Non pharmacological therapy for insomnia: a comparison between sleep hygiene and sleep restriction
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Published:
Jun 30, 2020
Keywords:
Insomnia, sleep hygiene, sleep restriction
Main Article Content
Abstract
Background
Insomnia is the most common sleep disorder and, over the lifetime, affects more than 40% of the population. The first therapeutic choice for insomnia consists of cognitive-behavioral therapy (CBT), a non-pharmacological treatment. The effectiveness of CBT techniques, such as sleep restriction therapy and sleep hygiene rules, has been studied over the years, either individually or as part of a more comprehensive program.
Objective
Evaluate and compare the effectiveness of sleep restriction and sleep hygiene in the treatment of chronic insomnia, also related to the quality of life.
Materials and methods
We evaluated the therapeutic efficacy using actigraphy measures and a sleep diary. Quality of life was self-assessed by the Short Form Health Survey (SF-36).
Results
20 subjects completed the study. In the sleep restriction group, Time in Bed (TIB) and Wake After Sleep Onset (WASO) decreased in T1 compared to T0, Sleep Efficiency (SE) increased in T1 compared to T0 and subjects also reported better general health at the SF36 (p= 0.05).
The sleep hygiene group did not show any significant variations of TST, TIB, WASO, or SE after the treatment. However, there was an increase in the SF-36 score related to general health, physical functioning, pain, and mental health.
Discussion
The sleep restriction group improved more on objective parameters but had a moderate drop-out rate. The sleep hygiene group reported better quality of life.
Conclusions
This study shows that both techniques effectively improve sleep in subjects with insomnia, albeit in different aspects.
Key words
Insomnia, sleep hygiene, sleep restriction.
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How to Cite
Cicolin, A., & Giordano, A. (2020). Non pharmacological therapy for insomnia: a comparison between sleep hygiene and sleep restriction. Journal of Biomedical Practitioners, 4(1). https://doi.org/10.13135/2532-7925/4655
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References
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[13] Stepanski, E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep medicine reviews, 7(3), 215–225. https://doi.org/10.1053/smrv.2001.0246
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[21] IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp
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[23] Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. The American journal of psychiatry, 151(8), 1172–1180. https://doi.org/10.1176/ajp.151.8.1172
[24] Friedman, L., Benson, K., Noda, A., Zarcone, V., Wicks, D. A., O'Connell, K., Brooks, J. O., 3rd, Bliwise, D. L., & Yesavage, J. A. (2000). An actigraphic comparison of sleep restriction and sleep hygiene treat-ments for insomnia in older adults. Journal of geriatric psychiatry and neurology, 13(1), 17–27. https://doi.org/10.1177/089198870001300103
[25] Riemann, D., & Perlis, M. L. (2009). The treatments of chronic insomnia: a review of benzodiazepine re-ceptor agonists and psychological and behavioral therapies. Sleep medicine reviews, 13(3), 205–214. https://doi.org/10.1016/j.smrv.2008.06.001
[26] Miller, C. B., Espie, C. A., Epstein, D. R., Friedman, L., Morin, C. M., Pigeon, W. R., Spielman, A. J., & Kyle, S. D. (2014). The evidence base of sleep restriction therapy for treating insomnia disorder. Sleep medicine reviews, 18(5), 415–424. https://doi.org/10.1016/j.smrv.2014.01.006
[27] Hoch, C. C., Reynolds, C. F., 3rd, Buysse, D. J., Monk, T. H., Nowell, P., Begley, A. E., Hall, F., & Dew, M. A. (2001). Protecting sleep quality in later life: a pilot study of bed restriction and sleep hygiene. The journals of gerontology. Series B, Psychological sciences and social sciences, 56(1), P52–P59. https://doi.org/10.1093/geronb/56.1.p52
[28] Chung, K. F., Lee, C. T., Yeung, W. F., Chan, M. S., Chung, E. W., & Lin, W. L. (2018). Sleep hygiene ed-ucation as a treatment of insomnia: a systematic review and meta-analysis. Family practice, 35(4), 365–375. https://doi.org/10.1093/fampra/cmx122
[29] Vincent, N., Lewycky, S., & Finnegan, H. (2008). Barriers to engagement in sleep restriction and stimulus control in chronic insomnia. Journal of consulting and clinical psychology, 76(5), 820–828. https://doi.org/10.1037/0022-006X.76.5.820
