Sleep therapy: coping with insomnia without drugs is possible, but requires patient involvement

Irene Ferrando, 72, began to suffer from insomnia in 2021, as a result of depression. “It was day after day sleeping very little. I remember my life quite badly, with no desire to do anything, no strength,” she explains to EL PAÍS. She visited a psychiatrist to address the depression and he prescribed her drugs for insomnia that she continues to take today, although for a few weeks now, to a lesser extent. The reduction is linked to her joining a Cognitive Behavioural Therapy for Insomnia (CBT-I) group offered as a treatment from the Sleep Unit of the University Clinical Hospital of Valencia. “A friend who is a doctor had spoken highly of this therapy, so I asked to be referred to the Sleep Unit. It is going very well for me, frankly. Basically, it is ordering and organizing my sleep. This is not immediate, I know, but I am quite encouraged. “I think I'm going to get over my insomnia,” he says optimistically.

Like Irene, according to data from a study led by the Insomnia Working Group of the Spanish Sleep Society, 14% of the Spanish adult population suffers from chronic insomnia (insomnia symptoms occur three or more nights a week, last more than 3 months and cannot be fully explained by another health problem). Twenty years ago, that percentage was 6.4%. “Insomnia is already a public health problem,” agree the experts consulted, who highlight the impact of insomnia at the health level (greater cardiovascular, neurodegenerative and metabolic morbidity) and at the economic level, due to its direct influence on absenteeism, presenteeism, work accidents and productivity. According to the report Social and economic burden of insomnia in adults , prepared by the international non-profit research organization RAND Europe, just due to the decrease in productivity, insomnia represents annual losses of more than 11.5 billion euros in Spain, which represents 0.82% of the GDP.

As indicated by all the main clinical practice guidelines, the first-line treatment for chronic insomnia is Cognitive Behavioural Therapy, as it has proven to be most effective in the medium and long term in addressing this sleep disorder. However, patients who access it are still the exception. A study published in January in the scientific journal Journal of Clinical Sleep Medicine indicated that only 1% of people with insomnia access it in Australia. In Spain there is no data, but the percentage could be even lower. There are only a handful of Sleep Units that currently offer this treatment.

“The problem with insomnia is that it is a very common disorder and is not well treated . The guidelines say that we should start with cognitive behavioural therapy, but we have thousands of patients taking hypnotics and benzodiazepines for years,” laments Dr. Manuel de Entrambasaguas, a clinical neurophysiologist at the Sleep Unit of the Hospital Clínico de Valencia. His opinion is shared by Odile Romero, coordinator of the Sleep Unit of the Vall d'Hebron Hospital in Barcelona, ​​who points to several factors. On the one hand, the lack of trained personnel and units that offer the therapy: “Most patients who suffer from insomnia find it difficult to reach a specialist.” On the other hand, the inability to look at the long term. “Healthcare resources are what they are and insomnia is not something that, apparently, generates a short-term risk, so it is not seen as something urgent and, therefore, it is not on the priority lists.” And finally, there is a lack of time, which means that the quickest solution is always a drug, even though these have significant side effects, one of which is dependency: it is very difficult to stop taking them and there are patients who are hooked on them for years, even though most of these drugs are indicated for just three or four weeks of treatment.

A therapy against the factors that perpetuate insomnia

According to the three-factor (3P) model of insomnia, there are three main factors that contribute to the development of chronic insomnia. The first would be the predisposing factors, those traits or conditions that increase a person's vulnerability to developing insomnia. The second, the precipitating factors, that is, those stressful situations or events in life that trigger the onset of insomnia. And third, the perpetuating factors, those behaviors and thoughts that contribute to the transition from acute to chronic insomnia and maintain the disorder in the long term. Cognitive Behavioral Therapy for Insomnia focuses primarily on addressing these last factors, the perpetuating ones.

As a general rule, in public hospitals in Spain where this therapy has been offered for the longest time and is a reference in the field, CBT-I is carried out in group dynamics of between 4 and 10 people, with between 5 and 7 sessions of one and a half hours. In these sessions, patients are offered advice on sleep hygiene, behavioural techniques (restricting time in bed and stimulus control), cognitive strategies to help patients regain confidence in returning to sleep, and breathing and relaxation techniques.

“I am not going to tell you that 100% of patients improve, but they are the vast majority, and around 50% completely overcome insomnia. Why only 50%? Well, because unfortunately we see many patients who have suffered from insomnia for many years, who have been prescribed various drugs… These patients also improve, but then we have to start taking them off the drugs, and sometimes that is a bit more difficult ,” explains Ainhoa ​​Álvarez, neurophysiologist at the Sleep Unit of the OSI Araba and coordinator of the Insomnia working group of the Spanish Sleep Society. “The truth is that these are very satisfying experiences. When you see patients who have not slept for 10 years and are taking drugs and in just five weeks they begin to see a significant change, it is very gratifying. But this does require, it is true, a significant dedication from the patients,” adds Odile Romero.

The importance of patient involvement

Nerea López Jáuregui is 48 years old. In 2018, she attended a group cognitive behavioural therapy at the Sleep Unit of the Araba University Hospital in Vitoria-Gasteiz. At that time, she had been suffering from insomnia for nine years, ever since she became a mother. “It is a very hard therapy to do and to comply with 100%. You have to change many habits and you have to be super-conscious and constant. In the end, the professionals make everything much easier for you, but you have to make the effort,” she explains. Since she finished the therapy, almost seven years ago, different life circumstances, her own day-to-day life, have caused Nerea to occasionally relapse, to have a chain of bad nights of sleep . The difference is that, now, she feels she has tools: “I have the information and that is now my medicine cabinet, it is no longer pills. Now I know what I have to do and as soon as I take the advice, I get my sleep back.”

“This therapy requires the involvement of the patient, as they will have to make some internal changes. It is totally different from when someone takes a pill, as then they are not changing anything, neither their habits nor their beliefs,” says Manuel de Entrambasaguas. This necessary involvement of the patients, maintains Odile Romero, is one of the main limitations of Cognitive Behavioural Therapy. It is not for everyone.

“I have patients who I tell that with this therapy they will have to make changes in their life , also in their social life, to be regular, and they tell me straight away to prescribe them a pill and stop messing around,” she says. The coordinator of the Sleep Unit at Vall d'Hebron Hospital in Barcelona admits that many times, when the therapy does not give results, it is precisely because of the lack of involvement of the patients : “If the patient does it well, the result is very good, but if the patient does not have an active participation or the therapist is not able to transmit the importance of following the rules in a strict manner, the therapy fails.”

For Ainhoa ​​Álvarez, the challenge now is to ensure that Cognitive Behavioural Therapy is effectively the first treatment that patients with insomnia access. “Scientific studies have shown that CBT-I is much more effective if used before prescribing drugs,” she maintains. In this sense, according to the neurophysiologist, the objective should be for this group therapy to be offered in Primary Care centres, which is where most patients with insomnia are treated in the first instance. “It may not be possible to offer it in all health centres, but there could be reference health centres in each town or city and patients could be referred there. I think that should be the future,” she concludes.