New AASM Guidelines Support Behavioral, Psychological Treatments for Insomnia

In recent clinical practice guidelines issued by the American Academy of Sleep Medicine (AASM), authors established recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults.¹

The guidelines, which were published in the Journal of Clinical Sleep Medicine, serve as an update to the AASM’s 2006 practice parameters. Developed by an expert task force and approved by the AASM board of directors, the process involves a systematic review of the literature and an assessment of the evidence, conducted via Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Notably, 1 strong recommendation involves the use of cognitive behavioral therapy for insomnia (CBT-I). Combining 1 or more cognitive therapy strategies with education about sleep regulation, CBT-I additionally provides behavioral strategies, such as stimulus control instructions and sleep restriction therapy, that are administered over 4 to 8 sessions.

"This is the first systematic review to use the GRADE system to evaluate behavioral insomnia therapies," said lead author Jack Edinger, PhD, professor in the section of sleep medicine at National Jewish Health in Denver, in a statement. "The multicomponent treatment, cognitive behavioral therapy for insomnia, is the most supported therapy."

In prior studies, CBT-I delivered via telemedicine was noninferior to in-person delivery for managing severity of insomnia. This could prove crucial amid the pandemic, as a separate study published in the Journal of Sleep Research finds that half of surveyed respondents have reported their sleep habits as being significantly affected by the pandemic, which has led to further stress and anxiety, as well as a greater dependence on sleep medication.²

“There have been significant advancements in behavioral and psychological treatments for chronic insomnia, which affects millions of American adults,” said Kannan Ramar, MBBS, MD, president of the AASM board of directors, in a statement. “The AASM guideline will help optimize patient-centered care by providing actionable recommendations for clinicians and patients.”

The AASM guidelines additionally included several conditional recommendations for clinicians:

• Clinicians are recommended to use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults.
• Stimulus control is recommended as a single-component therapy for the treatment of chronic insomnia disorder in adults.
• Sleep restriction therapy is recommended as a single-component therapy for the treatment of chronic insomnia disorder in adults.
• Relaxation therapy is recommended as a single-component therapy for the treatment of chronic insomnia disorder in adults.
• Clinicians are recommended against using sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults.

“Although sleep hygiene practices are often suggested and well-understood by patients, sleep hygiene recommendation [does] not constitute an effective stand-alone therapy,” said Edinger.

References

1. 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. Published online November 9, 2020. doi:10.5664/jcsm.8986

2. Robillard R, Dion K, Pennestri MH, et al. Profiles of sleep changes during the COVID-19 pandemic: demographic, behavioral and psychological factors. J Sleep Res. Published online November 17, 2020. doi:10.1111/jsr.13231