[30] Hebert, E. A., Vincent, N., Lewycky, S., & Walsh, K. (2010). Attrition and adherence in the online treat-ment of chronic insomnia. Behavioral sleep medicine, 8(3), 141–150. https://doi.org/10.1080/15402002.2010.487457
[31] Perlis, M. L., Sharpe, M., Smith, M. T., Greenblatt, D., & Giles, D. (2001). Behavioral treatment of in-somnia: treatment outcome and the relevance of medical and psychiatric morbidity. Journal of behavioral medicine, 24(3), 281–296. https://doi.org/10.1023/a:1010770807823
[32] Perlis, M., Aloia, M., Millikan, A., Boehmler, J., Smith, M., Greenblatt, D., & Giles, D. (2000). Behavioral treatment of insomnia: a clinical case series study. Journal of behavioral medicine, 23(2), 149–161. https://doi.org/10.1023/a:1005413117932
[33] Coradeschi D. Restrizione del sonno e controllo dello stimolo: il cuore dell’intervento comportamentale per l’insonnia. Cognitivismo Clinico (2016) 13, 1, 54-67
[34] Terzano, M. G., Parrino, L., Bonanni, E., Cirignotta, F., Ferrillo, F., Gigli, G. L., Savarese, M., Ferini-Strambi, L., & Members of the Advisory Board (2005). Insomnia in general practice: a consensus report produced by sleep specialists and primary-care physicians in Italy. Clinical drug investigation, 25(12), 745–764. https://doi.org/10.2165/00044011-200525120-00002
[35] Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. Journal of sleep research 2017; 26(6): 675–700; https://doi.org/10.1111/jsr.12594
[36] Morin, C. M., Bastien, C., Guay, B., Radouco-Thomas, M., Leblanc, J., & Vallières, A. (2004). Random-ized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discon-tinuation in older adults with chronic insomnia. The American journal of psychiatry, 161(2), 332–342. https://doi.org/10.1176
[37] Morin C. M. (2004). Cognitive-behavioral approaches to the treatment of insomnia. The Journal of clinical psychiatry, 65 Suppl 16, 33–40
[2] Chesson, A. L., Jr, Anderson, W. M., Littner, M., Davila, D., Hartse, K., Johnson, S., Wise, M., & Rafecas, J. (1999). Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep, 22(8), 1128–1133. https://doi.org/10.1093/sleep/22.8.1128
[3] Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological ther-apies for late-life insomnia: a randomized controlled trial. JAMA, 281(11), 991–999. https://doi.org/10.1001/jama.281.11.991999
[4] Petit, L., Azad, N., Byszewski, A., Sarazan, F. F., & Power, B. (2003). Non-pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age and ageing, 32(1), 19–25. https://doi.org/10.1093/ageing/32.1.19
[5] Morin, C. M. and Espie, C. A. Insomnia – A Clinical Guide to Assessment and Treatment. Springer, New York, 2004
[6] Morgenthaler, T., Kramer, M., Alessi, C., Friedman, L., Boehlecke, B., Brown, T., Coleman, J., Kapur, V., Lee-Chiong, T., Owens, J., Pancer, J., Swick, T., & American Academy of Sleep Medicine (2006). Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep, 29(11), 1415–1419
[7] Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psy-chological and behavioral treatment of insomnia:update of the recent evidence (1998-2004). Sleep, 29(11), 1398–1414. https://doi.org/10.1093/sleep/29.11.1398
[8] Siebern, A. T., & Manber, R. (2010). Insomnia and its effective non-pharmacologic treatment. The Medical clinics of North America, 94(3), 581–591. https://doi.org/10.1016/j.mcna.2010.02.005
[9] Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evalu-ation and management of chronic insomnia in adults. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 4(5), 487–504
[10] Wu, R., Bao, J., Zhang, C., Deng, J., & Long, C. (2006). Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psycho-therapy and psychosomatics, 75(4), 220–228. https://doi.org/10.1159/000092892
[11] Kay-Stacey, M., & Attarian, H. (2016). Advances in the management of chronic insomnia. BMJ (Clinical re-search ed.), 354, i2123. https://doi.org/10.1136/bmj.i2123
[12] Hassinger AB, Bletnisky N, Dudekula R, et al. Selecting a pharmacotherapy regimen for patients with chron-ic insomnia [published online ahead of print, 2020 Mar 23]. Expert Opin Pharmacother 2020; 1–9: https://doi.org/10.1080/14656566.2020.1743265
[13] Stepanski, E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep medicine reviews, 7(3), 215–225. https://doi.org/10.1053/smrv.2001.0246
[14] Spielman A.J., Saskin P., Thorpy M.J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep. 10(1):45-56
[15] Nathaniel Kleitman. Sleep and Wakefulness. University of Chicago Press.1987
[16] Hauri P.J. (1991) Sleep Hygiene, Relaxation Therapy, and Cognitive Interventions. In: Hauri P.J. (eds) Case Studies in Insomnia. Critical Issues in Psychiatry (An Educational Series for Residents and Clinicians). Springer, Boston, MA
