Chronic Insomnia: The New Role for Digital/Telehealth Treatment
Insomnia is the most common sleep disorder in the general population. It is defined as a persistent difficulty with sleep initiation, duration, consolidation or quality that occurs despite adequate opportunity for sleep, and leads to impairment in health and functioning. It may also be a symptom of another medical condition such as obstructive sleep apnea (OSA). Recent findings show that insomnia is on the rise. Factors such as stress and anxiety have contributed to an increase in its prevalence in the United States with diagnosis rising from 33% (pre-pandemic) to 56% (post-pandemic). Cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommendation for managing chronic insomnia. The American College of Physicians released recommendations for chronic insomnia in 2016 stating that only after patients fail CBT-I should medication options be considered. Seventy-five percent respond to CBT-I, therefore, why are so many people that are suffering from insomnia still taking sleep medications?
First, let’s define terms. According to the “International Classification of Sleep Disorders” (ICSD-3), insomnia is classified in three diagnostic categories:
- Chronic: Frequent and persistent difficulty initiating or maintaining sleep that results in sleep dissatisfaction and daytime impairment.
- Short-term: Occasional difficulty initiating and maintaining sleep, often associated with some sort of stressor, e.g., jetlag, grief, illness.
- Other: Rare cases that do not meet criteria for chronic or short-term insomnia but have symptoms indicating clinical suspicion of insomnia. This diagnostic category is used sparingly because of its nonspecific classification.
Although CBT-I is the first-line recommended intervention for insomnia, its utilization is limited by the lack of clinicians who are trained in this treatment. Currently there are less than 200 board-certified behavioral sleep medicine (DBSM) specialists, with less than 60 specializing in pediatrics. Many of these specialists are practicing in larger cities or are affiliated with universities leaving people outside these areas with few treatment options.
What is CBT-I? Sleep hygiene is not CBT-I, nor is CBT-I talk therapy. CBT-I consists of both psychological and behavioral interventions where a patient learns how to recognize and change beliefs and behaviors that reduce the anxiety associated with their sleep. This systemized approach for treating insomnia has been widely studied and determined effective in treating insomnia. The “Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults” published in the Journal of Clinical Sleep Medicine states a consensus that CBT-I treatment should be utilized as an initial intervention when appropriate and when conditions permit. A typical program consists of six to eight weekly face-to-face sessions.