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[[Cognitive-behavioral therapy]] delivered online may help according to [[randomized controlled trial]]s.<ref name="pmid26827250">{{cite journal| author=Christensen H, Batterham PJ, Gosling JA, Ritterband LM, Griffiths KM, Thorndike FP et al.| title=Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial. | journal=Lancet Psychiatry | year= 2016 | volume= 3 | issue= 4 | pages= 333-41 | pmid=26827250 | doi=10.1016/S2215-0366(15)00536-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26827250  }} </ref><ref name="pmid27902836">{{cite journal| author=Ritterband LM, Thorndike FP, Ingersoll KS, Lord HR, Gonder-Frederick L, Frederick C et al.| title=Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up: A Randomized Clinical Trial. | journal=JAMA Psychiatry | year= 2016 | volume=  | issue=  | pages=  | pmid=27902836 | doi=10.1001/jamapsychiatry.2016.3249 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27902836  }} </ref>
[[Cognitive-behavioral therapy]] delivered online may help according to [[randomized controlled trial]]s.<ref name="pmid26827250">{{cite journal| author=Christensen H, Batterham PJ, Gosling JA, Ritterband LM, Griffiths KM, Thorndike FP et al.| title=Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial. | journal=Lancet Psychiatry | year= 2016 | volume= 3 | issue= 4 | pages= 333-41 | pmid=26827250 | doi=10.1016/S2215-0366(15)00536-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26827250  }} </ref><ref name="pmid27902836">{{cite journal| author=Ritterband LM, Thorndike FP, Ingersoll KS, Lord HR, Gonder-Frederick L, Frederick C et al.| title=Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up: A Randomized Clinical Trial. | journal=JAMA Psychiatry | year= 2016 | volume=  | issue=  | pages=  | pmid=27902836 | doi=10.1001/jamapsychiatry.2016.3249 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27902836  }} </ref>
==Behavioral Therapy==
{| class="wikitable" align="right"
|+ Randomized controlled trial of treatment options for insomnia.<ref name="pmid19454639">{{cite journal|  author=Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et  al.| title=Cognitive behavioral therapy, singly and combined with  medication, for persistent insomnia: a randomized controlled trial. |  journal=JAMA | year= 2009 | volume= 301 | issue= 19 | pages= 2005-15 |  pmid=19454639 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19454639 | doi=10.1001/jama.2009.682 }} </ref>
! rowspan=2|Treatment!! colspan=2|Outcome at 6 months
|-
! Responders!! Remitters
|-
| 6 weeks of [[Cognitive behavioral therapy|CBT]]|| 55% || 40%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]|| 63% || 44%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 weeks of [[zolpidem]]||style="background:lightgreen"| 81% ||style="background:lightgreen"| 68%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 months of [[zolpidem]]|| 65% || 42%
|-
| colspan=3 | Adapted from Table 4 of Morin et al.<ref name="pmid19454639"/>
|-
|}
In many cases, insomnia is caused by another disease or psychological problem.  In this case, medical or psychological help may be useful.
A combination of short term pharmacotherapy and long-term behavioral therapy may be best according to a [[randomized controlled trial]] (see Table to the right).<ref name="pmid19454639">{{cite journal|  author=Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et  al.| title=Cognitive behavioral therapy, singly and combined with  medication, for persistent insomnia: a randomized controlled trial. |  journal=JAMA | year= 2009 | volume= 301 | issue= 19 | pages= 2005-15 |  pmid=19454639 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19454639 | doi=10.1001/jama.2009.682 }} </ref>
According to [[clinical practice guideline]]s by the [[American Academy of Sleep Medicine]]:
*"Psychological and behavioral interventions are effective for adults of all ages, including older adults, and chronic hypnotic users. These treatments should be utilized as an initial intervention when appropriate and when conditions permit."<ref name="pmid18853708">{{cite journal| author=Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M| title=Clinical guideline for the evaluation and management of chronic insomnia in adults. | journal=J Clin Sleep Med | year= 2008 | volume= 4 | issue= 5 | pages= 487-504 | pmid=18853708 | doi= | pmc=PMC2576317 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18853708  }} </ref>
* “Initial approaches to treatment should include at least one behavioral intervention such as stimulus control therapy or relaxation therapy, or the combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy—otherwise known as cognitive behavioral therapy for insomnia (CBT-I).”<ref name="pmid18853708">{{cite journal| author=Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M| title=Clinical guideline for the evaluation and management of chronic insomnia in adults. | journal=J Clin Sleep Med | year= 2008 | volume= 4 | issue= 5 | pages= 487-504 | pmid=18853708 | doi= | pmc=PMC2576317 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18853708  }} </ref>
