Introduction

When I am doing clinical work, my priority is always with the patient. And every patient is different – they each have their own varied lived experiences that come with a unique set of goals and beliefs. Therefore, there is no one-size-fits-all when it comes to providing treatment recommendations. I am not in the business of imposing my own values for what the best option is for another person. In fact, I rarely – if ever – tell what a patient what they must do. The reason is that I believe choices are most powerful when the individual takes ownership of their decision. I also believe that that you are the best person to make your own decisions. After all, you are the expert of yourself.

So, what do I do when a patient asks me: “do you think I should use medication or is it better for me to go to therapy for my insomnia problem?” or have another question where they are asking me to make an important decision in their life? In these cases, I consider myself to have two main roles:

1) To provide relevant and accurate information based on the data and my expertise as a clinician.

2) To guide the patient to a decision that is most consistent with their unique goals and values.

These two primary roles have the purpose of ensuring that the patient has all the information they need to make an informed decision and empowers them to make a choice that is most consistent with their authentic selves. Different goals and values for sleep could be “it’s most important for me to get 8 hours of sleep”; “I do not want to rely on anything to get good sleep”; “I’m sleeping terribly because of stress and just need a few good nights of sleep because my exam is coming up”. Depending on what is most important to you, your decisions to engage in medication or therapy (or something else) will differ.

In this case, one of the pills is actually a full course of cognitive-behavioural therapy
Photo by ANIRUDH on Unsplash

A Primer into Evidence-Based Strategies for Insomnia

There are two primary evidence-based treatments for chronic insomnia – sleep medication and cognitive behavioural interventions of insomnia. Hypnotics, such as benzodiazepines (e.g., lorazepam and alprazolam) and nonbenzodiazepines (e.g., the “z-drugs” zopiclone and zolpidem) among others, are a class of psychoactive drugs with a primary purpose of treating insomnia symptoms. On the other hand, behavioural treatments of insomnia can include a number of different strategies (e.g., stimulus control, relaxation therapy, sleep restriction therapy). The first-line recommended treatment for insomnia is cognitive-behavioural therapy for insomnia (CBT-I). I’ll primarily be talking about CBT-I when it comes to therapies for insomnia because it is the one that has shown the most high-quality evidence in treating insomnia.

When it comes to efficacy, both sleep medications and CBT-I are pretty comparable – at least in the short-term. There is research to suggest that CBT-I is more effective in the long-run. For example, Blom et al. (2016) found that people treated with insomnia tended to maintain their gains for at least 3 years after treatment. In terms of usage, medication tends to be more fast-acting (i.e., you take the pill and then you fall asleep); on other hand, CBT-I takes more time and commitment to restore your body’s natural sleep systems and make you feel more confident in your sleep. Along the same line then, medication only treats insomnia at the symptom level whereas CBT-I targets the causes of insomnia. This is one of the reasons why CBT-I has greater durability in its effects compared to medication. In terms of quality vs quantity of sleep, medication tends to be more reliable in increasing the quantity of sleep – getting you closer to your 8 hours (although see here for an article talking about the myth of 8 hours). On the other hand, CBT-I does not try to increase the sleep amount; instead, it focuses on consolidating your sleep to reduce nighttime awakenings and increases the quality of sleep. Below, I talk about the main pros and cons of sleep medication versus CBT-I

Contrary to popular belief, therapy for insomnia does not require the therapist to talk the patient to sleep!
Photo by Mark Williams on Unsplash

Pros and Cons of Medication versus Therapy

Benefits of Medication:

  • Immediate sleep relief
  • Good solution for short-term sleep problems
  • Increase the quantity of sleep

Benefits of CBT-I:

  • Long-term efficacy
  • Does not require external sleep aids because it leverage own body’s sleep systems
  • Increases quality of sleep and improves one’s own confidence in producing sleep

Weaknesses of Medication:

  • Dependence and tolerance issues
  • People can experience insomnia rebound when they get off medication
  • Side effects (e.g., feeling groggy in the morning, mood problems)
  • Is not a long-term solution

Weaknesses of CBT-I:

  • Takes time and commitment to see results
  • Can be costly to receive therapy
  • Recommendations may not be consistent with patient’s values (e.g., not reading a book in bed to break the association between bed and wakefulness)

*Ultimately, for those who are struggling with insomnia symptoms, it is up to you to decide what’s best for you when it comes to your own goals and values. There are no right or wrong answers. However, I hope this post was helpful in identifying certain pros and cons when it comes to going down the therapy route or the medication route!

But what about other cures for insomnia?

The reason I talk about medication and CBT-I is because they are the two strategies that have a significant amount of research to back up its efficacy. This doesn’t mean that other strategies don’t work. For example, there are studies beginning to look at the effects of certain teas (e.g., valerian, chamomile), weighted blankets, specialty mattresses, among other techniques. Currently, there is insufficient evidence to suggest that they are effective in improving sleep – but if you find them helpful, please continue! I am a strong proponent of people picking the strategies that work well for them.

I hope this post was helpful to learn a little bit more about the use of medication and therapy for treatment of insomnia!

Best wishes,

P