Dr Neil Stanley Independent Sleep Expert
© Dr. Neil Stanley 2013-2022
What is the recommended treatment for insomnia? In the UK, the National Institute of Health and Care Excellence (NICE) advise the use cognitive behavioural therapy for insomnia – CBTi. Current Nice guidelines for the management of insomnia - How should I manage a person with short-term insomnia (less than 3 months duration)? here Consider the need for referral to a sleep clinic or neurology if symptoms of another sleep disorder are present. Address any circumstances/stressors associated with onset of insomnia. Ensure comorbidities (for example anxiety or depression) are optimally managed. Offer advice on sleep hygiene. Advise the person not to drive if they feel sleepy. The DVLA must be informed if excessive sleepiness is having, or is likely to have, an adverse effect on driving such as: o Obstructive sleep apnoea syndrome (any severity). o Primary/central hypersomnias (such as narcolepsy). o Any other conditions or medication that may cause excessive sleepiness. If sleep hygiene measures fail, daytime impairment is severe causing significant distress, and insomnia is likely to resolve soon (for example due to a short term stressor): o Consider a short course (3-7 days) of a non-benzodiazepine hypnotic medication (z-drug). o Do not prescribe hypnotics routinely — use only for short courses if acutely distressed. o Do not prescribe hypnotics to older people or women who are pregnant or breastfeeding. If sleep hygiene measures fail, daytime impairment is severe causing significant distress, and insomnia is not likely to resolve soon: Offer cognitive behavioural therapy for insomnia (CBT-I). o CBT-I typically includes behavioural interventions (such as stimulus control and sleep restriction), cognitive therapy and relaxation training and can be provided face-to-face or digitally. Consider the need for adjunctive treatment with a short-term hypnotic medication (a z-drug or prolonged released melatonin if over 55 years of age). Do not prescribe hypnotics routinely — use only for short courses if acutely distressed. Do not prescribe hypnotics to older people or women who are pregnant or breastfeeding. If a hypnotic is prescribed: o Consider the duration of action (short-acting is usually most appropriate), adverse effects, interactions and potential for dependency and abuse. o Use the lowest effective dose for the shortest period possible — do not continue treatment for longer than 2 weeks (preferably less than one week). o Inform the person that further prescriptions for hypnotics will not usually be given, ensure that the reasons for this are understood, and document this in the person's notes. o Do not issue further prescriptions without seeing the person again. o If there has been no response to the first hypnotic, do not prescribe another. Provide patient information on insomnia Arrange follow up for review (for example 2–4 weeks, dependant on the clinical situation). If symptoms have not improved, reassess the person — consider CBT-I (if not already offered), alternative diagnoses and the need for referral. Do not recommend over-the-counter treatments for insomnia How should I manage someone with long-term insomnia (more than 3 months duration)? here Consider the need for referral to a sleep clinic or neurology if symptoms of another sleep disorder are present. Address any triggers or factors associated with maintenance of insomnia (for example illness or other stressors). Ensure comorbidities (such as anxiety and depression) are optimally managed. Offer advice on sleep hygiene. Advise the person not to drive if they feel sleepy. The DVLA must be informed if excessive sleepiness is having, or is likely to have, an adverse effect on driving including: o Obstructive sleep apnoea syndrome (any severity). o Primary/central hypersomnias (such as narcolepsy). o Any other conditions or medication that may cause excessive sleepiness. Offer cognitive behavioural therapy for insomnia (CBT-I) as the first-line treatment for chronic insomnia in adults of any age. o CBT-I typically includes behavioural interventions (such as stimulus control and sleep restriction), cognitive therapy and relaxation training. It can be provided face-to-face or digitally. Pharmacological therapy should be avoided in the long-term management of insomnia, however: o For some people with severe symptoms or an acute exacerbation a short course of a hypnotic drug (preferably less than 1 week) may be considered as a temporary adjunct to behavioural and cognitive treatment. o Do not prescribe long-term hypnotic treatment o For people over 55 years of age with persistent insomnia, treatment with a modified-release melatonin may be considered. The recommended initial duration of treatment is 3 weeks. If there is a response to treatment, continue for a further 10 weeks only. Discuss the risks (similar to