People with insomnia should try counseling before they turn to pills, which often carry dangerous side-effects, a doctors’ group advised Monday.
Specialized counseling can and does work, even if people don’t like doing it and even if doctors often don’t know how to do it, the American College of Physicians said in new guidelines on insomnia.
“The evidence is quite strong that cognitive behavioral therapy is effective. It works. It's long-lasting and it has the potential to decrease cost to the health care system,” Dr. Wayne Riley, president of the American College of Physicians, told NBC News.
A team at the organization looked at research on insomnia and at an evidence review by the Agency for Healthcare Research and Quality (AHRQ).
“We looked at 10 years of very strong research studies that looked at the effects of cognitive behavioral therapy and other interventions in terms of improving sleep for patients who have chronic insomnia,” Riley said.
Between 6 percent and 10 percent of U.S. adults have insomnia serious enough to be considered a clinical disorder. “Insomnia is more common in women and older adults and can occur independently or be caused by another disease,” the guidelines team, led by Dr. Amir Qaseem, wrote.
“People with the disorder often experience fatigue, poor cognitive function, mood disturbance, and distress or interference with personal functioning.”
Related: How to Manage Insomnia
But sleeping pills don’t work that well and carry risks. One study found that drugs including Ambien and Restoril may double someone's risk of a car crash.
The Food and Drug Administration says the drugs remain in the bloodstream at levels high enough to interfere with morning driving, which increases the risk of car accidents. It required makers to lower recommended doses.
“Americans do tend to be over medicated for sleep,” Riley said. “That’s why there’s a significant cost to the healthcare system. But also the potential side-effects of sleep medications are underestimated.”
And there’s not even enough evidence to tell whether drugs such as Valium and Xanax help people sleep, the review found. There’s also precious little evidence about alternative therapies such as herbal teas.
Related: Digital Devices Keep us Up All Night
But therapy, although time-consuming and potentially annoying, works, the studies show.
"Cognitive behavior therapy at the beginning is hard to do but once you get through the initial phase it’s lifelong. It’s durable," Riley said.
Dr. Judith Owens of Children’s Hospital in Boston, who was not involved in drawing up the guidelines, said the lack of sleep itself can affect people so they’re not thinking straight, and they may unable to take on board the recommendations without professional help.
"People with insomnia are more likely to have depression. They're more likely to have cognitive problems,” Owens told NBC News.
The first step is to change bad habits.
Related: Confessions of an Ambien Zombie
“Cognitive behavioral therapy will give you the tools and the techniques and little tricks to sort of say between 5 and 8 pm I’m going to have all my worries on the table here,” Riley said.
“I'm going to worry about my kids dental appointment tomorrow or the big project at work but at about 9 o'clock, I'm going to set that aside and I’m going to relax and release and think about a nice beach scene somewhere or something that will put me in the mood that will be more conducive for sleep.”
And a big part of it is putting away the electronics. Smart phones, tablet computers, televisions and computer screens all disrupt normal sleep patterns.
“So number one, it would teach you not to lie in bed for long periods of time being awake instead of asleep,” Owens said.
“So one strategy about that would be not to do anything in bed but sleep. So don't watch television, don't be on your iPad, don't do anything in particular that's going to wake you up,” she added.
Related: Sleeping Pills Raise Crash Risk
“Another strategy would be to get up out of bed if you haven't been able to fall asleep for about 20 minutes or so. We don't want you to watch the clock, but when you start getting annoyed about not being able to fall asleep, get out of bed, sit in a chair, read a boring book until you start feeling drowsy, and then get back into bed and attempt to sleep again. “
Also – no naps.
“Many people with insomnia take naps during the day and that's actually counterproductive and can make the insomnia worse,” Owens said.
The guidelines, published in the Annals of Internal Medicine, encourage patients to see their doctors.
“Many patients suffer for many years without discussing this with their physician,” Owens said.
The good thing about therapy is it gives people tools to help themselves, she said.
“Drugs are only effective as long as you take them, whereas the tools that you learn in cognitive behavioral therapy can last a lifetime.”
It can be hard finding a professional to help, and hard finding time to get there. Riley said help does not necessarily have to come in a one-on-one session. Group therapy also works.
“It would consist of several other individuals who have similar problems with sleep. They would be sharing experiences. More importantly, they will be sharing of techniques and exercises that some patients may have found very helpful that others in a group setting could adopt and get benefit out of it as well,” he said.
In an editorial, Dr. Roger Kathol of the University of Minnesota and colleagues wrote that some insurance plans don’t pay for this kind of help.
“It is frustrating that an intervention as effective as cognitive behavioral therapy for insomnia is difficult for many patients to access,” they wrote.
Insurers and policymakers need to work to make sure it’s as acceptable as medication. And doctors need to get on board, too.
“Some clinicians do not recognize insomnia as a health problem, often considering it merely a symptom secondary to another condition. Second, many clinicians and their patients harbor biases against and are reluctant to consider ‘psychological’ interventions ,” they wrote.
“Although cognitive behavioral therapy for insomnia requires substantial effort and can be uncomfortable for patients during the early stages, with persistence this nonpharmacologic treatment leads not only to better-quality sleep but also to improved daytime functioning."