Recognition that psychological and behavioral factors play an important role in insomnia
has led to increased interest in therapies targeting these factors. A review paper
published in 1999 summarized the evidence regarding the efficacy of psychological
and behavioral treatments for persistent insomnia. The present review provides an
update of the evidence published since the original paper. As with the original paper,
this review was conducted by a task force commissioned by the American Academy of
Sleep Medicine in order to update its practice parameters on psychological and behavioral
therapies for insomnia.
A systematic review was conducted on 37 treatment studies (N = 2246 subjects/patients)
published between 1998 and 2004 inclusively and identified through Psyclnfo and Medline
searches. Each study was systematically reviewed with a standard coding sheet and
the following information was extracted: Study design, sample (number of participants,
age, gender), diagnosis, type of treatments and controls, primary and secondary outcome
measures, and main findings. Criteria for inclusion of a study were as follows: (a)
the main sleep diagnosis was insomnia (primary or comorbid), (b) at least 1 treatment
condition was psychological or behavioral in content, (c) the study design was a randomized
controlled trial, a nonrandomized group design, a clinical case series or a single
subject experimental design with a minimum of 10 subjects, and (d) the study included
at least 1 of the following as dependent variables: sleep onset latency, number and/or
duration of awakenings, total sleep time, sleep efficiency, or sleep quality.
Psychological and behavioral therapies produced reliable changes in several sleep
parameters of individuals with either primary insomnia or insomnia associated with
medical and psychiatric disorders. Nine studies documented the benefits of insomnia
treatment in older adults or for facilitating discontinuation of medication among
chronic hypnotic users. Sleep improvements achieved with treatment were well sustained
over time; however, with the exception of reduced psychological symptoms/ distress,
there was limited evidence that improved sleep led to clinically meaningful changes
in other indices of morbidity (e.g., daytime fatigue). Five treatments met criteria
for empirically-supported psychological treatments for insomnia: Stimulus control
therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavior
therapy.
These updated findings provide additional evidence in support of the original review's
conclusions as to the efficacy and generalizability of psychological and behavioral
therapies for persistent insomnia. Nonetheless, further research is needed to develop
therapies that would optimize outcomes and reduce morbidity, as would studies of treatment
mechanisms, mediators, and moderators of outcomes. Effectiveness studies are also
needed to validate those therapies when implemented in clinical settings (primary
care), by non-sleep specialists. There is also a need to disseminate more effectively
the available evidence in support of psychological and behavioral interventions to
health-care practitioners working on the front line.