Behavior therapy may require as many as 16 sessions<ref name="pmid16785771">{{cite journal| author=Wu R, Bao J, Zhang C, Deng J, Long C| title=Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. | journal=Psychother Psychosom | year= 2006 | volume= 75 | issue= 4 | pages= 220-8 | pmid=16785771 | doi=10.1159/000092892 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16785771  }} </ref>.
A shorter number of sessions has been studied:
* "Brief behavioral therapy for insomnia" (BBTI) consists of "a 45 to 60-minute individual intervention session followed by a 30-minute follow-up session 2 weeks later and 20-minute telephone calls after 1 and 3 weeks." Goals of therapy were “reduce time in bed, get up at same time every day regardless of sleep duration, do not go to bed unless sleepy, do not stay in bed unless asleep.” In a trial of 82 older adults (mean age 71.7) BBTI led to a response rate of 67% which yielded a relative benefit increase of 2.7 and number needed to treat in their population of 2.4.<ref name="pmid21263078">{{cite journal| author=Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME et al.| title=Efficacy of brief behavioral treatment for chronic insomnia in older adults. | journal=Arch Intern Med | year= 2011 | volume= 171 | issue= 10 | pages= 887-95 | pmid=21263078 | doi=10.1001/archinternmed.2010.535 | pmc=PMC3101289 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21263078  }} </ref>
===Cognitive Behavioral Therapy===
[[Cognitive therapy|Cognitive behavior therapy]] for insomnia has been studied in a [[meta-analysis]] of 20 [[randomized controlled trial]]s that compared a combination of two modalities of CBT-i versus various control therapies. Different modalities of CBT-i were defined as cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation techniques. The meta-analysis found:
* Sleep onset latency improved by 19 (95% [[Confidence interval|CI]], 142 to 25) minutes
* Wake after sleep onset was reduced by 26 (95% [[Confidence interval|CI]], 15 to 37) minutes
* Total sleep time increased by 8 (95% [[Confidence interval|CI]], 1 to 16) minutes
* Sleep efficiency percentage improved by 10% (95% [[Confidence interval|CI]], 8% to 12%)
===Sleep Restriction Therapy===
Sleep restriction therapy for insomnia has been studied in a [[meta-analysis]] of 4 [[randomized controlled trial]]s that reported "Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement"; however, the authors add "variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy"<ref name="pmid24629826">{{cite journal| author=Miller CB, Espie CA, Epstein DR, Friedman L, Morin CM, Pigeon WR et al.| title=The evidence base of sleep restriction therapy for treating insomnia disorder. | journal=Sleep Med Rev | year= 2014 | volume= 18 | issue= 5 | pages= 415-24 | pmid=24629826 | doi=10.1016/j.smrv.2014.01.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24629826  }} </ref>.
===Complimentary and Alternative Therapies===
Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get up early in the morning and to retire to bed at a reasonable hour.
Many believe that listening to slow paced music will help insomniacs fall asleep. <ref name="pmid16269944">{{cite journal |author=Robinson SB, Weitzel T, Henderson L |title=The Sh-h-h-h Project: nonpharmacological interventions |journal=Holistic nursing practice |volume=19 |issue=6 |pages=263-6 |year=2005 |pmid=16269944 |doi=}}</ref>
The more relaxed a person is, the greater the likelihood of getting a good night's sleep. [[Relaxation techniques]] such as [[meditation]] have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.
[[Traditional Chinese medicine]] has included treatment for insomnia. A typical approach may utilize [[acupuncture]], dietary and lifestyle analysis, [[Herbalism|herbology]] and other techniques, with the goal of resolving the problem at a subtle level.
In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or ''[[metta]]''. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body<ref>{{cite journal |author=Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ |title=Long-term meditators self-induce high-amplitude gamma synchrony during mental practice |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=101 |issue=46 |pages=16369-73 |year=2004 |pmid=15534199 |doi=10.1073/pnas.0407401101 |url=http://www.pnas.org/cgi/content/full/101/46/16369 }}</ref>. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the ''Mettā (Mettanisamsa) Sutta''<ref>http://www.accesstoinsight.org/tipitaka/an/an11/an11.016.than.html</ref>, Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.
Using [[aromatherapy]], including jasmine oil, [[lavender oil]], [[Mahabhringaraj]] and other relaxing [[essential oil]]s, may also help induce a state of restfulness. [[Horlicks]] is marketed as a sleeping aid.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 20:26, 5 December 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Non-pharmacological therapy

