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Introduction: This guideline establishes clinical practice recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults. Methods: The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine and sleep psychology 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. 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. We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG) We suggest that clinicians use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) We suggest that clinicians use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) We suggest that clinicians use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) Citation: Edinger JD, Arnedt JT, Bertisch SM, 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(2):255–262.

For people with insomnia and often comorbid disorders such as depression, anxiety, and chronic pain, this book has methods from cognitive behavioral therapy for getting the sleep they need and improving their symptoms in the process.

Introduction: The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations. Methods: The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations. Results: The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations. Citation: Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(2):263–298.

سوف يساعدك هذا الكتاب في تهدئة عقلك مفرط النشاط عندما تحاول الخلود الى النوم ويقدم لك تمارين ونصائح يسيرة لمساعدتك على إنشاء النظام والبيئة اللذين يعززان حصولك على قسط جيد من النوم ووضع طبقة عازلة بين ضغوطك اليومية ووسادتك وتمرين عقلك المزعج على الهدوء عندما تأوي إلى الفراش، والكتاب نتاج عالمتين من عالمات النفس وهو يهدف لتهدئة العقل المفرط والنشاط، ويتضمن تمارين ونصائح تساعد على وضع طبقة عازلة بين الضغوط اليومية ووسادة النوم وتمرين العقل المزعج على التزام الهدوء.

Abstract Study Objectives We conducted a systematic review to explore the effectiveness of medical cannabis for impaired sleep. Methods We searched MEDLINE, EMBASE, CENTRAL, and PsychINFO to January 2021 for randomized trials of medical cannabis or cannabinoids for impaired sleep vs. any non-cannabis control. When possible, we pooled effect estimates for all patient-important sleep-related outcomes and used the GRADE approach to appraise the certainty of evidence. Results Thirty-nine trials (5100 patients) were eligible for review, of which 38 evaluated oral cannabinoids and 1 administered inhaled cannabis. The median follow-up was 35 days, and most trials (33 of 39) enrolled patients living with chronic cancer or noncancer chronic pain. Among patients with chronic pain, moderate certainty evidence found that medical cannabis probably results in a small improvement in sleep quality versus placebo (modeled risk difference [RD] for achieving the minimally important difference [MID], 8% [95% CI, 3 to 12]). Moderate to high certainty evidence shows that medical cannabis vs. placebo results in a small improvement in sleep disturbance for chronic non-cancer pain (modeled RD for achieving the MID, 19% [95% CI, 11 to 28]) and a very small improvement in sleep disturbance for chronic cancer pain (weighted mean difference of –0.19 cm [95%CI, –0.36 to –0.03 cm]; interaction p = .03). Moderate to high certainty evidence shows medical cannabis, versus placebo, results in a substantial increase in the risk of dizziness (RD 29% [95%CI, 16 to 50], for trials with ≥3 months follow-up), and a small increase in the risk of somnolence, dry mouth, fatigue, and nausea (RDs ranged from 6% to 10%). Conclusion Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small.

Cognitive behavioural therapy for insomnia (CBT-I) is an effective treatment for chronic insomnia that also improves non-sleep symptoms, such as mood and anxiety. Identifying sleep-specific variables that predict anxiety change after CBT-I treatment may support alternative strategies when people with generalized anxiety disorder (GAD) do not improve from standard GAD treatment. To investigate CBT-I on changes in anxiety and evaluate whether changes in sleep-specific variables predict anxiety outcomes. Seventy-two participants presenting with insomnia and GAD (GAD-I) completed four sessions of CBT-I. Participants completed daily diaries and self-report measures at baseline and post-treatment. CBT-I in a co-morbid GAD-I sample was associated with medium reductions in anxiety, and large reductions in insomnia severity. Subjective insomnia severity and tendencies to ruminate in response to fatigue predicted post-treatment anxiety change, in addition to younger age and lower baseline anxiety. The findings suggest that younger GAD-I participants with moderate anxiety symptoms may benefit most from the anxiety-relieving impact of CBT-I. Reducing perceived insomnia severity and the tendency to ruminate in response to fatigue may support reductions in anxiety in those with GAD-I.

Abstract Study Objectives There is mixed evidence for the relationship between poor sleep and daytime fatigue, and some have suggested that fatigue is simply caused by lack of sleep. Although retrospective measures of insomnia and fatigue tend to correlate, other studies fail to demonstrate a link between objectively disturbed sleep and fatigue. The current study prospectively explored the relationship between sleep and fatigue among those with and without insomnia disorder. Methods Participants meeting Research Diagnostic Criteria for insomnia disorder (n = 33) or normal sleepers (n = 32) completed the Consensus Sleep Diary (CSD) and daily fatigue ratings for 2 weeks. Baseline questionnaires evaluated cognitive factors including unhelpful beliefs about sleep and rumination about fatigue. Hierarchical linear modeling tested the within- and between-participant relationships between sleep quality, total sleep time, and daily fatigue ratings. Mediation analyses tested if cognitive factors mediated the relationship between insomnia and fatigue. Results Self-reported nightly sleep quality significantly predicted subsequent daily fatigue ratings. Total sleep time was a significant predictor of fatigue within, but not between, participants. Unhelpful sleep beliefs and rumination about fatigue mediated the relationship between insomnia and fatigue reporting. Conclusions The results suggest that perception of sleep plays an important role in predicting reports of daytime fatigue. These findings could be used in treatment to help shift the focus away from total sleep times, and instead, focus on challenging maladaptive sleep-related cognitions to change fatigue perception.

