Cognitive behavioral therapy (CBT) interventions -- particularly stimulus control and sleep hygiene -- are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of
 recommendation: A, based on systematic reviews). The long-term efficacy of CBT interventions, and their successful implementation by primary care physician (as compared with behavioral science providers), is unclear

Crownover, Brian K.

Nichols, William

Whitworth, James D.

University of Missouri: MOspace

836 VOL 56, NO 10 / OCTOBER 2007  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIES From the Family Physicians Inquiries NetworkCopy for evidence-based answerEvidence-based answerClinical commentary  Which nondrug alternatives can help with insomnia?gnitive behavioral th rapy (CBT) interventions—particularly stimulus control and sleep hygiene—are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of recommendation: A, based on systematic reviews). The long-term effi cacy of CBT interventions, and their successful implementation by primary care physicians (as compared with behavioral science providers), is unclear.Can I provide these interventionswithout a referral?A large proportion of people in my patient population are shift workers, so chronic insomnia plays a large role in my daily workload, both directly and indirectly. This summary tells me that I have a proven and equally effi cacious alternative to drugs for these sufferers—which is great.  However, I was disappointed to see that none of the CBT interventions were performed by family physicians in the offi ce. So the good news is that I have a nondrug intervention for insomnia; the bad news is I don’t know if it’s something I can provide without a referral. Maybe it’s time for some practice-based research to see if that is possible. John D. Hallgren, Lt Col, USAF, MCUniformed Services University of the Health Sciences, RAF Menwith Hill, UK❚ Evidence summaryApproximately 10% to 15% of adults complain of chronic insomnia, best defi ned as diffi culty initiating or main-taining sleep 3 or more nights per week for 6 months or longer, with second-ary impairments in daytime function-ing, including fatigue and disturbed mood.1–3 Behavioral and psychological treatments have emerged as increas-ingly popular adjunctive interventions to pharmacotherapy and as indepen-dent interventions for chronic insom-nia. No evidence exists that behavioral treatments have adverse effects.1 Sleep hygiene, relaxation training, and cognitive therapy improve sleepCBT interventions are based on the notion  that distorted thoughts about sleep and learned behavior patterns hyperarouse the central nervous system and deregulate sleep cycles, resulting in chronic insomnia.4 CBT interventions combine empirically tested behavioral, cognitive, and educational procedures to alter faulty beliefs and attitudes, modify sleep habits, and regulate sleep-wake schedules.3 These interventions include stimu-lus control, sleep hygiene, sleep restric-tion, relaxation training, and cognitive Clinical commentaryJames D. Whitworth, PhD and Brian K. Crownover, MD, FAAFP HQ Air Armament Center Family Medicine Residency, Eglin Air Force Base, FlaWilliam Nichols, MLSEglin Air Force Base, 96th Medical Group, Eglin Air Force Base, FlaFAST TRACKStimulus control and sleep hygiene are effective treatments for insomnia836_r1_JFP1007   836 9/21/07   10:17:38 AMFAST TRACKwww.jfponline.com  VOL 56, NO 10 / OCTOBER 2007 837Patient needs a good night’s sleep? Offer this adviceSTIMULUS CONTROL INSTRUCTIONS3• Don’t go to bed until you are sleepy•  Use the bed/bedroom only for sleeping (don’t read, watch TV, eat, or worry)•  Get out of bed when unable to sleep after 15 minutes; do something relaxing and avoid stimulating activity/thoughts• Arise from bed at the same time every day• Do not nap during the daySLEEP HYGIENE INSTRUCTIONS4•  Sleep only as much as you need to feel refreshed during the following day• Exercise regularly•  Make sure your bedroom is comfortable and free from disturbing light and noise•  Make sure your bedroom is at a comfortable temperature during the night• Eat regular meals and do not go to bed hungry • Avoid drinking too many fl uids in the evening• Reduce your caffeine intake •  Avoid drinking alcohol—especially in the evening •  Avoid smoking at night when you are having trouble sleeping• Don’t try too hard to fall asleep•  Put the clock under the bed or turn it so you can’t see itTABLECognitive behavioral therapy reduced sleep onset latency by an additional 8.8 minutes over medication, according to one meta-analysistherapy.5 These methods can be used separately; however, they are increas-ingly being used together to treat the complexities of individual patients.5 Five recent high-quality randomized control trials (RCTs) confi rmed fi ndings from earlier RCTs that CBT methods improve sleep.5 Compared with those given a placebo or placed on a waiting list, CBT-treated patients in these RCTs reported clinically signifi cant improve-ments in sleep onset latency, sleep effi -ciency, time awake after sleep onset, and total sleep time. In one RCT, 64% of CBT patients had improvements in sleep effi -ciency and time awake after sleep onset, compared with 8% who improved with a placebo intervention (number needed to treat [NNT]=1.8).5 Further, sleep on-set latency for primary care patients with chronic insomnia was decreased from 61 to 28 minutes, compared with 74 to 70 minutes for a waiting-list group.5 The maintenance of sleep gains from CBT beyond 1 year is unknown since no pub-lished RCT clinical trials to date have lasted