Kosin Med J.  2024 Dec;39(4):238-245. 10.7180/kmj.24.153.

Non-pharmacological treatments for insomnia: a focus on components of cognitive behavioral therapy for insomnia

• Park S
• Lim EJ
• Lee D
• Lee YJ

• KMID: 2562806
• DOI: http://doi.org/10.7180/kmj.24.153

Abstract

Insomnia is a prevalent disorder that affects 4% to 22% of the population in the United States. While cognitive behavioral therapy for insomnia (CBT-I) remains the gold standard for non-pharmacological treatment, accessibility barriers exist owing to a shortage of trained professionals and high costs. This review examines the efficacy of the individual components of CBT-I as stand-alone interventions to improve treatment accessibility, digital CBT-I, and other non-pharmacological interventions. Guidelines from organizations such as the American Academy of Sleep Medicine and, European Sleep Research Society, along with recent meta-analyses, support the effectiveness of these components as stand-alone treatments. Sleep restriction therapy and stimulus control therapy show promise as effective interventions. Although recommended by certain guidelines, relaxation therapy has yielded mixed results. Sleep hygiene education, a common component of CBT-I, has not demonstrated significant efficacy as a stand-alone treatment. Cognitive strategies have shown promise in recent studies. Sufficient clinical evidence supports the efficacy of digital CBT-I in treating insomnia. Internationally, various platforms for digital CBT-I have already been developed and are in use, and in South Korea, some digital CBT-I software programs have received digital therapeutic device approval in 2023. This review highlights the potential of individual components of CBT-I as effective stand-alone interventions for insomnia, as well as digital CBT-I, emphasizing their importance for improving the accessibility of non-pharmacological insomnia treatments in clinical settings where full CBT-I may not be available.

Keyword

Behavior therapy; Cognitive behavioral therapy; Insomnia

Reference

References

1. Roth T, Coulouvrat C, Hajak G, Lakoma MD, Sampson NA, Shahly V, et al. Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition criteria: results from the America Insomnia Survey. Biol Psychiatry. 2011; 69:592–600. DOI: 10.1016/j.biopsych.2010.10.023. PMID: 21195389.

2. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Publishing, Inc.; 2013.

3. Sateia MJ. International classification of sleep disorders-third edition: highlights and modifications. Chest. 2014; 146:1387–94. DOI: 10.1378/chest.14-0970. PMID: 25367475.

4. Riemann D, Espie CA, Altena E, Arnardottir ES, Baglioni C, Bassetti CL, et al. The European insomnia guideline: an update on the diagnosis and treatment of insomnia 2023. J Sleep Res. 2023; 32:e14035. DOI: 10.1111/jsr.14035. PMID: 38016484.

5. Lam S, Macina LO. Therapy update for insomnia in the elderly. Consult Pharm. 2017; 32:610–22. DOI: 10.4140/tcp.n.2017.610. PMID: 28992822.

6. Crowe SF, Stranks EK. The residual medium and long-term cognitive effects of benzodiazepine use: an updated meta-analysis. Arch Clin Neuropsychol. 2018; 33:901–11. DOI: 10.1093/arclin/acx120. PMID: 29244060.

7. Riemann D, Baglioni C, Bassetti C, Bjorvatn B, Dolenc Groselj L, Ellis JG, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017; 26:675–700. DOI: 10.1111/jsr.12594. PMID: 28875581.

8. Edinger JD, Arnedt JT, Bertisch SM, Carney CE, Harrington JJ, Lichstein KL, 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; 17:255–62. DOI: 10.5664/jcsm.8986. PMID: 33164742.

9. Morin CM, Bei B, Bjorvatn B, Poyares D, Spiegelhalder K, Wing YK, et al. World sleep society international sleep medicine guidelines position statement endorsement of “behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of sleep medicine clinical practice guidelines”. Sleep Med. 2023; 109:164–9. DOI: 10.1016/j.sleep.2023.07.001. PMID: 37454606.

10. Baglioni C, Espie CA, Riemann D. Cognitive-behavioural therapy for insomnia (CBT-I) across the life span: guidelines and clinical protocols for health professionals. John Wiley & Sons; 2022.

11. Hrehova L, Mezian K. Non-pharmacologic treatment of insomnia in primary care settings. Int J Clin Pract. 2021; 75:e14084. DOI: 10.22541/au.160708066.60329056/v1. PMID: 33555081.

12. Cho JW, Kim HW, Jeong J, Baek K. Insomnia treatment in the digital healthcare era: present and future. J Sleep Med. 2023; 20:81–90. DOI: 10.13078/jsm.230021.

