Editing Insomnia (section)

=== Non-medication based ===

Non-medication-based strategies have comparable efficacy to [[hypnotic]] medication for insomnia, and they may have longer-lasting effects. Hypnotic medication is only recommended for short-term use because [[substance dependence|dependence]] with [[rebound withdrawal effects]] upon discontinuation or [[drug tolerance|tolerance]] can develop.<ref>{{cite journal | author = National Prescribing Service | date = 1 February 2010 | url = http://www.nps.org.au/publications/health-professional/nps-news/2010/nps-news-67 | title = Addressing hypnotic medicines use in primary care | archive-url = https://web.archive.org/web/20131101224851/http://www.nps.org.au/publications/health-professional/nps-news/2010/nps-news-67 |archive-date=1 November 2013 | journal = NPS News | volume = 67 }}</ref>

Non-medication-based strategies provide long-lasting improvements to insomnia and are recommended as a first-line and long-term strategy of management. Behavioral sleep medicine offers non-medication strategies to address chronic insomnia including [[sleep hygiene]], [[stimulus control]], behavioral interventions, [[Cognitive behavioral therapy for insomnia#Sleep restriction therapy|sleep-restriction therapy]], [[paradoxical intention]], patient education, and [[relaxation technique|relaxation therapy]].<ref>{{cite journal | vauthors = Kirkwood CK | title = Management of insomnia | journal = Journal of the American Pharmaceutical Association | volume = 39 | issue = 5 | pages = 688–96; quiz 713–14 | year = 1999 | pmid = 10533351 | doi = 10.1016/s1086-5802(15)30354-5 }}</ref> Some examples are keeping a journal, restricting the time spent awake in bed, practicing [[relaxation technique]]s, and maintaining a regular sleep schedule and a wake-up time. Behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. Behavioral therapy may include learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies, and regulating the circadian clock.<ref name="insomnia JAMA"/>

Music may improve insomnia in adults (see [[music and sleep]]).<ref>{{cite journal | vauthors = Jespersen KV, Pando-Naude V, Koenig J, Jennum P, Vuust P | title = Listening to music for insomnia in adults | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 8 | pages = CD010459 | date = August 2022 | pmid = 36000763 | pmc = 9400393 | doi = 10.1002/14651858.CD010459.pub3 }}</ref> [[EEG biofeedback]] has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as the quality of sleep.<ref>{{Cite book | vauthors = Lake JA |title=Textbook of Integrative Mental Health Care |url=https://books.google.com/books?id=Bt5euqMwbpYC&pg=PA313 |date= 2006 |publisher=Thieme Medical Publishers |isbn=978-1-58890-299-3 |page=313 }}</ref> Self-help therapy (defined as a psychological therapy that can be worked through on one's own) may improve sleep quality for adults with insomnia to a small or moderate degree.<ref>{{cite journal | vauthors = van Straten A, Cuijpers P | title = Self-help therapy for insomnia: a meta-analysis | journal = Sleep Medicine Reviews | volume = 13 | issue = 1 | pages = 61–71 | date = February 2009 | pmid = 18952469 | doi = 10.1016/j.smrv.2008.04.006 }}</ref>

Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed or sleep in general with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred to interchangeably with the concept of [[sleep hygiene]]. Examples of such environmental modifications include using the bed for sleep and sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not occur in a reasonably brief period after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during night-time hours, and eliminating daytime naps.<ref>{{cite journal | vauthors = Lande RG, Gragnani C | title = Nonpharmacologic approaches to the management of insomnia | journal = The Journal of the American Osteopathic Association | volume = 110 | issue = 12 | pages = 695–701 | date = December 2010 | pmid = 21178150 }}</ref>

