Insomnia Insomnia

Cognitive-Behavioral Therapy 167
issues related to comorbid psychiatric and medical disorders, and the simultaneous
use of sedative hypnotics.
Treatment Compliance
The single most important complicating factor is poor treatment compliance. At
the beginning of treatment, the clinician should proactively address the fact that the
prescriptions may seem counterintuitive and that adhering to the treatment will be
difficult. Providing the patient with a complete and thoughtful rationale for each
aspect of the treatment, managing the patient’s expectations, and encouraging an
active self-management approach are essential. Providing the rationale for treatment
is likely to gain patient compliance in at least two ways. First, the effort to
explain therapy is less imperative, thereby making the patient an active partner in
the treatment process and making him or her less resistant or reactive to the prescriptions.
Second, a fluid, interesting, and compelling explanation will support
and enhance the patient’s perception of the clinician as a competent authority.
With respect to expectation, the patient should not anticipate that the results will
be immediate. In fact, the patient should be cautioned that his or her sleep problem
is likely to briefly “get worse before it gets better.” Sometimes an appeal to the
research literature, demonstrating that treatment gains are maintained and often
continue to improve in the long-term, may help maintain the patient’s motivation
despite the short-term difficulty adjusting to the procedures.
With respect to “active self-management,” it is important to remember that the
treatment alternative is medication and that this requires very little in the way of
lifestyle change. Thus, the clinician must spend a considerable amount of time
working with the patient to “make and stay with the investment.”
Comorbity of Mental and Medical Disorders
Many patients with chronic insomnia report mild or subthreshold levels of
depressive symptoms. When depressive symptoms become severe, they may interfere
with the patient’s ability and motivation to successfully follow the recommended
protocol. If medical factors become exacerbated, expectations for clinical
gains need to be tempered until stabilization occurs. Throughout the course of treatment,
both medical and psychiatric factors should be monitored and consideration
should be given for further evaluation and intervention.
CBT and Sedative Hypnotics
Not yet addressed is the possibility of using sedative hypnotics acutely, along with
CBT for insomnia (i.e., dual or combined therapy). This is a promising and
underinvestigated area of inquiry. Initial studies were mixed (46–48), but promising
work continues (49). The benefit of combined therapy is a more rapid reduction of
symptoms. The risk of combining pharmacotherapy with behavioral treatment, however,
is that once patients start using medications, they may be less inclined to adopt
or tolerate behavioral interventions. Work is ongoing to determine the most effective
way to combine these two strategies to capitalize on the immediate reduction in symptoms
afforded by sedative hypnotics and the long-term efficacy of CBT (50).