Is Cognitive Behavioral Therapy for Insomnia Worth the Cost?

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Several years ago, I injured my back. Immediate interventions for that injury were pain medications and muscle relaxers, but the ER doctor informed me the true way to treat my back was physical therapy. In physical therapy, I learned a lot about my anatomy and physiology, and why I had the vulnerability of injuring my back. I was also given several types of exercises that would train the muscles to protect my back, and good instructions on keeping my back safe when I re-entered my world of regular workouts. I keep up the interventions I learned, but I also occasionally slack off. My back is really good at reminding me when I am not keeping up my work of protecting it. 

It is good to keep this type of intervention in mind when you are looking for effective treatment for insomnia. Yes, there are medications, but the role of medications is meant to be short-term intervention when there is crisis, not long-term treatment of the problem. Medication is the most common treatment for insomnia, even though it is not the most effective treatment. In 2017, the American Academy of Sleep Medicine (AASM) reviewed the treatment efficacy of all the commonly prescribed medications for sleep, and only found weak evidence that these medications were more effective than no treatment at all (article is here). For several of the major medications, the benefit of taking the medication (often no more than incremental improvements in sleep) can be hard to justify over the risks of these medications (increased risk of falls, dementia, and cardiovascular risks).

The AASM practice standards state the gold standard of treatment for insomnia is Cognitive Behavioral Therapy for Insomnia, often called CBT-I. CBT-I treats insomnia effectively because it actively trains the brain to sleep. The hard part of CBT-I is the fact that training the brain to sleep, much like physical therapy for an injury, takes time and attention, but it is the best pathway to change. Luckily, I tend to see that sleep improvement can be a lot quicker than managing a back injury!

There are many different levels of CBT-I, and people can achieve success at each of these levels, depending on how complicated their insomnia may be. At the most accessible level, we have books, workbooks, and even blogs. There are several good books that provide great intervention in improving sleep, and the best part is the fact that they are incredibly affordable. The biggest challenge can be identifying which resources are the best, as there are a lot of options. I have links to my favorites in our resources page, but it can be good to look at the training of the author and whether or not there is an endorsement or membership in one of the sleep societies. Blogs are less likely to have this information, so may be less reliable, but they also are much less of a time investment.

The next level of CBT-I is using a web-based CBT-I program or an application designed to try to improve sleep. My favorite CBT-I web-based program is called Sleepio; it guides you through CBT-I using a professor avatar who has a Scottish accent. Dreamy! The challenge with these web applications is that they have costs associated with them, and they still require a lot of personal insight. For example, I could have watched videos of the exercises I needed for rehabilitation of my back, but chances are that I would get some of those movements wrong. If I did not have active engagement with my physical therapist, I could conclude that physical stretches were not making a difference. This is sometimes what I encounter with people who have tried online CBT-I and felt it was ineffective. For more complicated insomnias, personal intervention is the best delivery. 

CBT-I individual therapy consists of 4 to 12 sessions of individual therapy where we explore the source of the insomnia, what is necessary to treat it, treatment plans, medication taper (if necessary), and relapse prevention. It is important to understand your own vulnerability to insomnia so that you can make sure that you are adequately setting your expectations. I discovered that my vulnerability to back injury is related to some core instability, which means that I have to stabilize myself intentionally whenever I am engaging with exercises that may put me off balance. We use interventions to train the brain to sleep, and also teach the reasons for these exercises, so the lack of control over sleep can feel more controlled. Eliminating medications can be key to treatment, because being on medication actually increases risk of relapse of insomnia. Simple example- if my pain is well-medicated, I won’t know not to move in a way that makes the injury worse. Relapse prevention is meant to give you the skills you need to correct challenges on your own as they come up. This week, I forgot about keeping my core stable, and re-ignited the back injury, but I have all of the exercises I need to be able to get my back in a stable place again. CBT-I is meant to be a treatment that you complete, and arm you with skills to keep your sleep on track. 

So what about costs? Medications are not free, and many people take them for years. In a survey of prices on drugs.com, the annual cost of medication was between $120 to $3,000 depending on number of pills taken and which medication was selected. Most people take their medication for 7 years, which could mean $840-$21,000 on medications, plus physician visits for managing prescriptions. Possible long-term effects, depending on the medication, can mean increased risks of falls, dementia, and cardiovascular risks, and these costs would be hard to assess on an individual basis. Books cost around $20, so are definitely the cheapest route. Online programs are usually around $150. Individual CBT-I costs around $750 to $2,500, depending on the length of treatment. The benefits are long-term skills to manage challenges with sleep through your lifetime, and no long-term negative effects on your health!

Kristin Daley, Ph.D.