A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with the actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation. Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when [[Polysomnography#Interpretation|sleep efficiency]] improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock. [[Bright light therapy]] may be effective for insomnia.<ref>{{cite journal |vauthors=van Maanen A, Meijer AM, van der Heijden KB, Oort FJ |title=The effects of light therapy on sleep problems: A systematic review and meta-analysis |journal=[[Sleep Medicine Reviews|Sleep Med Rev]] |volume=29 |pages=52–62 |date=October 2016 |pmid=26606319 |doi=10.1016/j.smrv.2015.08.009 |s2cid=3410636 |url=https://dare.uva.nl/personal/pure/en/publications/the-effects-of-light-therapy-on-sleep-problems(723b9aaa-7eed-4f5c-a69e-39056a2c95c4).html |access-date=2020-06-30 |archive-date=2021-08-28 |archive-url=https://web.archive.org/web/20210828125128/https://dare.uva.nl/search?identifier=723b9aaa-7eed-4f5c-a69e-39056a2c95c4 |url-status=live }}</ref>

Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e., essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).<ref>{{cite journal | vauthors = Kierlin L | s2cid = 22141056 | title = Sleeping without a pill: nonpharmacologic treatments for insomnia | journal = Journal of Psychiatric Practice | volume = 14 | issue = 6 | pages = 403–07 | date = November 2008 | pmid = 19057243 | doi = 10.1097/01.pra.0000341896.73926.6c }}</ref>

==== Sleep Hygiene ====

[[Sleep hygiene]] is a common term for all of the behaviors that relate to the promotion of good sleep. They include habits that provide a good foundation for sleep and help to prevent insomnia. However, sleep hygiene alone may not be adequate to address chronic insomnia. Sleep hygiene recommendations are typically included as one component of [[cognitive behavioral therapy for insomnia]] (CBT-I).<ref name="Schutte-Rodin" /><ref name="AC2016" /> Recommendations include reducing caffeine, nicotine, and alcohol consumption, maximizing the regularity and efficiency of sleep episodes, minimizing medication usage and daytime napping, the promotion of regular exercise, and the facilitation of a positive sleep environment.<ref name="Ellis_2002">{{cite journal | vauthors = Ellis J, Hampson SE, Cropley M |title=Sleep hygiene or compensatory sleep practices: An examination of behaviours affecting sleep in older adults |journal=Psychology, Health & Medicine |date=May 2002 |volume=7 |issue=2 |pages=156–161 |doi=10.1080/13548500120116094 |s2cid=143141307 }}</ref> The creation of a positive sleep environment may also help reduce the symptoms of insomnia.<ref name="Insomnia">{{cite web |url= https://www.lecturio.com/concepts/insomnia/ |title= Insomnia |website= The Lecturio Medical Concept Library |access-date= 2021-06-24 |archive-date= 2021-06-24 |archive-url= https://web.archive.org/web/20210624220727/https://www.lecturio.com/concepts/insomnia/ |url-status= live }}</ref>
On the other hand, a systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred.<ref name="Behavioral and psychological treatm"/>

==== Cognitive behavioral therapy ====

{{main|Cognitive behavioral therapy for insomnia}}
There is some evidence that cognitive behavioral therapy for insomnia (CBT-I) is superior in the long-term to [[benzodiazepine]]s and the [[nonbenzodiazepine]]s in the treatment and management of insomnia.<ref name="Mitchell-2012">{{cite journal | vauthors = Mitchell MD, Gehrman P, Perlis M, Umscheid CA | title = Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review | journal = BMC Family Practice | volume = 13 | pages = 40 | date = May 2012 | pmid = 22631616 | pmc = 3481424 | doi = 10.1186/1471-2296-13-40 | doi-access = free }}</ref> In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include:{{Cn|date=November 2024}}
* Unrealistic sleep expectations.
* Misconceptions about insomnia causes.
* Amplifying the consequences of insomnia.
* Performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process.

Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and relaxation therapies. [[Hypnotic]] medications are equally effective in the short-term treatment of insomnia, but their effects wear off over time due to [[drug tolerance|tolerance]]. The effects of [[CBT-I]] have sustained and lasting effects on treating insomnia long after therapy has been discontinued.<ref name="JacobsG2004Cognitive">{{cite journal | vauthors = Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW | title = Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison | journal = Archives of Internal Medicine | volume = 164 | issue = 17 | pages = 1888–96 | date = September 2004 | pmid = 15451764 | doi = 10.1001/archinte.164.17.1888 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Morin CM, Colecchi C, Stone J, Sood R, Brink D | title = Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial | journal = JAMA | volume = 281 | issue = 11 | pages = 991–99 | date = March 1999 | pmid = 10086433 | doi = 10.1001/jama.281.11.991 | doi-access = free }}</ref> The addition of hypnotic medications with CBT-I adds no benefit in insomnia. The long-lasting benefits of a course of CBT-I shows superiority over pharmacological hypnotic drugs. Even in the short term, when compared to short-term hypnotic medication such as zolpidem, CBT-I still shows significant superiority. Thus, CBT-I is recommended as a first-line treatment for insomnia.<ref>{{Cite journal | vauthors = Miller KE |title=Cognitive Behavior Therapy vs. Pharmacotherapy for Insomnia |journal=American Family Physician |volume=72 |issue=2 |pages=330 |year=2005 |url=http://www.aafp.org/afp/2005/0715/p330.html |archive-url=https://web.archive.org/web/20110606060237/http://www.aafp.org/afp/2005/0715/p330.html |archive-date=6 June 2011}}</ref>

Common forms of CBT-I treatments include stimulus control therapy, sleep restriction, sleep hygiene, improved sleeping environments, relaxation training, paradoxical intention, and biofeedback.<ref>{{cite journal | vauthors = Ramakrishnan K, Scheid DC | title = Treatment options for insomnia | language = en-US | journal = American Family Physician | volume = 76 | issue = 4 | pages = 517–526 | date = August 2007 | pmid = 17853625 | url = https://www.aafp.org/pubs/afp/issues/2007/0815/p517.html | access-date = 2022-07-15 | archive-date = 2022-07-27 | archive-url = https://web.archive.org/web/20220727045819/https://www.aafp.org/pubs/afp/issues/2007/0815/p517.html | url-status = live }}</ref>

CBT is the well-accepted form of therapy for insomnia since it has no known adverse effects, whereas taking medications to alleviate insomnia symptoms has been shown to have adverse side effects.<ref>{{cite journal | vauthors = Krystal AD | title = A compendium of placebo-controlled trials of the risks/benefits of pharmacological treatments for insomnia: the empirical basis for U.S. clinical practice | journal = Sleep Medicine Reviews | volume = 13 | issue = 4 | pages = 265–74 | date = August 2009 | pmid = 19153052 | doi = 10.1016/j.smrv.2008.08.001 }}</ref> Nevertheless, the downside of CBT is that it may take a lot of time and motivation.<ref>{{cite journal | vauthors = Matthews EE, Arnedt JT, McCarthy MS, Cuddihy LJ, Aloia MS | title = Adherence to cognitive behavioral therapy for insomnia: a systematic review | journal = Sleep Medicine Reviews | volume = 17 | issue = 6 | pages = 453–64 | date = December 2013 | pmid = 23602124 | pmc = 3720832 | doi = 10.1016/j.smrv.2013.01.001 }}</ref>

==== Acceptance and commitment therapy ====

Treatments based on the principles of [[acceptance and commitment therapy]] (ACT) and [[metacognition]] have emerged as alternative approaches to treating insomnia.<ref>{{cite journal | vauthors = Ong JC, Ulmer CS, Manber R | title = Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia | journal = Behaviour Research and Therapy | volume = 50 | issue = 11 | pages = 651–60 | date = November 2012 | pmid = 22975073 | pmc = 3466342 | doi = 10.1016/j.brat.2012.08.001 }}</ref> ACT rejects the idea that behavioral changes can help insomniacs achieve better sleep since they require "sleep efforts" - actions which create more "struggle" and arouse the nervous system, leading to [[hyperarousal]].<ref name="meadows">Meadows, G. (2015) The sleep book: How to sleep well every night. London, UK: Orion Publishing Group, p.2-7</ref> The ACT approach posits that acceptance of the negative feelings associated with insomnia can, in time, create the right conditions for sleep. [[Mindfulness]] practice is a key feature of this approach, although mindfulness is not practiced to induce sleep (this in itself is a ''sleep effort'' to be avoided) but rather as a longer-term activity to help calm the nervous system and create the internal conditions from which sleep can emerge.

