Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Management of Insomnia Disorder in Adults

 

Am Fam Physician. 2018 Sep 1;98(5):319-322.

Related Practice Guideline: Treatment of Chronic Insomnia in Adults: ACP Guideline.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What are the effectiveness, comparative effectiveness, and adverse effects of interventions for insomnia disorder in adults?

Evidence-Based Answer

Cognitive behavior therapy (CBT) for insomnia improves sleep outcomes in the general adult population. (Strength of Recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) The effectiveness of CBT for insomnia was consistent across different delivery modes (i.e., in person as an individual or with a group, by telephone, through the web, or using a self-help book) and was sustained in the long term, which was defined as at least six months. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There was insufficient evidence to report on the adverse effects of CBT for insomnia. Of the U.S. Food and Drug Administration–approved prescription drugs for insomnia, eszopiclone, zolpidem, and suvorexant improved some outcomes among the general adult population in primarily short-term studies of three months or less. (SOR: A, based on consistent, good-quality patient-oriented evidence.) There was limited evidence for the long-term safety of pharmacotherapy for insomnia (eTable A), although observational studies suggest possible associations with head injuries, cancer, and dementia. Data were insufficient to evaluate the effectiveness of benzodiazepines or over-the-counter sleep aids such as diphenhydramine, doxylamine, or melatonin.1

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CLINICAL BOTTOM LINE

Effectiveness of Psychological and Behavioral Interventions for Insomnia Disorder When Compared with a Control*

InterventionGeneral adult populationAdults 55 years and olderAdults with pain conditions

Global outcomesSleep outcomesGlobal outcomesSleep outcomesGlobal outcomesSleep outcomes

Cognitive behavior therapy for insomnia†

Improves ● ○ ○ to ● ● ○

Improves ● ● ○

May improve ● ○ ○

Reduces awake time after sleep onset ● ● ○

May improve ● ○ ○

May improve some outcomes ● ○ ○

May improve other outcomes ● ○ ○

Cognitive behavior therapy for insomnia (studies lasting ≥ six months)

May improve ● ○ ○

Improves sleep efficiency ● ● ○

○ ○ ○

○ ○ ○

○ ○ ○

○ ○ ○

May improve other outcomes ● ○ ○

Stimulus control‡

○ ○ ○

May improve some outcomes ● ○ ○

○ ○ ○

May improve total sleep time ● ○ ○

○ ○ ○

○ ○ ○

Multicomponent behavior therapy or brief behavior therapy

○ ○ ○

○ ○ ○

○ ○ ○

May improve some outcomes ● ○ ○

○ ○ ○

○ ○ ○


Strength of evidence scale

● ● ● High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

● ● ○ Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

● ○ ○ Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

○ ○ ○ Insufficient: Evidence either is unavailable or does not permit a conclusion.

*—Controls included treatment as usual, attention control (i.e., sleep hygiene, sleep education), wait-list management, placebo or sham treatment, or no treatment.

†—The effectiveness of cognitive behavior therapy for insomnia was demonstrated across modes of delivery: in person as an individual, in person as a group, telephone, web-based, and self-help book.

‡—These results refer to stimulus control alone. Stimulus control is also often a component of cognitive behavior therapy for insomnia, multicomponent behavior, and brief behavior therapy.

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Management of insomnia disorder in adults: current state of the evidence. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; August 2017. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/insomnia_clinician.pdf. Accessed May 15, 2018.

CLINICAL BOTTOM LINE

Effectiveness of Psychological and Behavioral Interventions for Insomnia Disorder When Compared with a Control*

InterventionGeneral adult populationAdults 55 years and olderAdults with pain conditions

Global outcomesSleep outcomesGlobal outcomesSleep outcomesGlobal outcomesSleep outcomes

Cognitive behavior therapy for insomnia†

Improves ● ○ ○ to ● ● ○

Improves ● ● ○

May improve ● ○ ○

Reduces awake time after sleep onset ● ● ○

May improve ● ○ ○

May improve some outcomes ● ○ ○

May improve other outcomes ● ○ ○

Cognitive behavior therapy for insomnia (studies lasting ≥ six months)

Author disclosure: No relevant financial affiliations.

Address correspondence to Elizabeth Salisbury-Afshar, MD, MPH, FAAFP, FASAM, FACPM, at elizabeth.salisbury@gmail.com. Reprints are not available from the author.

References

show all references

1. Agency for Healthcare Research and Quality, Effective Health Care Program. Management of insomnia disorder in adults: current state of the evidence. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Qualit y; August 2017. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/insomnia_clinician.pdf. Accessed May 15...

2. Ford ES, Wheaton AG, Cunningham TJ, Giles WH, Chapman DP, Croft JB. Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among US adults: findings from the National Ambulatory Medical Care survey 1999–2010. Sleep. 2014;37(8):1283–1293.

3. Sleep-wake disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

4. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations and management of chronic insomnia in adults. Evid Rep Technol Assess (Summ). 2005;125:1–10.

5. Kyle SD, Morgan K, Espie CA. Insomnia and health-related quality of life. Sleep Med Rev. 2010;14(1):69–82.

6. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504.

7. Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–133.

8. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep. 2006;29(11):1415–1419.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based upon the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

See the full review, clinician summary, and consumer summary.

This series is coordinated by Kenny Lin, MD, MPH, Deputy Editor.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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