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Health Protocols


Treating Insomnia: Non-pharmacological Therapies

Non-pharmacological interventions have been shown to improve sleep quality in patients with insomnia. These treatment options include cognitive behavioral therapy, sleep restriction, sleep hygiene, and relaxation therapy.89

Improving Sleep Hygiene and General Lifestyle Considerations

One of the most widely effective behavioral therapies for insomnia is improving sleep hygiene.90 Sleep hygiene refers generally to habits surrounding sleep, such as consistent bedtime, limiting blue light exposure before bed, limiting time in bed to sleep only, etc. Good sleep habits may help prevent insomnia.15,16,90

A prospective cross-sectional analysis of 548 college students examined the relationship between sleep hygiene and insomnia severity. Students complained of inconsistent sleep-wake cycles and frequently worrying in bed. Improper sleep scheduling, uncomfortable sleep environments, and engaging in behaviors that create hyperarousal before bed were associated with insomnia severity. After controlling for other risk factors, sleep scheduling was most strongly associated with insomnia severity.91 Another analysis of 130 patients admitted to a hospital burn unit found that a nurse-driven sleep hygiene protocol was successful in helping patients fall asleep more quickly and experience fewer sleep disruptions.92

Consider the following sleep hygiene and general lifestyle measures:

  • Keep your bedroom cool, dark, and quiet.
  • Keep sleep and wake times consistent throughout the week.
  • Avoid eating large meals two to three hours before bed, as indigestion can make falling asleep difficult.
  • Limit stimulant intake (eg, caffeine, nicotine, and alcohol) during the day, especially close to bedtime.
  • Limit daytime sleep.
  • Spend time outdoors in natural light each day.
  • Engage in daily physical activity, but avoid vigorous exercise during the two hours prior to sleep.
  • Create bedtime rituals (eg, taking a warm bath and listening to soft music) to improve relaxation. Resolving stress may help improve sleep quality. People with insomnia should also review the Stress Management protocol.
  • Avoid activities not related to sleep (eg, watching TV, reading, or listening to the radio) in the bedroom. Use the bedroom for sexual activity and sleep only (stimulus control).11
  • If worrying about the time keeps you awake, cover the alarm clock.

Sleep Restriction to Reset Circadian Rhythms

Sleep restriction therapy limits time in bed (including naps) to increase the biological need for sleep at night. This process usually begins by restricting time in bed to the estimated amount of time one should spend sleeping. For example, a person who stays in bed for nine hours but only sleeps six will initially restrict time in bed to six hours. This causes mild sleep deprivation in the beginning, but the sleepiness it creates trains the body to fall asleep more quickly. As the body adjusts, people can extend time spent in bed by 15 to 20 minutes, until they are able to get a full night sleep without spending extra time in bed.93

A study comparing sleep hygiene therapy plus sleep restriction to sleep hygiene therapy alone found sleep restriction improved sleep efficiency.93,94 A review of evidence for sleep restriction as a standalone treatment for insomnia found it improved sleep efficiency and total sleep time, and researchers concluded it was an effective means of treating chronic insomnia.95

Cognitive Behavioral Therapy

In 2016, the American College of Physicians recommended that cognitive-behavioral therapy be the initial treatment protocol for patients with chronic insomnia.18 Cognitive behavioral therapy helps people develop behaviors more conducive to sleep. It involves regular visits to a clinician who will assess sleep patterns and work to change how the patient gets to sleep. Cognitive behavioral therapy works by teaching the subject to change their beliefs about sleep, develop good sleep habits, and improve their sleep environment.96

Cognitive behavioral therapy may involve sleep restriction and education on sleep hygiene. It also may involve biofeedback, which provides information via electrical sensors about certain biological functions, such as respiration, heart rate, and muscle contraction. This information allows a person to make subtle changes (such as in breathing rate or muscle relaxation) to try to control bodily functions to better manage conditions such as anxiety, pain, and insomnia. Stimulus control therapy focuses on removing factors that encourage people to resist sleep, such as an inconsistent bedtime or using the bedroom for activities other than sleep.96

Cognitive behavioral therapy has been shown to be an effective treatment for both primary and secondary insomnia.97-100 A recent randomized controlled trial that followed 36 people for six months suggests cognitive behavioral therapy improved insomnia severity scores, sleep measures, and dysfunctional sleep beliefs.101 A recent review concluded cognitive behavioral therapy may be more effective than benzodiazepine and non-benzodiazepine drugs for long-term treatment of insomnia.102 Other research suggests cognitive behavioral therapy decreases depression, improves mental health, and is more effective in treating insomnia than hypnotic sleep aids.103,104

Relaxation Therapy

Some patients with insomnia have high levels of cognitive and physiological arousal, as evidenced by increased cerebral metabolism of glucose. Relaxation therapies (including meditation, visualization techniques, breathing exercises, and progressive muscle relaxation) aim to achieve a more relaxed state prior to bedtime. Most of these techniques can be self-administered after some initial guidance from a medical professional.89

Social support, stress reduction techniques (including meditation and yoga), and improving coping mechanisms for dealing with stress may be useful ways to combat insomnia in some people.105 Research involving 30 adults with insomnia found that mindfulness-based stress reduction, including meditation training, resulted in significant improvements in sleep quality, including time to sleep and total sleep time.106 Another study of 44 postmenopausal women aged 50‒65 who were not undergoing hormone replacement therapy found practicing yoga for four months lowered insomnia and stress severity scores and increased quality of life.107