longer than 12 months.1 An important related meta-analysis of 21 studies validated behavior therapy, and revealed CBT reduced sleep onset latency by an additional 8.8 minutes over medication (95% confi dence interval, 0.17–1.04 minutes).6 Although not supe-rior on other outcomes, behavior therapy produced similar short-term results to pharmacotherapy across all other sleep measures, without attendant medication side effects. Stimulus control is the most effective CBT interventionA recent systematic review with meta-analysis of 37 clinical investigations determined that stimulus control was the most effective CBT intervention.3 Stimulus control consists of 5 basic in-structions (TABLE) designed to help the patient reassociate sleep stimuli (ie, bed/bedroom) with falling asleep and estab-lishing consistent sleep-wake schedules. These 5 instructions are frequently used in combination with CBT sleep hygiene techniques (TABLE) and can be easily integrated into the offi ce setting.3,4 Among the CBT techniques, stimu-lus control and sleep hygiene are the least time-consuming and may be more easily applied in the primary care setting; however, minimal research has been done into the specifi c incorporation of CBT into primary care settings. Researchers conducting a single-blind randomized group study in a Veter-ans Affairs primary care clinic concluded that an abbreviated CBT approach with two 25-minute sessions effectively im-proved participant sleep onset laten-cy, and time awake after sleep onset.7 Researchers reviewed participants’ sleep C O N T I N U E D  O N  PA G E  8 4 0837_r1_JFP1007   837 9/21/07   12:02:14 PMCLINICAL INQUIRIES840 VOL 56, NO 10 / OCTOBER 2007  THE JOURNAL OF FAMILY PRACTICEsive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecifi c somatic symptoms or reverse vegetative symptoms (eg, hyper-somnia and hyperphagia). Their recom-mendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8   ■References 1.  Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006; 67:115–125.  2.  National Institute of Mental Health research round-table on prepubertal bipolar disorder. J Am Acad Chld Adolesc Psychiatry 2001; 40:871–878.  3.  Youngstrom E, Findling R, Calabrese J, et al. Com-paring the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psy-chiatry 2004; 43:847–858.  4.  Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002; 23:42–56. 5.  Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003; 42:1494–1503.  6.  Carlson G, Jensen P, Findling R et al. Methodologi-cal Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003; 13:13–27.  7.  Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pedi-atric bipolar disorder. J Clin Child Adolesc Psychol 2005; 34:433–448.  8.  Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005; 7(Suppl 3):5–69. logs and a behavioral health provider of-fered patients a condensed education on sleep hygiene, stimulus control, and sleep restrictions strategies. The study was lim-ited because of small sample size (<25). Generalizability to practice is restricted because sessions were conducted by a behavioral health provider, not a family physician. Recommendations from othersThe Agency for Healthcare Research and Quality recommends CBT as an effective treatment in the management of chronic insomnia.8 It also recommends that fur-ther large-scale RCTs be conducted to establish CBT’s effectiveness across sub-sets of the population of individuals with chronic insomnia (ie, gender, age, shift workers, and those with psychiatric ill-nesses). The American Psychological Asso-ciation (APA) recommends CBT as the “treatment of choice” for chronic insom-nia, with 70% to 80% of patients show-ing a treatment response.9   ■AcknowledgmentsThe opinions and assertions contained herein are the private views of the authors and not to be construed as offi cial, or as refl ecting the views of the US Air Force Medical Service or the US Air Force at large. References 1.  NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consensus Science State-ment. 2005; 22(2). Available at: consensus.nih.gov/2005/2005InsomniaSOS026main.htm. Accessed on September 4, 2007.  2.  Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002; 6: 97–111.  3.  Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004; 65 Suppl 16:33–40. 4.  Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003; 5:1–9. 5.  Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006; 29:1398–1413.  6.  Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002; 159:5–11.  7.  Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003; 26:177–182.  8.  Buscemi N, Vandermeer B, Friesen C, et al. Mani-festations of chronic insomnia in adults. Evidence report/technology assessment No. 125. (Prepared by the University of Alberta Evidence-based Prac-tice Center, under Contract N. C400000021.) AHRQ Publication No. 05-E021-1. Rockville, Md: Agency for Healthcare Research and Quality. June 2005. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf. Accessed on September 4, 2007.  9.  American Psychological Association Web site. Get-ting a good night’s sleep with the help of psychol-ogy. Available at: www.psychologymatters.org/in-somnia.html. Accessed on September 4, 2007.Bipolar diagnosis   C O N T I N U E D  F R O M  PA G E  8 3 9Insomnia   C O N T I N U E D  F R O M  PA G E  8 3 7FAST TRACKThe APA recommendscognitive behavioral therapy as the treatment of choice for chronic insomnia840_r1_JFP1007   840 9/21/07   10:17:55 AM

Which nondrug alternatives can help with insomnia?

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