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
Dr. Rana Mandeep
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.