The guideline includes one strong recommendation – which is one that clinicians should follow under most circumstances – for the use of cognitive behavioural therapy for insomnia. CBT-I combines one or more cognitive therapy strategies with education about sleep regulation plus behavioural strategies such as stimulus control instructions and sleep restriction therapy. Treatment typically involves four to eight sessions.
"This is the first systematic review to use the GRADE system to evaluate behavioural insomnia therapies," said lead author Jack Edinger, who has a doctorate in clinical psychology and is a professor in the section of sleep medicine at National Jewish Health in Denver. "The multicomponent treatment, cognitive behavioural therapy for insomnia, is the most supported therapy."
Published online as an accepted paper in the Journal of Clinical Sleep Medicine, the guideline updates the AASM's 2006 practice parameters. It was developed by an expert task force and approved by the AASM board of directors. The process included a systematic literature review, meta-analyses, and assessment of the evidence using the GRADE methodology. A draft of the guideline was made available for public comment.
"There have been significant advancements in behavioural and psychological treatments for chronic insomnia, which affects millions of American adults," said AASM President Dr Kannan Ramar. "The AASM guideline will help optimise patient-centred care by providing actionable recommendations for clinicians and patients."
The guideline includes several conditional recommendations — which require the clinician to use clinical knowledge and experience while considering the patient's values and preferences — suggesting that clinicians use multi-component brief therapies and three single-component therapies: stimulus control, sleep restriction therapy, and relaxation therapy. The guideline also suggests that sleep hygiene should not be used as a single-component treatment for chronic insomnia disorder in adults.
"Although sleep hygiene practices are often suggested and well-understood by patients, sleep hygiene recommendation do not constitute an effective stand-alone therapy," said Edinger.
Insomnia involves difficulty falling asleep or staying asleep, or regularly waking up earlier than desired, despite allowing enough time in bed for sleep. Daytime symptoms include fatigue or sleepiness; feeling dissatisfied with sleep; having trouble concentrating; feeling depressed, anxious, or irritable; and having low motivation or energy. Chronic insomnia disorder, which affects about 10 percent of the adult population, is distinguished by a sleep disturbance with associated daytime symptoms occurring at least three times per week for at least three months.
The AASM's previously published clinical practice guideline for the pharmacologic treatment of chronic insomnia also emphasises that medications for chronic insomnia disorder 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.
Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline
Jack D. Edinger, J. Todd Arnedt, Suzanne M. Bertisch, Colleen E. Carney, John J. Harrington, Kenneth L. Lichstein, Michael J. Sateia, Wendy M. Troxel, Eric S. Zhou, Uzma Kazmi, Jonathan L. Heald, Jennifer L. Martin.
Journal of Clinical Sleep Medicine, 16 December 2020
This guideline establishes clinical practice recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults.
The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The task force evaluated a summary of the relevant literature and the quality of evidence, the balance of clinically relevant benefits and harms, patient values and preferences, and resource use considerations that underpin the recommendations. The AASM Board of Directors approved the final recommendations.
The following recommendations are intended as a guide for clinicians in choosing a specific behavioral and psychological therapy for the treatment of chronic insomnia disorder in adult patients. Each recommendation statement is assigned a strength (“strong” or “conditional”). A “strong” recommendation (ie, “We recommend…”) is one that clinicians should follow under most circumstances. A “conditional” recommendation is one that requires that the clinician use clinical knowledge and experience, and to strongly consider the patient’s values and preferences to determine the best course of action.
1. We recommend that clinicians use multi-component cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG)
2. We suggest that clinicians use multi-component brief therapies for insomnia for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)
3. We suggest that clinicians use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)
4. We suggest that clinicians use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)
5. We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)
6. We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)
Full study in Journal of Clinical Sleep Medicine (Open access)