Abstract Study Objective: To compare cognitive behavioral therapy for insomnia (CBT-I) + antidepressant medication (AD) against treatments that target solely depression or solely insomnia. Design: A blinded, randomized split-plot experimental study. Setting: Two urban academic clinical centers. Participants: 107 participants (68% female, mean age 42 ± 11) with major depressive disorder and insomnia. Interventions: Randomization was to one of three groups: antidepressant (AD; escitalopram) + CBT-I (4 sessions), CBT-I + placebo pill, or AD + 4-session sleep hygiene control (SH). Measurements and Results: Subjective sleep was assessed via 2 weeks of daily sleep diaries (use of medication was covaried in all analyses); although there were no statistically significant group differences detected, all groups improved from baseline to posttreatment on subjective sleep efficiency (SE) and total wake time (TWT) and the effect sizes were large. Objective sleep was assessed via overnight polysomnographic monitoring at baseline and posttreatment; analyses revealed both CBT groups improved on TWT (p = .03), but the AD + SH group worsened. There was no statistically significant effect for PSG SE (p = .07). There was a between groups medium effect observed for the AD + SH and CBT + placebo group differences on diary TWT and both PSG variables. All groups improved significantly from baseline to posttreatment on the Hamilton Rating Scale for Depression (HAMD-17); the groups did not differ. Conclusions: Although all groups self-reported sleeping better after treatment, only the CBT-I groups improved on objective sleep, and AD + SH’s sleep worsened. This suggests that we should be treating sleep in those with depression with an effective insomnia treatment and relying on self-report obscures sleep worsening effects. All groups improved on depression, even a group with absolutely no depression-focused treatment component (CBT-I + placebo). The depression effect in CBT-I only group has been reported in other studies, suggesting that we should further investigate the antidepressant properties of CBT-I.

Adolescence represents a period of marked vulnerability for sleep difficulties because of maturations in sleep systems that push towards more sleep opportunity and psychosocial factors (e.g., early school start times) that limit sleep. Adolescents are a unique population that has been understudied in terms of empirical rigour and would benefit from a comprehensive investigation of sleep patterns using a mixed-methods approach. We conducted a community-based participatory research study (student n = 369, school n = 6) in private high schools using a combination of quantitative and qualitative survey questions. Descriptive and between-group analyses were conducted to understand adolescent sleep patterns and how sleep patterns differed between age groups. Qualitative survey data were analyzed using reflexive thematic analysis. Nearly half of the students did not meet the recommended sleep duration. There was also significant weekly variability in bed and rise times, contributing to jet lag symptoms. Older students preferred to go to bed and get out of bed later compared to their younger counterparts. Qualitative analyses dovetailed with these findings in addition to identifying daytime fatigue as an important challenge. However, many students also reported a pattern of positive sleep health. Results demonstrated that private high school students experience significant sleep disruptions consistent with the broader literature though there was less evidence of excessive sleepiness. Possible policy recommendations and interventions include staggered school start times and evidence-informed intervention strategies that do not require significant health care resources and are enjoyable to use for adolescents to support engagement. L'adolescence représente une période de vulnérabilité marquée aux troubles du sommeil en raison de la maturation des systèmes de sommeil qui favorisent l'augmentation des possibilités de sommeil et des facteurs psychosociaux (par exemple, le début des classes tôt le matin) qui limitent la durée du sommeil. Les adolescents constituent une population unique qui a été peu étudiée en termes de rigueur empirique et qui bénéficierait d'une étude approfondie des habitudes de sommeil à l'aide d'une approche de méthodes mixtes. Nous avons mené une étude de recherche participative basée sur la communauté (étudiant N = 369, école N = 6) dans des écoles secondaires privées en utilisant une combinaison de questions d'enquête quantitatives et qualitatives. Des analyses descriptives et des analyses entre groupes ont été effectuées pour comprendre les habitudes de sommeil des adolescents et les différences entre les groupes d'âge. Les données qualitatives de l'enquête ont été analysées à l'aide d'une analyse thématique réflexive. Près de la moitié des élèves ne respectaient pas la durée de sommeil recommandée. Les heures de coucher et de lever varient également beaucoup d'une semaine à l'autre, ce qui contribue aux symptômes du décalage horaire. Les étudiants plus âgés préféraient se coucher et se lever plus tard que leurs homologues plus jeunes. Les analyses qualitatives vont dans le même sens que ces résultats et identifient la fatigue diurne comme un problème important. Toutefois, de nombreux élèves ont également fait état d'une bonne santé du sommeil. Les résultats ont montré que les élèves des écoles secondaires privées subissent d'importantes perturbations du sommeil, conformément à la littérature générale, bien qu'il y ait moins de preuves de somnolence excessive. Les recommandations en matière de politiques et d'interventions possibles comprennent des horaires de début des classes décalés et des stratégies d'intervention fondées sur des données probantes qui ne nécessitent pas de ressources importantes en matière de soins de santé et qui sont agréables à utiliser pour les adolescents afin de les encourager à s'engager. Public Significance Statement There is a public health crisis in the adolescent population which is leading to poorer health and performance at school. This study mapped out sleep habits in several private high schools in British Columbia and Ontario and found that a significant number of students report insomnia symptoms (difficulties falling and/or staying asleep) and are not meeting guidelines for sufficient sleep. The results help us identify areas of sleep health in Canadian adolescents to further support through intervention and policy recommendations such as staggered school start times.