Cognitive behavior therapy -- offered online by insurers -- is more effective than pills, an expert says.
By Francesca Lunzer Kritz
November 3, 2008
Health insurers are sometimes better known for causing sleepless nights than for creating restful ones, but in the last few months, helping consumers get a good night's sleep has become a priority for most of the top-tier U.S. health insurance companies, including WellPoint, Aetna, Cigna, Kaiser Permanente and several Blue Cross plans.
Their new programs don't involve sleeping pills. Instead, insurers are advocating the use of cognitive behavior therapy. Traditionally, the therapy has been done largely through face-to-face sessions, but many of the programs are now available online.
Cognitive behavior therapy for insomnia is far superior to sleep medications, says Meir H. Kryger, director of sleep medicine at Gaylord Hospital in Wallingford, Conn., and chairman of the National Sleep Foundation, a consumer education group. "It can actually cure the insomnia -- not just treat it as medicines do -- without the side effects, such as daytime sleepiness or dizziness, that can occur with even the newest sleeping pills."
Why would health insurers, often tight-fisted for even life-saving treatments, be so quick to cover the cost of a few extra Zs? "To reduce the tens of millions they're spending on sleeping pills each year, as well as improve medical conditions that may be caused by a lack of sleep," says Helen Darling, head of the National Business Group on Health in Washington, D.C., which advises large employers on health cost issues.
About 50 million to 70 million people in the U.S. suffer from various forms of insomnia (such as having a hard time falling asleep or staying asleep, and waking up too soon), according to the National Institutes of Health. And for about 20 million of those sufferers, nighttime insomnia affects their daytime hours as well -- making it hard to stay awake or concentrate, Kryger says. Insomnia of all kinds has been linked to an increased risk of a variety of medical problems, including high blood pressure and depression, accidents and lowered productivity at work.
"Mounting evidence indicates that sleep may be as important as diet and physical activity [for a] healthy lifestyle," says Michael Twery, director of the National Center on Sleep Disorders Research, a division of the NIH. "Getting a good night's sleep is necessary for optimal cardiovascular and metabolic health. Insufficient sleep affects the way we see the world, mood, performance, vigilance, awareness, ability to perceive our environment and [how we] respond to challenges."
And use of sleeping pills has skyrocketed. A study this year in the journal Health Affairs found a 50% jump in sleeping pill use -- from 5,445 people per 100,000 in 1998 to 8,194 per 100,000 people in 2006. Though one version of Ambien, a popular sleep aid, is now available as a lower-cost generic costing about 50 cents per pill, newer drugs such as Rozerem and Lunesta cost about $4 and $5 per pill, respectively, or a minimum of nearly $1,500 per year for patients who take a sleeping pill every night. Online behavioral therapy programs cost less than $40 per user, and face-to-face counseling can range from about $300 to $1,800, depending on how many sessions a patient goes through and what level of specialist, from social worker to psychiatrist, provides the therapy.
Unlike sleeping pills, counseling is usually a one-time thing and costs do not continue year to year.
Sleep-related fears
Cognitive behavior therapy has been in use for decades and is part of the American Academy of Sleep Medicine's clinical guidelines for treating insomnia. "The only problem with CBT is that there are not nearly enough trained practitioners in the U.S. to help the millions of people with insomnia," says Dr. Michael Sateia, head of the sleep medicine program at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and a former president of the American Academy of Sleep Medicine.
During cognitive behavior therapy, trained specialists work with people who have insomnia to eliminate their sleep-related fears and misconceptions. Some such worries are so encompassing that people simply can't sleep.
The therapy may include sleep-restriction exercises to encourage drowsiness and stimulus control. An example of the latter would be not going downstairs upon leaving the bed because a return up the stairs could increase wakefulness, says Lynelle Schneeberg, an insomnia therapist at Gaylord Hospital. The therapy can also include so-called sleep hygiene strategies that can help promote shut-eye, such as forgoing alcohol and exercise in the hours before bed and using the bedroom only for sleep and sex.
"Many people 'catastrophize' their inability to fall asleep -- they lie there and tell themselves over and over that they won't fall asleep -- and then they don't," Sateia says. "By using behavioral changes, we can help them understand that no disaster will occur if they don't fall asleep and encourage them to think and do other things rather than lie there anxiously."
For face-to-face therapy, two to four sessions are typically scheduled every few weeks, though six to eight sessions are also common, Schneeberg says. Online programs take about the same amount of time; the programs now in use by insurers offer five to six sessions that users typically access once a week, though they can go through the program faster if they wish. Both online and face-to-face programs begin with a health assessment. Although insomnia often has no underlying physical cause, it can be a side effect of a medical condition such as Parkinson's disease, depression or cancer. In a 2006 article published in the journal Sleep, Charles M. Morin, a sleep researcher from Université Laval in Québec, reviewed 37 studies on cognitive behavior therapy for insomnia and ultimately suggested that it be the first-line treatment -- over medication.
Further, Morin said in the article that the studies showed the therapy is effective for older patients and for people whose other health issues, such as chronic illness, may be contributing to their sleeplessness. Those two groups are notoriously hard to treat for sleep problems.
The lack of trained professionals has prevented the academy from pushing the therapy to the front of the list of treatments, Sateia says.
Web sessions
The online programs simulate many of the strategies used in face-to-face counseling. Overcoming Insomnia, for example, the program now in use by Highmark, Aetna and Kaiser Permanente, teaches users to evaluate their thoughts and beliefs and reminds them that "not all of our thoughts and beliefs are based on facts."
Users can repeat sessions as often as they like, which helps reinforce a positive attitude toward getting to sleep -- much as they'd be reminded to try to dispel negative notions in a face-to-face setting, says Richard Bedrosian, head of mental health at HealthMedia of Ann Arbor, Mich., which sells Overcoming Insomnia. The programs also teach relaxation techniques -- such as concentrating on breathing while turning attention away from worry about sleep.
Consumers don't have to go through their insurer to try the programs. Conquer Insomnia, an early version of the program now used by Kaiser, Aetna and Highmark, is available for $19.95 at www.myselfhelp.com. Conquering Insomnia, a version of the program being used by Blue Cross Blue Shield of Massachusetts, is available for $24.95 at CBTforinsomnia.com.
Curiously, while online sleep therapy is all the rage among insurers, few sleep specialists -- including Twery, Sateia and Kryger -- seemed to be aware of it. A study showing the therapy to be more effective than no treatment was presented at the Sleep Academy's annual meeting last summer -- but it didn't even make it to the meeting blog produced each day.
The NIH's Twery says the agency would be very interested in assessing and refining the programs. "There has been little education about sleep and its significance in the U.S.," he says. "Too many people think their sleep habits are just their own quirkiness and there's nothing they can do to improve them."
"We're on the ground floor . . . moving toward national awareness and strategies," says Janet Croft, a senior epidemiologist at the national Centers for Disease Control and Prevention. The CDC, for example, will be meeting with the NIH and organizations such as the National Sleep Foundation to create a consensus on insomnia public education and treatment.
Sleep experts suggest that patients who are going to try online sleep therapy let their doctors know when they start the program as well as how effective it seems to be.
"If online therapy doesn't work for a particular patient," says Sonia Ancoli-Israel, head of the sleep disorders clinic at UC San Diego, "having the doctor in the loop can mean that another strategy, such as a brief course of medication or face-to-face therapy, can be started promptly."
Kritz is a freelance writer.
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