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“The greatest medicine of all is teaching people how not to need it.” – Hippocrates
For many years, over-the-counter and prescription medications indicated for sleep problems/disorders have been available to patients. But the side effects associated with some of these medications are many. In light of the numerous nonpharmacologic interventions that are available to patients, they should be offered first when appropriate.
One of the top nonpharmacologic interventions is cognitive-behavioral therapy for insomnia, or CBT-I, which the American Academy of Sleep Medicine’s clinical guidelines say should be used as initial treatment if possible.1 Elements of CBT-I include cognitive therapy, which is aimed at reducing dysfunctional beliefs about sleep. Common distortions expressed by patients include: “I cannot sleep without medications” and “I must get 8 hours of sleep to feel refreshed and function well the next day.” It helps in dealing with anxiety and catastrophic thinking to establish realistic expectations and treatment related to insomnia.
CBT-I can be delivered in the form of monotherapy or in a combined manner. The individual components include psychoeducation, behavioral strategies, cognitive therapy, and relaxation training. CBT-I combines cognitive therapy with behavioral interventions. Behavioral elements include stimulus control therapy and sleep restriction therapy. Relaxation therapy might or might not be included. Sleep hygiene education usually is a part of it.2
Two other kinds of CBT that can be effective options are telephone-based CBT-I and Internet-based CBT-I.3,4 Meanwhile, among the disadvantages of CBT for insomnia are longer duration of therapy and lack of skilled clinicians.5
Many other kinds of behavioral interventions are available to patients with problems related to sleep, including stimulus control therapy, relaxation therapy, exercise therapy, and sleep restriction therapy.
Stimulus control therapy
This is a strategy aimed at strengthening the association of bed and bedroom to sleep, establishing a consistent sleep-wake rhythm, and reducing the activities that might interfere with sleep. This behavioral therapy is based on the idea that arousal occurs as a conditioned response to the stimulus of sleep environment, and it is among the most effective behavioral treatments.6,7 Strategies include the following:
1. Lie down with the intention of sleeping when sleepy.
2. Do not watch television, read, eat or worry while in bed. Use bed only for sleep and sex.
3. Get out of bed if unable to fall asleep within 10-15 minutes and go to another room. Return to bed only when sleepy. Do not watch the clock. Repeat this step as many times as necessary throughout the night.
4. Set an alarm clock to wake up at a fixed time each morning, including weekends, regardless of how much sleep you got during the night.
5. Do not take a nap during the day.
The goal of these strategies is to extinguish negative associations between bed and undesirable outcomes, such as wakefulness and frustration. One study showed that stimulus control participants, unlike control group participants, experienced significant improvement at follow-up for total sleep time, sleep efficiency, and sleep quality.8
Relaxation therapy
This encompasses different techniques that produce a relaxation response and reduce somatic arousal. It can be implemented before each sleep period. Progressive muscle relaxation, autogenic training, and biofeedback help reduce somatic arousal. Attention-focused procedures, such as imagery training and meditation, tend to lower presleep cognitive arousal (for example, intrusive thoughts, racing minds).9 Slow paced breathing prior to onset of sleep enhances vagal activity, which results in improved sleep parameters.10 One study showed improved quality of sleep and cognitive functions in the elderly by self-relaxation training.11
Exercise training
Participating in physical exercise can be useful in the treatment of insomnia.12 One randomized, controlled trial found that exercising regularly for at least 150 minutes per week was optimal.13 Another study found that, among overweight and obese men with insomnia, aerobic exercise over a 6-month period reduced difficulty in initiating and improving sleep.14
Sleep restriction therapy
The goal of this therapy is to increase the homeostatic drive to sleep. This is carried out by limiting the amount of time spent in bed to the same amount of time that the person reports sleeping. Naps are not allowed. Patients improve with increased drive to sleep in successive nights. In patients with bipolar disorder, however, sleep restriction should be used with caution as it can trigger manic episodes.15
Always ask about sleep
Clinicians should always ask patients about sleep during visits. Sleep duration and sleep quality should be assessed. Insomnia, which is an independent condition, may or may not coexist with other conditions. It is important to determine whether another sleep disorder, or a physical (such as pain, heart, or lung disease), neurological (such as Parkinson’s disease or cerebrovascular disease), or psychiatric disorder (such as depressive illness, anxiety disorder, or substance misuse) is the primary diagnosis. Treatment of insomnia can improve comorbidities.16
In addition, it is important to teach patients about basic sleep hygiene, which includes abiding by a consistent bedtime, and avoiding coffee, alcohol, and nicotine. Eliminating a bedroom clock, not exercising in the late afternoon/early evening, and consuming light bedtime snacks are other measures that can be taken. Avoiding the prolonged use of light-emitting screens before bedtime is another positive step.17
In conclusion, cognitive and behavioral methods are just as effective as prescription medications for short-term treatment of chronic insomnia and should be considered as first line before considering medications. The beneficial effects of CBT-I, in contrast to those produced by medication, might last well beyond the termination of active treatment.