those of other hypnotics including falls, and fractures) associated with melatonin treatment in the elderly. Arrange follow up for review (2–4 weeks, dependant on the clinical situation). If symptoms have not improved, reassess the person — consider alternative diagnoses and the need for referral. Do not recommend over-the-counter treatments for insomnia. Cognitive Behavioural Therapy for Insomnia (CBT-I) is also recommended by the British Association of Psychopharmacology here European Sleep Research Society here American Academy of Sleep Medicine here CBTi (or CBT-I) CBTi has been shown to be successful in treating mild to moderate insomnia in some people (Soong C, Burry L, Greco M, Tannenbaum C. Advise non-pharmacological therapy as first line treatment for chronic insomnia. bmj. 2021 Mar 23;372) Unlike sleeping tablets the benefits of CBTi have been found to persist for up to 12 months after the end of therapy (Ritterband, L.M., Thorndike, F.P., Ingersoll, K.S., Lord, H.R., Gonder-Frederick, L., Frederick, C., Quigg, M.S., Cohn, W.F. and Morin, C.M., 2017. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. Jama psychiatry, 74(1), pp.68-75; Vedaa, Ø., Hagatun, S., Kallestad, H., Pallesen, S., Smith, O.R., Thorndike, F.P., Ritterband, L.M. and Sivertsen, B., 2019. Long-term effects of an unguided online cognitive behavioral therapy for chronic insomnia. Journal of Clinical Sleep Medicine, 15(01), pp.101-110) CBTi, is usually delivered over the course 6-8 sessions (Perlis ML, Jungquist C, Smith MT, Posner D. Cognitive behavioral treatment of insomnia: A session-by-session guide. Springer Science & Business Media; 2005 Aug 17) CBTi is designed to target both the inappropriate thought processes and behaviours that can lead to sleep problems. (Parsons CE, Zachariae R, Landberger C, Young KS. How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change. Clinical Psychology Review. 2021 Apr 3:102027) CBTi can be delivered either face to face with a trained therapist, in small groups or digitally via the internet or an app (Smith, M.T., Huang, M.I. and Manber, R., 2005. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical psychology review, 25(5), pp.559-592; Wickwire, E.M., 2019. The value of digital insomnia therapeutics: what we know and what we need to know. Journal of Clinical Sleep Medicine, 15(01), pp.11-; Jacobsen, P.B., Prasad, R., Villani, J., Lee, C.M., Rochlin, D., Scheuter, C., Kaplan, R.M., Freedland, K.E., Manber, R., Kanaan, J. and Wilson, D.K., 2019. The role of economic analyses in promoting adoption of behavioral and psychosocial interventions in clinical settings. Health Psychology, 38(8), p.680; Sunnhed, R., Hesser, H., Andersson, G., Carlbring, P., Morin, C.M., Harvey, A.G. and Jansson-Fröjmark, M., 2019. Comparing internet-delivered Cognitive Therapy and Behavior Therapy with telephone support for insomnia disorder: A randomized controlled trial. Sleep; Cheung, J.M., Bartlett, D.J., Armour, C.L., Laba, T.L. and Saini, B., 2019. Patient perceptions of treatment delivery platforms for cognitive behavioral therapy for insomnia. Behavioral sleep medicine, 17(1), pp.81-97]) CBT-I is made up of a number of different techniques that are combined together, while CBT-I was developed in the mid’ 1990’s aspect of it were developed much earlier There are a number of techniques that come under the umbrella of CBT-I; o Stimulus Control Therapy o Sleep Restriction Therapy o Sleep Hygiene Education o Cognitive Therapy o Relaxation Training Stimulus Control Therapy This aims to create a strong associate between the bed and sleep (Bootzin, R.R., 1972. Stimulus control treatment for insomnia. Proceedings of the American Psychological Association, 7, pp.395-396). Its basic principles are go to bed only when they are tired. limit activities in bed to sleep, (and sex). get out of bed at the same time every morning. get out of bed when sleep-onset does not occur within 30 minutes. Sleep Restriction The aim of sleep restriction to restore the natural drive to sleep by restricting a patients’ time in bed (TIB). (Spielman, A.J., Saskin, P. and Thorpy, M.J., 1987. Treatment of chronic insomnia by restriction of time in bed. Sleep, 10(1), pp.45-56; Maurer LF, Schneider J, Miller CB, Espie CA, Kyle SD. The clinical effects of sleep restriction therapy for insomnia: A meta-analysis of randomised controlled trials. Sleep Medicine Reviews. 2021 Apr 21:101493) Sleep restriction is not recommended for patients with history of mania, obstructive sleep apnoea, seizure disorder, parasomnias or those at significant risk for falls. NB This process may take several weeks or months to be effective and it is important to understand that for the first few weeks it could lead to high levels of daytime sleepiness, so those people who cannot safely be sleep deprived should not undergo this process. Sleep Hygiene Sleep hygiene was originally developed in the early 1980’s and the original “Rules of Sleep Hygiene” advised the following 1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing the time in bed seems to solidify sleep; excessively long times in bed seem related to fragmented and shallow sleep. 