Which nondrug alternatives can help with insomnia?

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Clinical Inquiries

Which nondrug alternatives can help with insomnia?

J Fam Pract. 2007 October;56(10):836-840

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References

1. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consensus Science Statement. 2005; 22(2). Available at: consensus.nih.gov/2005/2005InsomniaSOS026main.htm. Accessed on September 4, 2007.

2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.

3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.

4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.

5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.

6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.

7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.

8. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations of chronic insomnia in adults. Evidence report/technology assessment No. 125. (Prepared by the University of Alberta Evidence-based Practice Center, under Contract N. C400000021.) AHRQ Publication No. 05-E021-1. Rockville, Md: Agency for Healthcare Research and Quality. June 2005. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf. Accessed on September 4, 2007.

9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.

An important related meta-analysis of 21 studies validated behavior therapy, and revealed CBT reduced sleep onset latency by an additional 8.8 minutes over medication (95% confidence interval, 0.17–1.04 minutes).⁶ Although not superior on other outcomes, behavior therapy produced similar short-term results to pharmacotherapy across all other sleep measures, without attendant medication side effects.

FAST TRACK

The APA recommends cognitive behavioral therapy as the treatment of choice for chronic insomnia

Stimulus control is the most effective CBT intervention

A recent systematic review with meta-analysis of 37 clinical investigations determined that stimulus control was the most effective CBT intervention.³ Stimulus control consists of 5 basic instructions (TABLE) designed to help the patient reassociate sleep stimuli (ie, bed/bedroom) with falling asleep and establishing consistent sleep-wake schedules. These 5 instructions are frequently used in combination with CBT sleep hygiene techniques (TABLE) and can be easily integrated into the office setting.^3,4

Among the CBT techniques, stimulus control and sleep hygiene are the least time-consuming and may be more easily applied in the primary care setting; however, minimal research has been done into the specific incorporation of CBT into primary care settings.

Researchers conducting a single-blind randomized group study in a Veterans Affairs primary care clinic concluded that an abbreviated CBT approach with two 25-minute sessions effectively improved participant sleep onset latency, and time awake after sleep onset.⁷ Researchers reviewed participants’ sleep logs and a behavioral health provider offered patients a condensed education on sleep hygiene, stimulus control, and sleep restrictions strategies. The study was limited because of small sample size (<25). Generalizability to practice is restricted because sessions were conducted by a behavioral health provider, not a family physician.

TABLE
Patient needs a good night’s sleep? Offer this advice

STIMULUS CONTROL INSTRUCTIONS³
Don’t go to bed until you are sleepy Use the bed/bedroom only for sleeping (don’t read, watch TV, eat, or worry) Get out of bed when unable to sleep after 15 minutes; do something relaxing and avoid stimulating activity/thoughts Arise from bed at the same time every day Do not nap during the day
SLEEP HYGIENE INSTRUCTIONS⁴
Sleep only as much as you need to feel refreshed during the following day Exercise regularly Make sure your bedroom is comfortable and free from disturbing light and noise Make sure your bedroom is at a comfortable temperature during the night Eat regular meals and do not go to bed hungry Avoid drinking too many fluids in the evening Reduce your caffeine intake Avoid drinking alcohol—especially in the evening Avoid smoking at night when you are having trouble sleeping Don’t try too hard to fall asleep Put the clock under the bed or turn it so you can’t see it

Recommendations from others

The Agency for Healthcare Research and Quality recommends CBT as an effective treatment in the management of chronic .⁸ It also recommends that further large-scale RCTs be conducted to establish CBT’s effectiveness across subsets of the population of individuals with chronic (ie, gender, age, shift workers, and those with psychiatric illnesses).

The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.⁹

Acknowledgments

The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.

Evidence-based answers from the Family Physicians Inquiries Network

Which nondrug alternatives can help with insomnia?

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