References
1. J Clin Sleep Med. 2008 Oct 15;4(5):487-504.
2. J Clin Psychol. 2010;66(11):1148-60.
3. Sleep. 2013 Mar 1;36(3):353-62.
4. Sleep Med Rev. 2016 Dec;30:1-10.
5. BMC Family Prac. 2012;13:40.
6. Sleep. 2006 Nov;29(11):1398-414.
7. Behavioral Treatments for Sleep Disorders. 1991. doi: 10.1016/13978-0-12-381522-4.00002-X.
8. Behav Modif 1998 Jan;22(1):3-28.
9. Am Fam Physician. 1999 Jun;59(11):3029-38.
10. Psychophysiology. 2015 Mar;52(3):388-96.
11. J Clin Nursing. 2013 April 10. doi: 10.1111/jocn.12096.
12. J Physiother. 2012;58(3):157-63.
13. J Sleep Res. 2015 Oct;24(5):526-34.
14 Sleep Med. 2016 Sep;25:113-121.
15. Am J Psychiatry. 2013 Jul;170(7):716-20.
16. JAMA Intern Med. 2015 Sep;175(9):1461-72.
17. Proc Natl Acad Sci USA. 2015;112(4):1232-7.
Dr. Lamba is a psychiatrist and medical director at Bayridge Hospital in Lynn, Mass. Dr. Rana is assistant professor of pediatrics at Boston University.
“The greatest medicine of all is teaching people how not to need it.” – Hippocrates
For many years, over-the-counter and prescription medications indicated for sleep problems/disorders have been available to patients. But the side effects associated with some of these medications are many. In light of the numerous nonpharmacologic interventions that are available to patients, they should be offered first when appropriate.
One of the top nonpharmacologic interventions is cognitive-behavioral therapy for insomnia, or CBT-I, which the American Academy of Sleep Medicine’s clinical guidelines say should be used as initial treatment if possible.1 Elements of CBT-I include cognitive therapy, which is aimed at reducing dysfunctional beliefs about sleep. Common distortions expressed by patients include: “I cannot sleep without medications” and “I must get 8 hours of sleep to feel refreshed and function well the next day.” It helps in dealing with anxiety and catastrophic thinking to establish realistic expectations and treatment related to insomnia.
CBT-I can be delivered in the form of monotherapy or in a combined manner. The individual components include psychoeducation, behavioral strategies, cognitive therapy, and relaxation training. CBT-I combines cognitive therapy with behavioral interventions. Behavioral elements include stimulus control therapy and sleep restriction therapy. Relaxation therapy might or might not be included. Sleep hygiene education usually is a part of it.2
Two other kinds of CBT that can be effective options are telephone-based CBT-I and Internet-based CBT-I.3,4 Meanwhile, among the disadvantages of CBT for insomnia are longer duration of therapy and lack of skilled clinicians.5
Many other kinds of behavioral interventions are available to patients with problems related to sleep, including stimulus control therapy, relaxation therapy, exercise therapy, and sleep restriction therapy.
Stimulus control therapy
This is a strategy aimed at strengthening the association of bed and bedroom to sleep, establishing a consistent sleep-wake rhythm, and reducing the activities that might interfere with sleep. This behavioral therapy is based on the idea that arousal occurs as a conditioned response to the stimulus of sleep environment, and it is among the most effective behavioral treatments.6,7 Strategies include the following:
1. Lie down with the intention of sleeping when sleepy.
2. Do not watch television, read, eat or worry while in bed. Use bed only for sleep and sex.
3. Get out of bed if unable to fall asleep within 10-15 minutes and go to another room. Return to bed only when sleepy. Do not watch the clock. Repeat this step as many times as necessary throughout the night.
4. Set an alarm clock to wake up at a fixed time each morning, including weekends, regardless of how much sleep you got during the night.
