Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline

Abstract

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. 1. We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG). 2. We suggest that clinicians use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 3. We suggest that clinicians use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 4. We suggest that clinicians use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 5. We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL). 6. We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL).

Keywords: behavioral treatment; chronic insomnia disorder; clinical practice guideline; psychological treatment.

Conflict of interest statement

The development of this paper was funded by the American Academy of Sleep Medicine. Dr. Martin serves on the AASM Board of Directors. Ms. Kazmi is employed by the AASM. Mr. Heald was employed by the AASM during his work on this paper, but his employment by the AASM ended in July 2020. The following include all the conflicts managed throughout guideline development. Dr. Edinger received funding from Merck for an insomnia research study, and his research program was loaned portable PSG recorders from Philips/Respironics to support a NIMH funded research grant. Dr. Arnedt was loaned an FDA-cleared device treatment for insomnia by Ebb (2018–present), served as a consultant to Magna Seating Systems Engineering until 2016 to develop a report on drowsy driving, served on a contract project with NHTSA on drowsy driving (2018–present) and was a co-investigator for a study funded by the NBA contracted with the University of Michigan to evaluate the validity of commercially available devices to measure sleep (ended 2019). Dr. Bertisch was a co-investigator on an insomnia research project funded by Merck (ended 2017), serves as an unpaid member of the Board of Directors of the Alliance of Sleep Apnea Partners, a non-profit patient centered group. Dr. Lichstein is a member of the insomnia advisory board for Merck, the topic of which is unrelated to the behavioral treatments of insomnia. Dr. Sateia served as a consultant for Physicians Seal for melatonin – 30 minutes consultation in 2018. Dr. Troxel was a co-investigator on a study about the prevalence and risk factors for nocturia using data from the British Healthy Workers (ended March 2020), served as a consultant for Guidepoint, as a subject matter expert on sleep to industry clients (January 2018–present), has received research funding from the National Institutes of Health, was principal investigator on a grant funded by Feelmore Labs to review a clinical trial design and protocol for an investigational neurostimulation device (ended June 2020), and serves on the scientific advisory board for Feelmore Labs.

© 2021 American Academy of Sleep Medicine.