From the Guidelines
Healthcare providers should prioritize cognitive behavioral therapy for insomnia (CBT-I) as the first-line non-pharmacological approach for managing insomnia in patients with impaired sleep, due to its strong evidence base and effectiveness in improving sleep quality. According to the American Academy of Sleep Medicine clinical practice guideline 1, CBT-I is a multicomponent intervention that includes sleep restriction therapy, stimulus control, and cognitive therapy, and is considered the treatment of choice for chronic insomnia disorder.
Key Components of CBT-I
- Sleep restriction therapy: limiting time in bed to match actual sleep time
- Stimulus control: using the bed only for sleep and sex, leaving the bedroom when unable to sleep
- Cognitive therapy: challenging unhelpful beliefs about sleep Other non-pharmacological approaches, such as behavioral therapy (BTIs), sleep restriction therapy, stimulus control, and relaxation therapy, may also be useful interventions with minimal undesirable effects, but CBT-I is the most widely evaluated and effective treatment 1.
Implementation and Considerations
- Providers should discuss different CBT-I delivery modalities with their patients, including in-person individual treatment, group treatment, and internet-based programs, and align the delivery modality based on availability, affordability, treatment format, duration, and the patient’s preferences and values 1.
- Clinicians should be aware of the potential challenges patients may face when undergoing CBT-I, including the ability to attend sessions and adhere to treatment recommendations, and help set realistic expectations before starting treatment 1.
- Patients should be reminded that psychological and behavioral insomnia therapies typically produce gradual improvements in insomnia symptoms, but the benefits are durable beyond the end of treatment 1.
Additional Recommendations
- Providers should recommend consistent sleep-wake schedules, even on weekends, and encourage patients to create a sleep-conducive environment that is dark, quiet, and cool 1.
- Physical activity during the day (but not within 3-4 hours of bedtime) can promote better sleep quality, and patients should avoid caffeine after midday, limit alcohol consumption, and refrain from using electronic devices with blue light at least one hour before bedtime.
From the Research
Non-Pharmacological Approaches for Insomnia Management
- Cognitive-behavioral therapy for insomnia (CBT-I) is considered the standard of care and the most effective non-pharmacological treatment for chronic insomnia 2, 3, 4.
- CBT-I is a multimodal intervention that combines behavioral and cognitive therapy strategies, and psychoeducation to modify maladaptive cognitions, behaviors, and arousal perpetuating insomnia 2.
- Other non-pharmacological approaches that are recommended include:
- Sleep hygiene education may be a necessary but insufficient condition for promoting good sleep and should be considered an adjunct to another empirically supported treatment 2.
- The five key components of CBT-I are:
- Sleep consolidation
- Stimulus control
- Cognitive restructuring
- Sleep hygiene
- Relaxation techniques 3.
Effectiveness of Non-Pharmacological Approaches
- CBT-I produces results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment 3.
- Non-pharmacological approaches can be effectively managed in primary care settings, and primary care physicians may use these approaches as first-line treatment 5.
- CBT-I can affect remission, sleep onset latency, wakefulness after sleep, sleep efficiency, and sleep quality in adults with insomnia, including older adults and adolescents 4.