5. Do not take a nap during the day.
The goal of these strategies is to extinguish negative associations between bed and undesirable outcomes, such as wakefulness and frustration. One study showed that stimulus control participants, unlike control group participants, experienced significant improvement at follow-up for total sleep time, sleep efficiency, and sleep quality.8
Relaxation therapy
This encompasses different techniques that produce a relaxation response and reduce somatic arousal. It can be implemented before each sleep period. Progressive muscle relaxation, autogenic training, and biofeedback help reduce somatic arousal. Attention-focused procedures, such as imagery training and meditation, tend to lower presleep cognitive arousal (for example, intrusive thoughts, racing minds).9 Slow paced breathing prior to onset of sleep enhances vagal activity, which results in improved sleep parameters.10 One study showed improved quality of sleep and cognitive functions in the elderly by self-relaxation training.11
Exercise training
Participating in physical exercise can be useful in the treatment of insomnia.12 One randomized, controlled trial found that exercising regularly for at least 150 minutes per week was optimal.13 Another study found that, among overweight and obese men with insomnia, aerobic exercise over a 6-month period reduced difficulty in initiating and improving sleep.14
Sleep restriction therapy
The goal of this therapy is to increase the homeostatic drive to sleep. This is carried out by limiting the amount of time spent in bed to the same amount of time that the person reports sleeping. Naps are not allowed. Patients improve with increased drive to sleep in successive nights. In patients with bipolar disorder, however, sleep restriction should be used with caution as it can trigger manic episodes.15
Always ask about sleep
Clinicians should always ask patients about sleep during visits. Sleep duration and sleep quality should be assessed. Insomnia, which is an independent condition, may or may not coexist with other conditions. It is important to determine whether another sleep disorder, or a physical (such as pain, heart, or lung disease), neurological (such as Parkinson’s disease or cerebrovascular disease), or psychiatric disorder (such as depressive illness, anxiety disorder, or substance misuse) is the primary diagnosis. Treatment of insomnia can improve comorbidities.16
In addition, it is important to teach patients about basic sleep hygiene, which includes abiding by a consistent bedtime, and avoiding coffee, alcohol, and nicotine. Eliminating a bedroom clock, not exercising in the late afternoon/early evening, and consuming light bedtime snacks are other measures that can be taken. Avoiding the prolonged use of light-emitting screens before bedtime is another positive step.17
In conclusion, cognitive and behavioral methods are just as effective as prescription medications for short-term treatment of chronic insomnia and should be considered as first line before considering medications. The beneficial effects of CBT-I, in contrast to those produced by medication, might last well beyond the termination of active treatment.
References
1. J Clin Sleep Med. 2008 Oct 15;4(5):487-504.
2. J Clin Psychol. 2010;66(11):1148-60.
3. Sleep. 2013 Mar 1;36(3):353-62.
4. Sleep Med Rev. 2016 Dec;30:1-10.
5. BMC Family Prac. 2012;13:40.
6. Sleep. 2006 Nov;29(11):1398-414.
7. Behavioral Treatments for Sleep Disorders. 1991. doi: 10.1016/13978-0-12-381522-4.00002-X.
8. Behav Modif 1998 Jan;22(1):3-28.
9. Am Fam Physician. 1999 Jun;59(11):3029-38.
10. Psychophysiology. 2015 Mar;52(3):388-96.
11. J Clin Nursing. 2013 April 10. doi: 10.1111/jocn.12096.
12. J Physiother. 2012;58(3):157-63.
13. J Sleep Res. 2015 Oct;24(5):526-34.
14 Sleep Med. 2016 Sep;25:113-121.
15. Am J Psychiatry. 2013 Jul;170(7):716-20.
16. JAMA Intern Med. 2015 Sep;175(9):1461-72.
17. Proc Natl Acad Sci USA. 2015;112(4):1232-7.
Dr. Lamba is a psychiatrist and medical director at Bayridge Hospital in Lynn, Mass. Dr. Rana is assistant professor of pediatrics at Boston University.
“The greatest medicine of all is teaching people how not to need it.” – Hippocrates
For many years, over-the-counter and prescription medications indicated for sleep problems/disorders have been available to patients. But the side effects associated with some of these medications are many. In light of the numerous nonpharmacologic interventions that are available to patients, they should be offered first when appropriate.
One of the top nonpharmacologic interventions is cognitive-behavioral therapy for insomnia, or CBT-I, which the American Academy of Sleep Medicine’s clinical guidelines say should be used as initial treatment if possible.1 Elements of CBT-I include cognitive therapy, which is aimed at reducing dysfunctional beliefs about sleep. Common distortions expressed by patients include: “I cannot sleep without medications” and “I must get 8 hours of sleep to feel refreshed and function well the next day.” It helps in dealing with anxiety and catastrophic thinking to establish realistic expectations and treatment related to insomnia.
CBT-I can be delivered in the form of monotherapy or in a combined manner. The individual components include psychoeducation, behavioral strategies, cognitive therapy, and relaxation training. CBT-I combines cognitive therapy with behavioral interventions. Behavioral elements include stimulus control therapy and sleep restriction therapy. Relaxation therapy might or might not be included. Sleep hygiene education usually is a part of it.2
Two other kinds of CBT that can be effective options are telephone-based CBT-I and Internet-based CBT-I.3,4 Meanwhile, among the disadvantages of CBT for insomnia are longer duration of therapy and lack of skilled clinicians.5
Many other kinds of behavioral interventions are available to patients with problems related to sleep, including stimulus control therapy, relaxation therapy, exercise therapy, and sleep restriction therapy.