Clinical practice guideline by the American Academy of Sleep Medicine (AASM) noted about cognitive behavior therapy for insomnia:

  • “Initial approaches to treatment should include at least one behavioral intervention such as stimulus control therapy or relaxation therapy, or the combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy—otherwise known as cognitive behavioral therapy for insomnia (CBT-I).”[1]

Cognitive behavior therapy for insomnia has been studied in a meta-analysis of 20 randomized controlled trials that compared a combination of two modalities of CBT-i versus various control therapies. Different modalities of CBT-i were defined as cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation techniques. The meta-analysis found:

  • Sleep onset latency improved by 19 (95% CI, 142 to 25) minutes
  • Wake after sleep onset was reduced by 26 (95% CI, 15 to 37) minutes
  • Total sleep time increased by 8 (95% CI, 1 to 16) minutes
  • Sleep efficiency percentage improved by 10% (95% CI, 8% to 12%)

Sleep restriction therapy for insomnia has been studied in a meta-analysis of 4 randomized controlled trials that reported "Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement"; however, the authors add "variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy"[2].

Implementing behavior therapy

Behavior therapy may require as many as 16 sessions[3].

A shorter number of sessions has been studied:

  • "Brief behavioral therapy for insomnia" (BBTI) consists of "a 45 to 60-minute individual intervention session followed by a 30-minute follow-up session 2 weeks later and 20-minute telephone calls after 1 and 3 weeks." Goals of therapy were “reduce time in bed, get up at same time every day regardless of sleep duration, do not go to bed unless sleepy, do not stay in bed unless asleep.” In a trial of 82 older adults (mean age 71.7) BBTI led to a response rate of 67% which yielded a relative benefit increase of 2.7 and number needed to treat in their population of 2.4.[4]

Cognitive-behavioral therapy delivered online may help according to randomized controlled trials.[5][6]

Behavioral Therapy

Randomized controlled trial of treatment options for insomnia.[7]
Treatment Outcome at 6 months
Responders Remitters
6 weeks of CBT 55% 40%
6 months of CBT 63% 44%
6 months of CBT
6 weeks of zolpidem
81% 68%
6 months of CBT
6 months of zolpidem
65% 42%
Adapted from Table 4 of Morin et al.[7]

In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful.

A combination of short term pharmacotherapy and long-term behavioral therapy may be best according to a randomized controlled trial (see Table to the right).[7]

According to clinical practice guidelines by the American Academy of Sleep Medicine:

  • "Psychological and behavioral interventions are effective for adults of all ages, including older adults, and chronic hypnotic users. These treatments should be utilized as an initial intervention when appropriate and when conditions permit."[1]
  • “Initial approaches to treatment should include at least one behavioral intervention such as stimulus control therapy or relaxation therapy, or the combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy—otherwise known as cognitive behavioral therapy for insomnia (CBT-I).”[1]

Behavior therapy may require as many as 16 sessions[3].

