Chronic Insomnia Disorder

Abstract

Background: Individuals who suffer from chronic insomnia disorder (CID) also experience decreased daytime functioning and increased emotional distress. As scientific research and medical practices progress towards a holistic approach in the treatment and management of this disease, healthcare professionals are empowering their clients with additional treatment modalities that offer both short-term and long-term benefits. Cognitive-behavioral therapy (CBT) and pharmacological interventions is a combined approach that has progressively gained more attention in their synergistic, therapeutic effects for CID.

Objective: The objective of this systematic literature review is to analyze and synthesize published research data that focuses on the impact of CBT treatment paired with medication in comparison to that of medication alone, on the QOL for middle-aged adults, diagnosed with CID.

Method: Published, peer-reviewed, academic journals, published in English, from January 2015 to January 2020, were considered from the following electronic databases: PubMed and Cumulated Index of Nursing and Allied Health Literature (CINAHL).

Results: A total of 13 articles, consisting of nine randomized controlled trial (RCT), three secondary analysis from a RCT, and one randomized wait-list controlled trial, were included in this systematic review.

Conclusion: The studies reveal that CBT is an effective treatment for insomnia. The results indicate that better sleep outcomes are obtained when CBT is given in combination with pharmaceutical therapies. The results of the studies show that the best results are achieved with extended cognitive behavioral therapies, usually six months’ treatment plan.

Keywords: Chronic insomnia disorder, holistic approach, literature review, CBT

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Chronic insomnia disorder, also refered to as “chronic insomnia”, affects approximately 6% to 10% of the adult population (Qaseem et al., 2016). Those who suffer from CID often experience decreased cognitive function, increased distress, fatigue, and are at a higher risk of secondary mental health conditions (e.g. anxiety, depression). Therefore, healthcare professionals are seeking pharmacological and non-pharmacological treatment options that will produce positive, sustainable outcomes in CID patients’ comorbidities. Individually both treatment modalities offer their own strengths and limitations, whereas a combined effect offers potential increased positive effects. Therefore, the aim of this systematic literature review is to explore the evidence to identify the effects of CBT paired with medication compared with medication only on the quality of sleep of in middle-aged adults with CI, within a six-month period.

Methods

Search Strategy

A literature search was carried out using from the following electronic databases: PubMed and CINAHL. It was limited to studies published in the English language, conducted between January 2015 to January 2020. The keywords used included: CBT OR cognitive behavioral therapy OR behavioral therapy; middle-aged adult OR middle aged adult; quality of sleep; cognitive*; insomnia OR chronic insomnia OR chronic insomnia disease OR sleep disorders; medication; non pharmacological. This generated a list of articles that were manually screened for pertinent articles.

Study Selection

The 182 articles were first assessed for any duplication of publications. Of the remaining 141 articles, a review of titles for relevancy was conducted. Appendix A presents a summary of the study selection process in combination with the details outlined in the following paragraphs. inclusion and exclusion criteria. The remaining full texts included studies were then retrieved and critically appraised.

Inclusion Criteria

The primary outcome for this systematic literature review was quality of sleep measurements. Studies that met the following criteria were included: 1) Offered one of two possible modes for the implementation of CBT, face-to-face or digital (e.g. online, electronic media, or mobile phone applications). 2) Sample population consisted of middle-aged adults (45 to 65 years old), with a primary diagnosis of CID. 3) Studies that separated participants into at least one group receiving both CBT with medication and one group receiving medication only or treatment as usual (TAU).

Exclusion Criteria

Studies that were conducted in in-patient settings, study samples that comprised of a population with a short-term, secondary diagnosis of CID (e.g. menopause, CID due to post-traumatic stress disorder or chronic pain), study groups that suffered from chemical dependence, intervention did not combine CBT with medication, and contrasting outcome measurements were excluded.

Current Literature

Beaulieu-Bonneau et al. (2017) documented the long term sleep outcomes to patients who were experiencing chronic insomnia. This was done by treating them with cognitive behavioral therapy (CBT), either by using CBT alone or with Zolpidem medication. A sample of 160 participants was used and was randomized for a six week acute treatment phase, and then followed up for 12 to 24 months. In another study conducted by Cape et al. (2016), 239 study participants were randomized for a treatment as usual (TAU) or a five session CBT. The assessment of depression and sleep patterns were conducted at baseline and outcomes assessed after 20 weeks. Espie et al. (2019) documented the effectiveness of using digital cognitive behavioral therapy in treating insomnia. 1711 participants who had self-reported patterns of insomnia were included in this study. Rochefort et al. (2019) recruited a sample of 159 adult women who were experiencing insomnia and used CBT singly or with a combination of a medication in order to improve the sleep patterns of this population.

Results

A total of 13 articles, consisting of nine randomized controlled trial (RCT), three secondary analysis from a RCT, and one randomized wait-list controlled trial, were included in this systematic review, consistently a total of 2,705 participants. The studies were conducted across six countries, including the United States (n= 3), United Kingdom (n = 2), Canada (n = 3), Japan (n = 1), Norway (n = 2), and Netherlands (n = 2). Unfortunately, not all the studies provided details of the exact settings. The samples did not exclusively include middle-aged adults, but excluded them (e.g. Adults, ≥18 y/o or ≥30).

Discussion

The main findings indicate that CBT is an effective treatment for the QOL for CID in the previously mentioned study samples, alone or in combination with pharmaceutical interventions. Furthermore, the new advancements in the delivery method of CBT have proven beneficial and remove the limitations of in-person or face-to-face treatment. With the target population, middle-aged adults, fall within the inclusion criteria of said study samples, but not always being a majority of the participants. Despite the target population not being the main focus of previous studies, their inclusion in the study samples provides support. This limitation, including the inability to generalize the studies’ findings due to missing details on the settings or study sample criteria. Furthermore, the lack of consistent, matching variables results in a lower level of evidence between the studies.

Conclusion

In conclusion, the findings from the current review provide evidence of CBT is an effective therapy for insomnia independently or in combination with medication, and digitally or in-person. The main positive outcome of a majority of these studies provide enough evidence of a positive, desired effect on CID symptoms with long-term treatment plans.

References

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