The American Academy of Sleep Medicine publishes a guideline that evaluates single- and multi-component behavioral and psychological therapies for patients who experience months-long problems falling or staying asleep.
By Jane Kollmer
Millions of people—about 10% of the US adult population—experience chronic insomnia.1
“Chronic insomnia disorder is different than a bad night of sleep here and then,” says Jennifer L. Martin, PhD, professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles, coauthor of a new clinical practice guideline issued by the American Academy of Sleep Medicine (AASM).2 “Those with chronic insomnia haven’t been sleeping well for months, and it impacts their functioning during the day.”
A person with chronic insomnia disorder will regularly experience fatigue or sleepiness; feel dissatisfied with sleep; have trouble concentrating; feel depressed, anxious, or irritable; and have low motivation or energy.
The treatment of chronic insomnia disorder using behavioral and psychological therapy in adult patients is the subject of a new AASM guideline. The recommendations, written by a task force of experts in sleep medicine (including sleep psychology), are intended to help healthcare providers select the most appropriate treatment for patients.
The task force evaluated the best available treatment options among both single- and multi-component interventions. The included interventions were cognitive-behavioral therapy for insomnia (CBT-I), brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness.
The task force assessed the evidence for each using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Methodology.3 They formed the recommendations based on the following considerations:
- a systematic review of scientific literature and the quality of evidence;
- the balance of clinically relevant benefits and harms;
- patient values and preferences; and
- resource use.
The treatment supported by the most evidence was CBT-I, a patient-centered, multi-component approach that combines one or more cognitive therapy strategies with education about sleep regulation plus behavioral strategies such as stimulus control instructions and sleep restriction therapy. CBT-I also often includes sleep hygiene education, relaxation training, and other counter-arousal methods. Treatment typically involves between four and eight sessions. Progress is tracked using information logged in the patient’s sleep diary.
CBT-I was the only approach to receive a “strong” recommendation, meaning it should be followed by clinicians in most cases.
Sleep Hygiene Is Not Treatment for Chronic Insomnia
The guideline also advises against sleep hygiene as a standalone therapy. Martin acknowledges sleep hygiene is probably the most familiar of all the treatments.
“Most patients know about basic sleep hygiene, just as most people know that a diet rich in fruits and vegetables is good for you,” Martin says. “Sleep hygiene is almost never enough to solve chronic insomnia disorder, and we as providers need to evolve and think of sleep hygiene as education for all our patients and not as a treatment for a chronic condition.”
The other multi-component brief therapies for insomnia and single-component therapies—sleep restriction therapy, stimulus control, and relaxation therapy—are also potentially useful interventions with minimal undesirable effects, and thus all received “conditional” recommendations, meaning they may be useful in some patients.
“Even the single-component therapies are simple to deliver and not hard for patients to learn,” Martin says. “They may address just one aspect of insomnia, which could make them a suitable option for some patients.”
The guideline updates recommendations that were first released in 2006.4
“This current review of the published data on CBT-I is very thorough and offers the best insights we have as to the effectiveness of the therapy,” says Derek Loewy, PhD, DABSM, CBSM, director of behavioral sleep medicine at the Scripps Clinic Sleep Center, who was not involved in writing the guidelines. “One notable finding is the demonstrated superiority of a combined approach over the use of the individual techniques that make up CBT-I. This is consistent with my own clinical experience.”
Barry Krakow, MD, a board-certified sleep medicine specialist who was not involved in writing the guidelines, concurs CBT-I is effective for insomnia, but he points out that many patients who experience chronic insomnia may also have co-occurring sleep apnea, which frequently goes undiagnosed. In a randomized clinical trial, Krakow found that treating the sleep apnea using the advanced positive airway pressure mode adaptive servo-ventilation cured the chronic insomnia of nearly 70% of study participants.5
“The AASM’s work is invaluable to those unfamiliar with insomnia treatments; however, the guidelines assume most chronic insomnia is solely of a psychological origin,” Krakow says. “The physiology of sleep breathing appears to play a much larger role than previously recognized.”
What About Sleeping Pills?
