Neurology Learning NetworkThe Role of Cognitive Behavioral Therapy and Medication in the Treatment of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBTI) Emerges as First-Line Treatment, Offering Behavioral Strategies to Address Sleep Disorders

In this video interview, Dr. Charles Raison, a psychiatrist and professor at the University of Wisconsin, Madison, emphasizes the primacy of cognitive behavioral therapy for insomnia (CBTI) over pharmacological interventions. This approach marks a shift in treating primary insomnia, highlighting the effectiveness of behavioral strategies in addressing sleep disorders. Dr. Raison outlines the key components of CBTI and discusses the appropriate use of medications when behavioral interventions prove insufficient.

Key Points:

• CBTI is recommended as the preferred initial treatment for primary insomnia.
• Core CBTI strategies include:
  • Sleep restriction: avoiding naps and limiting time in bed
  • Stimulus control: using the bed only for sleep and sex
  • Establishing consistent sleep and wake times
  • Creating an optimal sleep environment: dark, cool room
• Additional behavioral strategies to improve sleep:
  • Exposure to bright light in the morning
  • Heat exposure 1.5-2 hours before bedtime
  • Using orange or amber glasses to block blue light in the evening
  • Early day exercise
  • Avoiding alcohol and limiting caffeine after 2 PM
• Medications should be considered when behavioral strategies fail or for acute insomnia:
  • Short-term use (3-4 weeks) is recommended, especially for benzodiazepines
  • Long-term medication options include melatonergic agonists and orexin antagonists
  • Sedating antidepressants and atypical antipsychotics are sometimes used but carry risks
• Chronic insomnia is recognized as a disorder in DSM-5-TR due to its daytime effects on attention and functionality
• Insomnia is a risk factor for developing depression and other mental health issues

“Now I’m talking about insomnia as the primary problem, not people who have secondary insomnia because they’re depressed or manic or something like that. How do we think about treating primary insomnia?”
– Dr. Charles Raison, Professor of Human Ecology and Psychiatry at the University of Wisconsin, Madison

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