Stimulus control therapy
This is a strategy aimed at strengthening the association of bed and bedroom to sleep, establishing a consistent sleep-wake rhythm, and reducing the activities that might interfere with sleep. This behavioral therapy is based on the idea that arousal occurs as a conditioned response to the stimulus of sleep environment, and it is among the most effective behavioral treatments.6,7 Strategies include the following:
1. Lie down with the intention of sleeping when sleepy.
2. Do not watch television, read, eat or worry while in bed. Use bed only for sleep and sex.
3. Get out of bed if unable to fall asleep within 10-15 minutes and go to another room. Return to bed only when sleepy. Do not watch the clock. Repeat this step as many times as necessary throughout the night.
4. Set an alarm clock to wake up at a fixed time each morning, including weekends, regardless of how much sleep you got during the night.
5. Do not take a nap during the day.
The goal of these strategies is to extinguish negative associations between bed and undesirable outcomes, such as wakefulness and frustration. One study showed that stimulus control participants, unlike control group participants, experienced significant improvement at follow-up for total sleep time, sleep efficiency, and sleep quality.8
Relaxation therapy
This encompasses different techniques that produce a relaxation response and reduce somatic arousal. It can be implemented before each sleep period. Progressive muscle relaxation, autogenic training, and biofeedback help reduce somatic arousal. Attention-focused procedures, such as imagery training and meditation, tend to lower presleep cognitive arousal (for example, intrusive thoughts, racing minds).9 Slow paced breathing prior to onset of sleep enhances vagal activity, which results in improved sleep parameters.10 One study showed improved quality of sleep and cognitive functions in the elderly by self-relaxation training.11
Exercise training
Participating in physical exercise can be useful in the treatment of insomnia.12 One randomized, controlled trial found that exercising regularly for at least 150 minutes per week was optimal.13 Another study found that, among overweight and obese men with insomnia, aerobic exercise over a 6-month period reduced difficulty in initiating and improving sleep.14
Sleep restriction therapy
The goal of this therapy is to increase the homeostatic drive to sleep. This is carried out by limiting the amount of time spent in bed to the same amount of time that the person reports sleeping. Naps are not allowed. Patients improve with increased drive to sleep in successive nights. In patients with bipolar disorder, however, sleep restriction should be used with caution as it can trigger manic episodes.15
Always ask about sleep
Clinicians should always ask patients about sleep during visits. Sleep duration and sleep quality should be assessed. Insomnia, which is an independent condition, may or may not coexist with other conditions. It is important to determine whether another sleep disorder, or a physical (such as pain, heart, or lung disease), neurological (such as Parkinson’s disease or cerebrovascular disease), or psychiatric disorder (such as depressive illness, anxiety disorder, or substance misuse) is the primary diagnosis. Treatment of insomnia can improve comorbidities.16
In addition, it is important to teach patients about basic sleep hygiene, which includes abiding by a consistent bedtime, and avoiding coffee, alcohol, and nicotine. Eliminating a bedroom clock, not exercising in the late afternoon/early evening, and consuming light bedtime snacks are other measures that can be taken. Avoiding the prolonged use of light-emitting screens before bedtime is another positive step.17
In conclusion, cognitive and behavioral methods are just as effective as prescription medications for short-term treatment of chronic insomnia and should be considered as first line before considering medications. The beneficial effects of CBT-I, in contrast to those produced by medication, might last well beyond the termination of active treatment.
References
1. J Clin Sleep Med. 2008 Oct 15;4(5):487-504.
2. J Clin Psychol. 2010;66(11):1148-60.
3. Sleep. 2013 Mar 1;36(3):353-62.
4. Sleep Med Rev. 2016 Dec;30:1-10.
5. BMC Family Prac. 2012;13:40.
6. Sleep. 2006 Nov;29(11):1398-414.
7. Behavioral Treatments for Sleep Disorders. 1991. doi: 10.1016/13978-0-12-381522-4.00002-X.
8. Behav Modif 1998 Jan;22(1):3-28.
9. Am Fam Physician. 1999 Jun;59(11):3029-38.
10. Psychophysiology. 2015 Mar;52(3):388-96.
11. J Clin Nursing. 2013 April 10. doi: 10.1111/jocn.12096.
12. J Physiother. 2012;58(3):157-63.
13. J Sleep Res. 2015 Oct;24(5):526-34.
14 Sleep Med. 2016 Sep;25:113-121.
15. Am J Psychiatry. 2013 Jul;170(7):716-20.
16. JAMA Intern Med. 2015 Sep;175(9):1461-72.
17. Proc Natl Acad Sci USA. 2015;112(4):1232-7.
Dr. Lamba is a psychiatrist and medical director at Bayridge Hospital in Lynn, Mass. Dr. Rana is assistant professor of pediatrics at Boston University.