[17] Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2017; 13(2):3 07–349; Published 2017 Feb 15. https://doi.org/10.5664/jcsm.6470
[18] Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. Journal of sleep research 2017; 26(6): 675–700; https://doi.org/10.1111/jsr.12594
[19] Apolone G., Mosconi P., (1998). The italian SF 36 Health Survey: translation, validation and norming. J Clin Epidemiol. 51:1025
[20] Folstein, M.F., Folstein, S.E., McHugh P.R. (1975) Mini-Mental State: A practical methodfor grading the cognitive state of patients for the clinician Psychiatr Res. 12:189-198
[21] IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp
[22] WMA declaration of Helsinki – ethical principles for medical research involving human subjects Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended
[23] Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994). Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. The American journal of psychiatry, 151(8), 1172–1180. https://doi.org/10.1176/ajp.151.8.1172
[24] Friedman, L., Benson, K., Noda, A., Zarcone, V., Wicks, D. A., O'Connell, K., Brooks, J. O., 3rd, Bliwise, D. L., & Yesavage, J. A. (2000). An actigraphic comparison of sleep restriction and sleep hygiene treat-ments for insomnia in older adults. Journal of geriatric psychiatry and neurology, 13(1), 17–27. https://doi.org/10.1177/089198870001300103
[25] Riemann, D., & Perlis, M. L. (2009). The treatments of chronic insomnia: a review of benzodiazepine re-ceptor agonists and psychological and behavioral therapies. Sleep medicine reviews, 13(3), 205–214. https://doi.org/10.1016/j.smrv.2008.06.001
[26] Miller, C. B., Espie, C. A., Epstein, D. R., Friedman, L., Morin, C. M., Pigeon, W. R., Spielman, A. J., & Kyle, S. D. (2014). The evidence base of sleep restriction therapy for treating insomnia disorder. Sleep medicine reviews, 18(5), 415–424. https://doi.org/10.1016/j.smrv.2014.01.006
[27] Hoch, C. C., Reynolds, C. F., 3rd, Buysse, D. J., Monk, T. H., Nowell, P., Begley, A. E., Hall, F., & Dew, M. A. (2001). Protecting sleep quality in later life: a pilot study of bed restriction and sleep hygiene. The journals of gerontology. Series B, Psychological sciences and social sciences, 56(1), P52–P59. https://doi.org/10.1093/geronb/56.1.p52
[28] Chung, K. F., Lee, C. T., Yeung, W. F., Chan, M. S., Chung, E. W., & Lin, W. L. (2018). Sleep hygiene ed-ucation as a treatment of insomnia: a systematic review and meta-analysis. Family practice, 35(4), 365–375. https://doi.org/10.1093/fampra/cmx122
[29] Vincent, N., Lewycky, S., & Finnegan, H. (2008). Barriers to engagement in sleep restriction and stimulus control in chronic insomnia. Journal of consulting and clinical psychology, 76(5), 820–828. https://doi.org/10.1037/0022-006X.76.5.820
[30] Hebert, E. A., Vincent, N., Lewycky, S., & Walsh, K. (2010). Attrition and adherence in the online treat-ment of chronic insomnia. Behavioral sleep medicine, 8(3), 141–150. https://doi.org/10.1080/15402002.2010.487457
[31] Perlis, M. L., Sharpe, M., Smith, M. T., Greenblatt, D., & Giles, D. (2001). Behavioral treatment of in-somnia: treatment outcome and the relevance of medical and psychiatric morbidity. Journal of behavioral medicine, 24(3), 281–296. https://doi.org/10.1023/a:1010770807823
[32] Perlis, M., Aloia, M., Millikan, A., Boehmler, J., Smith, M., Greenblatt, D., & Giles, D. (2000). Behavioral treatment of insomnia: a clinical case series study. Journal of behavioral medicine, 23(2), 149–161. https://doi.org/10.1023/a:1005413117932
[33] Coradeschi D. Restrizione del sonno e controllo dello stimolo: il cuore dell’intervento comportamentale per l’insonnia. Cognitivismo Clinico (2016) 13, 1, 54-67
[34] Terzano, M. G., Parrino, L., Bonanni, E., Cirignotta, F., Ferrillo, F., Gigli, G. L., Savarese, M., Ferini-Strambi, L., & Members of the Advisory Board (2005). Insomnia in general practice: a consensus report produced by sleep specialists and primary-care physicians in Italy. Clinical drug investigation, 25(12), 745–764. https://doi.org/10.2165/00044011-200525120-00002
[35] Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. Journal of sleep research 2017; 26(6): 675–700; https://doi.org/10.1111/jsr.12594
[36] Morin, C. M., Bastien, C., Guay, B., Radouco-Thomas, M., Leblanc, J., & Vallières, A. (2004). Random-ized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discon-tinuation in older adults with chronic insomnia. The American journal of psychiatry, 161(2), 332–342. https://doi.org/10.1176
[37] Morin C. M. (2004). Cognitive-behavioral approaches to the treatment of insomnia. The Journal of clinical psychiatry, 65 Suppl 16, 33–40