2. A regular arousal time in the morning strengthens circadian cycling and, finally, leads to regular times of sleep onset. 3. A steady daily amount of exercise probably deepens sleep: occasional exercise does not necessarily improve sleep the following night. 4. Occasional loud noises (e.g. aircraft flyovers) disturb sleep even in people who are not awakened by noises and cannot remember them in the morning. Sound attenuated bedrooms may help those who must sleep close to noise. 5. Although excessively warm rooms disturb sleep, there is no evidence that an excessively cold room solidifies sleep. 6. Hunger may disturb sleep; a light snack may help sleep. 7. An occasional sleeping pill may be of some benefit, but their chronic use is ineffective in most insomniacs. 8. Caffeine in the evening disturbs sleep, even in those who feel it does not. 9. Alcohol helps tense people fall asleep more easily, but the ensuing sleep is then fragmented. 10. People who feel angry and frustrated they cannot sleep should not try harder and harder to fall asleep but turn on the light and do something different. 11. The chronic use of tobacco disturbs sleep. © “The Sleep Disorders: A Current Concepts Monograph” by P. Hauri and W. C. Orr (Kalamazoo, Mich.: Upjohn, 1982) Since their publication there have been countless versions of sleep hygiene, which are more or less related to these original rules (Morin, C.M., 2004. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry, 65(Suppl 16), pp.33-40) Although its use is recommened by NICE, studies have shown that sleep hygiene is not actually efficacious as a stand-alone treatment for insomnia and needs to be combined with treatments such as, relaxation, stimulus control, and sleep restriction (Morin, C.M., Stone, J., McDonald, K. and Jones, S., 1994. Psychological management of insomnia: a clinical replication series with 100 patients. Behavior Therapy, 25(2), pp.291-309; Morin, C.M., Hauri, P.J., Espie, C.A., Spielman, A.J., Buysse, D.J. and Bootzin, R.R., 1999. Nonpharmacologic treatment of chronic insomnia. Sleep, 22(8), pp.1134-1156; Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A. and Lichstein, K.L., 2006. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998–2004). Sleep, 29(11), pp.1398-14; Murtagh, D.R. and Greenwood, K.M., 1995. Identifying effective psychological treatments for insomnia: a meta-analysis. Journal of consulting and clinical psychology, 63(1), p.79. 14) Relaxation training This is essentially helping people to relax prior to bedtime to help them fall asleep. Now I am not quite certain why you cannot do this yourself and why you need ‘training’, but it’s your life. Various techniques used by therapists include hypnosis, guided imagery and meditation but essentially anything that helps you wind down and relax at the end of the day will help. (Turner, R.M. and Ascher, L.M., 1979. Controlled comparison of progressive relaxation, stimulus control, and paradoxical intention therapies for insomnia. Journal of Consulting and Clinical Psychology, 47(3), p.500; Means, M.K., Lichstein, K.L., Epperson, M.T. and Johnson, C.T., 2000. Relaxation therapy for insomnia: nighttime and day time effects. Behaviour Research and Therapy, 38(7), pp.665-678) Cognitive Therapy This is designed to decrease the anxiety and arousal associated with insomnia by targeting the patients’ dysfunctional beliefs/attitudes about sleep. Unhelpful thoughts such as the above can actually make your insomnia worse, by creating unrealistic expectations, and an inaccurate perception of the amount of time you spend lying awake. For instance research has shown that people who claim to suffer from insomnia actually overestimate the amount of time they take to fall asleep and the amount of disturbance they suffer during the night., after learning they slept for longer than they’d thought, they began sleeping better. (Harvey, A.G., Sharpley, A.L., Ree, M.J., Stinson, K. and Clark, D.M., 2007. An open trial of cognitive therapy for chronic insomnia. Behaviour Research and Therapy, 45(10), pp.2491-2501) CBTi in the Elderly CBTi is equally effective in treating the poor sleep seen in older people (Cassidy-Eagle EL, Siebern A, Chen H, Kim HM, Palesh O. Cognitive-Behavioral Therapy for Insomnia in Older Adults. Cognitive and Behavioral Practice. 2021 May 8; Lovato N, Lack L, Wright H, Kennaway DJ. Evaluation of a brief treatment program of cognitive behavior therapy for insomnia in older adults. Sleep. 2014 Jan 1;37(1):117-26, Bélanger L, LeBlanc M, Morin CM. Cognitive behavioral therapy for insomnia in older adults. Cognitive and Behavioral Practice. 2012 Feb 1;19(1):101-15].