A shorter number of sessions has been studied:

  • "Brief behavioral therapy for insomnia" (BBTI) consists of "a 45 to 60-minute individual intervention session followed by a 30-minute follow-up session 2 weeks later and 20-minute telephone calls after 1 and 3 weeks." Goals of therapy were “reduce time in bed, get up at same time every day regardless of sleep duration, do not go to bed unless sleepy, do not stay in bed unless asleep.” In a trial of 82 older adults (mean age 71.7) BBTI led to a response rate of 67% which yielded a relative benefit increase of 2.7 and number needed to treat in their population of 2.4.[4]

Cognitive Behavioral Therapy

Cognitive behavior therapy for insomnia has been studied in a meta-analysis of 20 randomized controlled trials that compared a combination of two modalities of CBT-i versus various control therapies. Different modalities of CBT-i were defined as cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation techniques. The meta-analysis found:

  • Sleep onset latency improved by 19 (95% CI, 142 to 25) minutes
  • Wake after sleep onset was reduced by 26 (95% CI, 15 to 37) minutes
  • Total sleep time increased by 8 (95% CI, 1 to 16) minutes
  • Sleep efficiency percentage improved by 10% (95% CI, 8% to 12%)

Sleep Restriction Therapy

Sleep restriction therapy for insomnia has been studied in a meta-analysis of 4 randomized controlled trials that reported "Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement"; however, the authors add "variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy"[2].

Complimentary and Alternative Therapies

Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get up early in the morning and to retire to bed at a reasonable hour.

Many believe that listening to slow paced music will help insomniacs fall asleep. [8]

The more relaxed a person is, the greater the likelihood of getting a good night's sleep. Relaxation techniques such as meditation have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.

Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, herbology and other techniques, with the goal of resolving the problem at a subtle level.

In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or metta. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body[9]. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the Mettā (Mettanisamsa) Sutta[10], Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.

Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness. Horlicks is marketed as a sleeping aid.


References

  1. 1.0 1.1 1.2 Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M (2008). "Clinical guideline for the evaluation and management of chronic insomnia in adults". J Clin Sleep Med. 4 (5): 487–504. PMC 2576317. PMID 18853708.
  2. 2.0 2.1 Miller CB, Espie CA, Epstein DR, Friedman L, Morin CM, Pigeon WR; et al. (2014). "The evidence base of sleep restriction therapy for treating insomnia disorder". Sleep Med Rev. 18 (5): 415–24. doi:10.1016/j.smrv.2014.01.006. PMID 24629826.
  3. 3.0 3.1 Wu R, Bao J, Zhang C, Deng J, Long C (2006). "Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia". Psychother Psychosom. 75 (4): 220–8. doi:10.1159/000092892. PMID 16785771.
  4. 4.0 4.1 Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME; et al. (2011). "Efficacy of brief behavioral treatment for chronic insomnia in older adults". Arch Intern Med. 171 (10): 887–95. doi:10.1001/archinternmed.2010.535. PMC 3101289. PMID 21263078.
  5. Christensen H, Batterham PJ, Gosling JA, Ritterband LM, Griffiths KM, Thorndike FP; et al. (2016). "Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial". Lancet Psychiatry. 3 (4): 333–41. doi:10.1016/S2215-0366(15)00536-2. PMID 26827250.
  6. Ritterband LM, Thorndike FP, Ingersoll KS, Lord HR, Gonder-Frederick L, Frederick C; et al. (2016). "Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up: A Randomized Clinical Trial". JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.3249. PMID 27902836.
  7. 7.0 7.1 7.2 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C; et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial". JAMA. 301 (19): 2005–15. doi:10.1001/jama.2009.682. PMID 19454639.
  8. Robinson SB, Weitzel T, Henderson L (2005). "The Sh-h-h-h Project: nonpharmacological interventions". Holistic nursing practice. 19 (6): 263–6. PMID 16269944.
  9. Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ (2004). "Long-term meditators self-induce high-amplitude gamma synchrony during mental practice". Proc. Natl. Acad. Sci. U.S.A. 101 (46): 16369–73. doi:10.1073/pnas.0407401101. PMID 15534199.
  10. http://www.accesstoinsight.org/tipitaka/an/an11/an11.016.than.html