13. Maurer LF, Espie CA, Kyle SD. How does sleep restriction therapy for insomnia work? A systematic review of mechanistic evidence and the introduction of the Triple-R model. Sleep Med Rev. 2018; 42:127–38. DOI: 10.1016/j.smrv.2018.07.005. PMID: 30177248.

14. Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987; 10:541–53. DOI: 10.1016/s0193-953x(18)30532-x. PMID: 3332317.

15. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987; 10:45–56. DOI: 10.1093/sleep/10.1.45. PMID: 3563247.

16. Maurer LF, Schneider J, Miller CB, Espie CA, Kyle SD. The clinical effects of sleep restriction therapy for insomnia: a meta-analysis of randomized controlled trials. Sleep Med Rev. 2021; 58:101493. DOI: 10.1016/j.smrv.2021.101493. PMID: 33984745.

17. Furukawa Y, Sakata M, Yamamoto R, Nakajima S, Kikuchi S, Inoue M, et al. Components and delivery formats of cognitive behavioral therapy for chronic insomnia in adults: a systematic review and component network meta-analysis. JAMA Psychiatry. 2024; 81:357–65. DOI: 10.1001/jamapsychiatry.2023.5060. PMID: 38231522.

18. Verreault MD, Granger E, Neveu X, Delage JP, Bastien CH, Vallieres A. The effectiveness of stimulus control in cognitive behavioural therapy for insomnia in adults: a systematic review and network meta-analysis. J Sleep Res. 2024; 33:e14008. DOI: 10.1111/jsr.14008. PMID: 37586843.

19. Nowakowski S, Garland S, Grandner MA, Cuddihy L. Adapting cognitive behavioral therapy for insomnia. Elsevier; 2021.

20. Jansson-Frojmark M, Nordenstam L, Alfonsson S, Bohman B, Rozental A, Norell-Clarke A. Stimulus control for insomnia: a systematic review and meta-analysis. J Sleep Res. 2024; 33:e14002. DOI: 10.1111/jsr.14002. PMID: 37496454.

21. De la Pena A. Toward a psychophysiologic conceptualization of insomnia. In: Williams RL, Karacan I, editors. Sleep disorders: diagnosis and treatment. Wiley; 1978. p. 101-43.

22. Hauri P. Current concepts: the sleep disorders. Upjohn; 1977.

23. Harvey AG. A cognitive theory and therapy for chronic insomnia. J Cogn Psychother. 2005; 19:41–59. DOI: 10.1891/jcop.19.1.41.66332.

24. Tang NK, Saconi B, Jansson-Frojmark M, Ong JC, Carney CE. Cognitive factors and processes in models of insomnia: a systematic review. J Sleep Res. 2023; 32:e13923. DOI: 10.1111/jsr.13923. PMID: 37364869.

25. Espie CA. Revisiting the Psychobiological Inhibition Model: a conceptual framework for understanding and treating insomnia using cognitive and behavioural therapeutics (CBTx). J Sleep Res. 2023; 32:e13841. DOI: 10.1111/jsr.13841. PMID: 36747476.

26. Morin CM, Buysse DJ. Management of insomnia. N Engl J Med. 2024; 391:247–58. DOI: 10.1056/nejmcp2305655. PMID: 39018534.

27. Digital Therapeutics Alliance. Digital therapeutics definition and core principles [Internet]. Digital Therapeutics Alliance; c2019 [cited 2024 Dec 1]. https://dtxalliance.org/wp-content/uploads/2021/01/DTA_DTx-Definition-and-Core-Principles.pdf.

28. Shah AM, Shah SV. Digital therapeutics: a new era in health care. Natl J Physiol Pharm Pharmacol. 2023; 13:2190–6. DOI: 10.5455/njppp.2023.13.09464202302102023.

29. Cho CH. Clinical application of digital therapeutics for insomnia. Sleep Med Psychophysiol. 2021; 28:6–12.

30. Erten Uyumaz B, Feijs L, Hu J. A review of digital cognitive behavioral therapy for insomnia (CBT-I Apps): are they designed for engagement? Int J Environ Res Public Health. 2021; 18:2929. DOI: 10.3390/ijerph18062929. PMID: 33809308.

31. Wang X, Ju J, Li J, Fan Y, Xu H. Chaihu Longgu Muli decoction, a Chinese herbal formula, for the treatment of insomnia: a systematic review and meta-analysis. Medicine (Baltimore). 2020; 99:e22462. DOI: 10.1097/md.0000000000022462. PMID: 33019437.

32. Chen BW, Yi J, Sun B, Jia P, Zhang WJ, Liu BY. Efficacy and safety of Zaoren Anshen capsules in the treatment of insomnia: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020; 99:e19033. DOI: 10.1097/md.0000000000019033. PMID: 32028417.

