Around six to 10 percent of American adults take a sleeping pill, such as Ambien, Xanax or Valium. While these so-called hypnotics work very well, they’re drugs, which may cause side effects or encourage dependence, and so many people would prefer psychotherapy. A new study examining cognitive behavior therapy finds it can improve sleep without any of the adverse outcomes caused by pills.

"In a direct comparison, CBT-i has been found to be superior to hypnotics for the management of chronic insomnia, with effects sustained over six months of follow-up," wrote the authors in their conclusion.

Cognitive behavioral therapy (or CBT) refers to a number of psychotherapy techniques that merge behavioral therapy and cognitive therapy. CBT is known to be problem-focused and action-oriented; this style of therapy directly confronts and then attempts to change a targeted difficulty, such as depression. CBT-i, then, is designed specifically for treating insomnia.

Broken down into five specific components, CBT-i begins with cognitive therapy aiming to identify, challenge, and replace dysfunctional beliefs and attitudes about sleep and insomnia, including overestimating the consequences of poor sleep. A second component is stimulus control, which offers behavioral instructions, such as going to bed only when sleepy, intended to strengthen the association between bed and sleep. Sleep restriction, a third component, limits time in bed to increase motivation and reduce awake time spent on the mattress. The fourth component is sleep hygiene, which recommends environmental and physiologic factors to promote sound sleep, some as simple as turning the clock face out of sight. The fifth and final component is relaxation; these techniques include meditation, progressive muscle relaxation, and guided imagery.

All of this is well and good, but how effective is CBT-i?

Sleep Efficiency

From 91 full-text articles, the authors of the current research hand-picked 20 published studies assessing the efficacy of CBT for adults with chronic insomnia and no underlying medical causes. They discovered that CBT helped patients enter sleep about 20 minutes faster, reduced the amount of time spent awake after falling asleep by nearly 30 minutes, and improved sleep efficiency by almost 10 percent.

“Cognitive behavioral therapy for insomnia improves nocturnal sleep and some aspects of daytime functioning (such as fatigue and distress),” Dr. Charles M. Morin of Université Laval in Québec wrote in an editorial accompanying the research. There is less evidence about CBT’s effects on long-term health associated with improved sleep, and so, he says, further research is needed.

Yet, Morin also comments on the greater amount of time and effort required by CBT (as compared to a pill). An investment in CBT is worth it, he argues, since, by learning skills useful at any time, patients become active participants in their own care.

"The reality is that drug therapy alone does not address the underlying psychological and behavioral factors that perpetuate insomnia over time," Morin concluded. And, as the authors of the study point out, hypnotics may be effective, but some patients cannot tolerate them, they have side effects, and there's a possibility of developing "rebound insomnia" after discontinuation.

Take your pick.

Source: Trauer JM, Qian MY, Doyle JS, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Annals of Medicine. 2015.