Non-pharmacological management of insomnia

non pharmacological treatment of insomnia

Cognitive behavioural therapy for insomnia (CBT-I) is the first line treatment in chronic insomnia.

• can be delivered either individually or in small group format
• has been found to be as effective as prescription medications for short-term treatment of chronic insomnia

This psychological intervention addresses the various cognitive and behavioural aspects with the use of following interventions:

• behavioural strategies
  • sleep restriction
    • can be used in primary care and is useful for people who spend a lot of time in bed but not sleeping.
    • main aim is to reduce the time spent in bed to closely match actual time spent asleep
      • strict bedtime and rising schedule should be followed which is calculated according to the average expected hours of sleep
      • wake time should be fixed (regardless of actual sleep duration)
    • if patient is still not sleeping better
      • reduce the time in bed by 30 min
      • continue for at least two weeks before making another change
      • time in bed usually should not be reduced to less than 5 hours or the average expected hours of sleep
    • if patient is sleeping better but feels sleep deprived
      • add 30 minutes to the time in bed every week and continue till the the feeling of sleep deprivation disappear
        
        
  • stimulus control therapy
    • main aim is to reassociate the bed and bedroom with sleep and create a constant sleep-wake routine
      • go to bed only when sleepy
      • use the bedroom only for sleep and sex
      • read or engage in other quiet activities and return to bed only when sleepy
        • if unable to sleep after 15 to 20 minutes in bed, get out of the bed and return only when sleepy ( repeat as necessary)
      • avoid naps
      • wake up at the same time each day
        
        
  • relaxation
    • can use variety of techniques e.g. - breathing, focused relaxation, visual imagery, and meditation
    • carry out daily, engage in short relaxation periods (2-3 minutes) several times during the day
      
      
• education - about sleep hygiene
  • stress on the importance of environmental and physiological factors, behaviours, and habits to promote sound sleep
  • following principles in basic sleep hygiene can be provided to the patient
    • limit use of caffeine to 1 cup of coffee in the morning (if at all), avoid alcohol and cigarettes at night, and limit other substances that can affect sleep
    • go to bed when drowsy and feeling sleepy
    • daytime naps should be avoided
    • regular exercise (avoid exercise late in the evening)
    • avoid computer screens hours before bed and also watching the bedroom clock
    • bedtime environment should be conducive to sleep e.g. - bed should be comfortable, the temperature not too hot or cold, the room dark, and noise minimised
      
      
• cognitive strategies - cognitive therapy
  • targets on changing false beliefs and attitudes about sleep which may result in anxiety and distress (e.g., everyone needs at least 8 hours of sleep for good health (1,2,3,4)

Reference:

• (1) Falloon K et al. The assessment and management of insomnia in primary care. BMJ. 2011;342:d2899.
• (2) Cunnington D, Junge M. Chronic insomnia: diagnosis and non-pharmacological management. BMJ. 2016;355:i5819.
• (3) Kay-Stacey M, Attarian H. Advances in the management of chronic insomnia. BMJ. 2016;354:i2123
• (4) Ramar K, Olson EJ.Management of common sleep disorders. Am Fam Physician. 2013;88(4):231-8.