary care provider. And I think this is were there is a huge untapped opportunity to spread access to CBTi.

If primary care providers, instead of recommending sleep hygiene which does not treat insomnia or prescribing sleep aids that typically worsen the problem instead recommended CBTi I think millions of people could sleep better.

It is not easy to be a primary care provider. You have to know how to manage the entire spectrum of physical and mental health and it may not be realistic to expect that CBTi becomes part of what every PCP does. However, if everyone PCP knew what CBTi was and/or that it is first line therapy they could make that initial referral when a patient first starts having sleeping problems.

I think what needs to happen if we are to seriously move the needle when it comes to helping people sleep better is:

1. CBTi needs to be part of the curriculum for every accredited medical school.

2. CBTi needs to be part of the curriculum for every accredied residency training program.

Every PCP knows that you probably need a colonoscopy if you have unexplained intestinal blood loss. That does not meand that your PCP will pefrorm this procedure but rather knows when a referral is in place. Similarly I am not saying that every PCP should be expected to administer CBTi but should know that this is the first thing to do for a patient with difficulties sleeping.

Access to CBTi is a problem but I believe once demand picks up supply would follow. Studies have shown that CBTi can be just as effective when administed via an internet based program, via a traditional CBTi program consisting of 4-6 hour long sessions, as brief CBTi with 1-2 sessions, administered by trained medical professionals or even when administered by lay people that have received manual based instruction (more on this in a later blog).

Just today I was contacted by a PCP asking for advice. I was asked the most common question I get from colleagues that are not in the sleep field: what medication would I recommend for insomnia? I decided to reply a bit lengthier than I usually do and reviewed how insonmia is a symptom not a condition and how CBTi really should be front and center of any effort to treat insomnia. Maybe these type of one on one interactions between medical professionals can help but if we are going to make big changes we have to aim the extinguisher at the base and not the flames.

Medical education, not only for physicians but also for NPs, PAs and anyone else providing primary care should include CBTi as part of the curriculum.

As always please share your thoughts and if you have someone’s ear that is a policy maker please tell them how this could improve the lives of countless people with insomnia.