A key distinction between CBT-I and ACT lies in the divergent approaches to time spent awake in bed. Proponents of CBT-i advocate minimizing time spent awake in bed, on the basis that this creates a cognitive association between being in bed and wakefulness. The ACT approach proposes that avoiding time in bed may increase the pressure to sleep and arouse the nervous system further.<ref name=meadows/>

Research has shown that "ACT has a significant effect on primary and comorbid insomnia and sleep quality, and ... can be used as an appropriate treatment method to control and improve insomnia".<ref name="Salari_2020">{{cite journal | vauthors = Salari N, Khazaie H, Hosseinian-Far A, Khaledi-Paveh B, Ghasemi H, Mohammadi M, Shohaimi S | title = The effect of acceptance and commitment therapy on insomnia and sleep quality: A systematic review | journal = BMC Neurology | volume = 20 | issue = 1 | pages = 300 | date = August 2020 | pmid = 32791960 | pmc = 7425538 | doi = 10.1186/s12883-020-01883-1 | doi-access = free }}</ref>

==== Internet Interventions ====

Despite the therapeutic effectiveness and proven success of CBT, treatment availability is significantly limited by a lack of trained clinicians, poor geographical distribution of knowledgeable professionals, and expense.<ref>{{cite journal | vauthors = Edinger JD, Means MK | title = Cognitive-behavioral therapy for primary insomnia | journal = Clinical Psychology Review | volume = 25 | issue = 5 | pages = 539–58 | date = July 2005 | pmid = 15951083 | doi = 10.1016/j.cpr.2005.04.003 }}</ref> One way to potentially overcome these barriers is to use the Internet to deliver treatment, making this effective intervention more accessible and less costly. The Internet has already become a critical source of health-care and medical information.<ref name="pewinternet.org">{{cite web | vauthors = Fox S, Fallows D | date = 5 October 2005 | title = Digital Divisions | url = http://www.pewinternet.org/PPF/r/165/report_display.asp | work = Internet health resources | location = Washington, DC | publisher = Pew Internet & American Life Project | archive-url = https://web.archive.org/web/20051021001805/http://www.pewinternet.org/PPF/r/165/report_display.asp | archive-date = 21 October 2005 }}</ref> Although the vast majority of health websites provide general information,<ref name="pewinternet.org"/><ref>{{cite journal | vauthors = Rabasca L |title=Taking telehealth to the next step |url=http://www.apa.org/monitor/apr00/telehealth.aspx |journal=Monitor on Psychology |year=2000 |volume=31 |pages=36–37 |doi=10.1037/e378852004-017 |url-status=live |archive-url=https://web.archive.org/web/20121230005926/http://www.apa.org/monitor/apr00/telehealth.aspx |archive-date=30 December 2012 }}</ref> there is growing research literature on the development and evaluation of Internet interventions.<ref>{{cite book | vauthors = Marks IM, Cavanagh K, Gega L | date = 2007 | title = Hands-on Help: Computer-Aided Psychotherapy | location = Hove, England and New York | publisher = Psychology Press | isbn = 978-1-84169-679-9 }}</ref><ref name=ritter>{{Cite journal | vauthors = Ritterband LM, Gonder-Frederick LA, Cox DJ, Clifton AD, West RW, Borowitz SM |s2cid=161666 |doi=10.1037/0735-7028.34.5.527 |title=Internet interventions: In review, in use, and into the future |journal=Professional Psychology: Research and Practice |volume=34 |issue=5 |pages=527–34 |year=2003 }}</ref>

These online programs are typically behaviorally based treatments that have been operationalized and transformed for delivery via the Internet. They are usually highly structured; automated or human supported; based on effective face-to-face treatment; personalized to the user; interactive; enhanced by graphics, animations, audio, and possibly video; and tailored to provide follow-up and feedback.<ref name=ritter/>

There is good evidence for the use of computer-based CBT for insomnia.<ref>{{cite journal | vauthors = Cheng SK, Dizon J | s2cid = 10527276 | title = Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis | journal = Psychotherapy and Psychosomatics | volume = 81 | issue = 4 | pages = 206–16 | date = 2012 | pmid = 22585048 | doi = 10.1159/000335379 }}</ref>