Nonpharmacologic treatment of chronic insomnia: An American Academy of Sleep Medicine Review

Université Laval, Ecole de Psychologie, Ste-Foy, Quebec, Canada.
Sleep (Impact Factor: 4.59). 12/1999; 22(8):1134-56.
Source: PubMed

ABSTRACT This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.

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    • "Reference lists of published meta-analyses and systematic reviews of CBT-I trials, including two reviews commissioned by the American Academy of Sleep Medicine [13] [14], were also searched to locate any additional relevant papers. "
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    ABSTRACT: Sleep restriction therapy is a core element of contemporary cognitive-behavioural therapy for insomnia and is also effective as a single-component therapeutic strategy. Since its original description, sleep restriction therapy has been applied in several different ways, potentially limiting understanding of key therapeutic ingredients, mode of action, evidence synthesis, and clinical implementation. We sought to examine the quality of reporting and variability in the application of sleep restriction therapy within the context of insomnia intervention trials. Systematic literature searches revealed 88 trials of cognitive-behavioural therapy/sleep restriction therapy that met pre-defined inclusion/exclusion criteria. All papers were coded in relation to their description of sleep restriction therapy procedures. Findings indicate that a large proportion of papers (39%) do not report any details regarding sleep restriction therapy parameters and, for those papers that do, variability in implementation is present at every level (sleep window generation, minimum time-in-bed, sleep efficiency titration criteria, and positioning of sleep window). Only 7% of papers reported all parameters of sleep restriction treatment. Poor reporting and variability in the application of sleep restriction therapy may hinder progress in relation to evidence synthesis, specification of mechanistic components, and refinement of therapeutic procedures for patient benefit. We set out guidelines for the reporting of sleep restriction therapy as well as a research agenda aimed at advancing understanding of sleep restriction therapy. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Sleep Medicine Reviews 02/2015; 23. DOI:10.1016/j.smrv.2015.02.003 · 8.51 Impact Factor
    • "However, this recommendation is typically presented with the caveat that one should avoid exercising near bedtime. This warning concerning the timing of exercise with respect to bedtime is endorsed by sleep medicine experts [2] [3] and lay media [4] [5]. It is speculated that exercise near bedtime could disrupt sleep by altering circadian phase [6], elevating core body temperature [7], or increasing physiological arousal [8]. "
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    Chest 01/2015; 147(3). DOI:10.1378/chest.14-1187 · 7.48 Impact Factor
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    • "Besides, study designs on this topic could not be randomised, which weakened the validity of these studies. Recently, growing evidence indicates favourable effects and less adverse events of non-pharmacological interventions (such as cognitive-behavioural therapy (CBT), acupuncture, exercise, bright light therapy, etc.) on primary insomnia [29], which are potential effective methods to improve the sleep quality in dialysis-dependent population as well. But the results of available clinical researches in dialysis-dependent population were inconsistent and were not summarised. "
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    ABSTRACT: We conducted a meta-analysis to summarise and quantify the effects of non-pharmacological interventions on sleep quality improvement in uraemic patients on dialysis. We defined the primary outcome as the change of sleep quality before and after interventions (evaluated by polysomonography or subjective questionnaires such as Pittsburgh sleep quality index, PSQI). The change of fatigue scales, inflammatory cytokines and adverse events were analysed as secondary outcomes. Twelve eligible randomised controlled trials and one prospective cohort study were identified. All three identified non-pharmacological interventions could result in a greater PSQI score reduction compared to controls: 1) cognitive-behavioural therapy (CBT) versus sleep hygiene education (standardised mean difference (SMD) 0.85, 95% CI 0.37-1.34); 2) physical training versus no training (SMD 3.36, 95% CI 2.16-4.57) and 3) Acupressure (including other acupoints massages) versus control (SMD 1.77, 95% CI 0.80-2.73). In terms of subscores, we found that CBT may shorten sleep latency, alleviate sleep disturbance and reduce the use of sleep medications. The finding of the cohort study suggested that intradialytic aerobic exercise training improved sleep quality in haemodialysis patients with restless leg syndrome. In conclusion, in dialysis-dependent patients, CBT could shorten sleep latency, alleviate sleep disturbance and reduce the use of sleep medications. Acupressure (including other acupoints massages) and exercise training are promising interventions but the results in these subgroups should be interpreted cautiously due to the concern of methodological quality and potential confounding factors.
    Sleep Medicine Reviews 12/2014; 23C:68-82. DOI:10.1016/j.smrv.2014.11.005 · 8.51 Impact Factor
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