Insomnia non-pharmacological therapy

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## Overview

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Clinical practice guideline by the American Academy of Sleep Medicine (AASM) noted about non-pharmacological 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]

## Behavioral Therapy

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According to clinical practice guidelines by the American Academy of Sleep Medicine:[1]

* "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."
* “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).”

Randomized controlled trial of treatment options for insomnia.[2] 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.[2]

More recently, 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).[2]

#### Implementing behavior therapy

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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

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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.[5] 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%)

Cognitive-behavioral therapy delivered online may help according to randomized controlled trials.[6][7]

### Sleep Restriction Therapy

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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"[8].

### Complimentary and Alternative Therapies

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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. [9]

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[10]. 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[11], 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.

## Hospitalized patents

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Randomized controlled trials suggest that eye masks and earplugs may improve the quality of sleep[12][13].

An earlier systematic review that included three trials published through 2017 found possible benefit from masks earplugs[14].

Reducing nighttime interruptions may help[15].

## References

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1. ↑ 1.0 1.1 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.CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
2. ↑ 2.0 2.1 2.2 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ 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.CS1 maint: Multiple names: authors list (link)
4. ↑ 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)
5. ↑ Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D (2015). "Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis". Ann Intern Med. 163 (3): 191–204. doi:10.7326/M14-2841. PMID 26054060.CS1 maint: Multiple names: authors list (link)  Review in: Evid Based Ment Health. 2016 Feb;19(1):e2
6. ↑ 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
8. ↑ 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
9. ↑ Robinson SB, Weitzel T, Henderson L (2005). "The Sh-h-h-h Project: nonpharmacological interventions". Holistic nursing practice. 19 (6): 263–6. PMID 16269944.CS1 maint: Multiple names: authors list (link)
10. ↑ 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.CS1 maint: Multiple names: authors list (link)
11. ↑ http://www.accesstoinsight.org/tipitaka/an/an11/an11.016.than.html
12. ↑ Sweity S, Finlay A, Lees C, Monk A, Sherpa T, Wade D (2019). "SleepSure: a pilot randomized-controlled trial to assess the effects of eye masks and earplugs on the quality of sleep for patients in hospital". Clin Rehabil. 33 (2): 253–261. doi:10.1177/0269215518806041. PMID 30322272.CS1 maint: Multiple names: authors list (link)
13. ↑ Obanor OO, McBroom MM, Elia JM, Ahmed F, Sasaki JD, Murphy KM; et al. (2021). "The Impact of Earplugs and Eye Masks on Sleep Quality in Surgical ICU Patients at Risk for Frequent Awakenings". Crit Care Med. 49 (9): e822–e832. doi:10.1097/CCM.0000000000005031. PMID 33870919 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
14. ↑ Miller MA, Renn BN, Chu F, Torrence N (2019). "Sleepless in the hospital: A systematic review of non-pharmacological sleep interventions". Gen Hosp Psychiatry. 59: 58–66. doi:10.1016/j.genhosppsych.2019.05.006. PMC 6620136 Check `|pmc=` value (help). PMID 31170567.CS1 maint: Multiple names: authors list (link)
15. ↑ Arora VM, Machado N, Anderson SL, Desai N, Marsack W, Blossomgame S; et al. (2019). "Effectiveness of SIESTA on Objective and Subjective Metrics of Nighttime Hospital Sleep Disruptors". J Hosp Med. 14 (1): 38–41. doi:10.12788/jhm.3091. PMID 30667409.CS1 maint: Multiple names: authors list (link)