Despite cognitive behavioral therapy for insomnia having been identified as the standard of care, the reality is that pharmacologic treatment remains, by far, the most common approach to therapy, after treatment of comorbidities.
“It continues to be rare for me to see a patient who hasn’t first been tried on a variety of sedating medications, despite the well-recognized risks of reliance on such medications,” says Ryan G. Wetzler, PsyD, CBSM, DBSM, ABPP, a board-certified behavioral sleep specialist who was not involved in writing the guidelines. “It seems the only way patients are referred for CBT-I is if the patient expresses a strong preference for a nonpharmacologic approach.”
In 2017, the AASM published a clinical practice guideline for the pharmacologic treatment of chronic insomnia and concluded that medication should be considered mainly in patients who are unable to participate in CBT-I, patients who still have symptoms after this therapy, or those who require a temporary adjunct to CBT-I.6
Loewy, who is also director of behavioral sleep medicine at BetterNight, says, “When considering the relative harms of CBT-I compared to those of sleep medications, it’s clear that CBT-I should be the preferred first-line treatment approach for chronic insomnia.”
The recent AASM guideline focused on behavioral and psychological treatment builds on recommendations issued by the National Institutes of Health since 20057 and the American College of Physicians since 2016.8
As a member of the AASM task force, Martin was encouraged by the number of robust, well-designed studies that support the use of CBT-I. “The overwhelming evidence should inspire a lot of confidence in using this treatment,” she says.
According to Wetzler, there have been attempts made to disseminate this information to providers. He cites Choosing Wisely, an initiative of the American Board of Internal Medicine, which states that providers should “avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive-behavioral therapy, and reserve medication for adjunctive treatment when necessary.”9
Despite all of these efforts, Wetzler says, it continues to be rare for those with insomnia to be referred for CBT-I. In fact, a study conducted in 2015 found that very few (approximately 1%) insomnia patients are referred for treatment with CBT-I alone, despite availability of a well-known sleep center with practitioners certified in behavioral sleep medicine.10
Wetzler says, “I believe publication of these guidelines is valuable; however, it appears we have a lot of work to do to see them implemented in a meaningful way.”
Martin admits that more research is needed to determine the best ways to disseminate CBT-I and implement it into routine care. An advantage is the many convenient and patient-friendly ways to deliver cognitive behavioral therapy, such as through telehealth, individual therapy, group therapy, online, or books. The delivery modality can depend on the patient setting and the patient’s preferences and goals.
She suggests sleep medicine providers do a little homework to reach out to clinical psychologists who practice CBT-I, find out who is available, and develop relationships with those practitioners.
Martin says, “It falls on the team of providers who take care of patients to ask questions about their insomnia symptoms and connect them with providers who can do CBT-I, even if it’s through telehealth or self-directed delivery methods. It doesn’t matter how patients get [CBT-I] as long as they get it.”
Jane Kollmer is co-owner of Ch/At Communications, which provides writing and editing services to clients in the healthcare and travel industries. This is her first article for Sleep Review.
- Saddichha S. Diagnosis and treatment of chronic insomnia. Ann Indian Acad Neurol. 2010 Apr-Jun;13(2):94–102.
- Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Feb 1;17(2):255-62.
- Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021 Feb 1;17(2):263-98.
- Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep. 2006 Nov;29(11):1415-9.
- Krakow B, McIver ND, Ulibarri VA, et al. Prospective randomized controlled trial on the efficacy of continuous positive airway pressure and adaptive servo-ventilation in the treatment of chronic complex insomnia. EClinicalMedicine. 2019 Aug 8;13:57-73.
- Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307-49.
- National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep. 2005 Sep;28(9):1049-57.
- Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016 Jul 19;165(2):125-33.
- American Academy of Sleep Medicine. Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive-behavioral therapy, and reserve medication for adjunctive treatment when necessary. 2014 Dec 2. Available at https://www.choosingwisely.org/clinician-lists/aasm-hypnotics-for-chronic-insomnia.
- Conroy DA, Ebben MR. Referral practices for cognitive behavioral therapy for insomnia: a survey study. Behav Neurol. 2015;2015:819402.