33. Zakiei A, Khazaie H, Rostampour M, Lemola S, Esmaeili M, Dursteler K, et al. Acceptance and commitment therapy (ACT) improves sleep quality, experiential avoidance, and emotion regulation in individuals with insomnia: results from a randomized interventional study. Life (Basel). 2021; 11:133. DOI: 10.3390/life11020133. PMID: 33572330.

34. Chapoutot M, Peter-Derex L, Schoendorff B, Faivre T, Bastuji H, Putois B. Telehealth-delivered CBT-I programme enhanced by acceptance and commitment therapy for insomnia and hypnotic dependence: a pilot randomized controlled trial. J Sleep Res. 2021; 30:e13199. DOI: 10.1111/jsr.13199. PMID: 33020985.

35. Saldana KS, McGowan SK, Martin JL. Acceptance and commitment therapy as an adjunct or alternative treatment to cognitive behavioral therapy for insomnia. Sleep Med Clin. 2023; 18:73–83. DOI: 10.1016/j.jsmc.2022.09.003. PMID: 36764788.

36. Ell J, Schmid SR, Benz F, Spille L. Complementary and alternative treatments for insomnia disorder: a systematic umbrella review. J Sleep Res. 2023; 32:e13979. DOI: 10.1111/jsr.13979. PMID: 37527850.

37. Chen R, Wang S, Hu Q, Kang N, Xie H, Liu M, et al. Exercise intervention in middle-aged and elderly individuals with insomnia improves sleep and restores connectivity in the motor network. Transl Psychiatry. 2024; 14:159. DOI: 10.1038/s41398-024-02875-2. PMID: 38519470.

38. D’Aurea CV, Frange C, Poyares D, Souza AA, Lenza M. Physical exercise as a therapeutic approach for adults with insomnia: systematic review and meta-analysis. Einstein (Sao Paulo). 2022; 20:eAO8058. DOI: 10.31744/einstein_journal/2022AO8058. PMID: 35894372.

39. Choong SY, Tan XY, Cheng LJ, Lau Y. Effectiveness of exercise in improving sleep outcomes among perinatal women: a systematic review and meta-analysis of randomised controlled trials. Behav Sleep Med. 2022; 20:410–28. DOI: 10.1080/15402002.2021.1931221. PMID: 34081551.

40. Li S, Li Z, Wu Q, Liu C, Zhou Y, Chen L, et al. Effect of exercise intervention on primary insomnia: a meta-analysis. J Sports Med Phys Fitness. 2021; 61:857–66. DOI: 10.23736/s0022-4707.21.11443-4. PMID: 34110122.

41. Kwon CY, Lee B, Cheong MJ, Kim TH, Jang BH, Chung SY, et al. Non-pharmacological treatment for elderly individuals with insomnia: a systematic review and network meta-analysis. Front Psychiatry. 2021; 11:608896. DOI: 10.3389/fpsyt.2020.608896. PMID: 33584374.

42. Amiri S, Hasani J, Satkin M. Effect of exercise training on improving sleep disturbances: a systematic review and meta-analysis of randomized control trials. Sleep Med. 2021; 84:205–18. DOI: 10.1016/j.sleep.2021.05.013. PMID: 34166987.

43. Baglioni C, Bostanova Z, Bacaro V, Benz F, Hertenstein E, Spiegelhalder K, et al. A systematic review and network meta-analysis of randomized controlled trials evaluating the evidence base of melatonin, light exposure, exercise, and complementary and alternative medicine for patients with insomnia disorder. J Clin Med. 2020; 9:1949. DOI: 10.3390/jcm9061949. PMID: 32580450.

44. Lowe H, Haddock G, Mulligan LD, Gregg L, Fuzellier-Hart A, Carter LA, et al. Does exercise improve sleep for adults with insomnia? A systematic review with quality appraisal. Clin Psychol Rev. 2019; 68:1–12. DOI: 10.1016/j.cpr.2018.11.002. PMID: 30617012.

45. Banno M, Harada Y, Taniguchi M, Tobita R, Tsujimoto H, Tsujimoto Y, et al. Exercise can improve sleep quality: a systematic review and meta-analysis. PeerJ. 2018; 6:e5172. DOI: 10.7717/peerj.5172. PMID: 30018855.

46. Mercier J, Savard J, Bernard P. Exercise interventions to improve sleep in cancer patients: a systematic review and meta-analysis. Sleep Med Rev. 2017; 36:43–56. DOI: 10.1016/j.smrv.2016.11.001. PMID: 27939642.

47. Chambe J, Reynaud E, Maruani J, Fraih E, Geoffroy PA, Bourgin P. Light therapy in insomnia disorder: a systematic review and meta-analysis. J Sleep Res. 2023; 32:e13895. DOI: 10.1111/jsr.13895. PMID: 37002704.