Treating Chronic Insomnia Overnight
Intensive sleep retraining is a novel, brief, and effective treatment for sleep-onset insomnia.
Stimulus control therapy (SCT) is the major behavioral treatment for chronic insomnia. These authors studied a novel, 25-hour, nonpharmacological treatment, intensive sleep retraining (ISR), alone and in combination with SCT.
The 79 adults (mean age, 41) had sleep-onset insomnia and no other sleep disorder or major psychiatric illness. They were randomized to sleep hygiene advice (control condition), SCT (5 weekly appointments with a psychologist, focusing on reassociating bed/bedroom with sleep and establishing a consistent sleep schedule), ISR followed by SCT plus sleep hygiene, or ISR followed by sleep hygiene. ISR was conducted in a sleep laboratory and started at 10:30 PM after a restricted, 5-hour sleep the previous night. Over the next 25 hours, participants underwent 50 half-hour sleep trials. At each trial, participants who fell asleep within 20 minutes were awakened after 3 minutes of polysomnographically confirmed sleep, asked whether they thought they had been asleep, and told that they had been asleep.
All three active treatments significantly improved sleep-onset latency and total sleep time, compared with sleep hygiene. ISR produced the most rapid improvement, over the first week. Six weeks after treatment, response (sleep-onset latency, <30 minutes or <50% of baseline) was seen in 61% of the SCT+ISR group, 47% of the ISR group, and 38% of the SCT group. Gains in all groups were largely maintained through 6 months of follow-up.
Comment: As both authors and commentators explain, intensive sleep retraining counters the conditioned psychophysiological arousal that maintained insomnia, allows massed practice in falling asleep rapidly, and provides feedback about objectively recorded sleep onset. The rapid and sustained effects of ISR make it an exciting new treatment. Clinicians should consider this option for their patients with chronic sleep-onset insomnia. Eventual development of home-based, less expensive versions of ISR should make it more widely available.
Deborah Cowley, MD
Published in Journal Watch Psychiatry February 6, 2012