Insomnia is the most common type of sleep disorder in clinical practice. The results of a global epidemiological study (questionnaire survey) on insomnia in 10 countries in 2002 showed that 45.4% of Chinese people had experienced insomnia to varying degrees in the past month. In order to standardize the clinical application of insomnia treatment drugs, the Insomnia Treatment Consensus Expert Group drafted an expert consensus on the definition, diagnosis and drug treatment of insomnia in China in 2004, which was officially published in 2006 after several revisions. In 2010, the Sleep Disorders Group of the Neurology Branch of the Chinese Medical Association invited experts from relevant disciplines to develop a set of guidelines for the diagnosis and treatment of insomnia in adults in China in accordance with the principles of evidence-based medicine, with reference to recent advances in the field of insomnia diagnosis and treatment, and taking into account the national conditions of China, with the aim of providing clinicians with a standardized framework for the treatment of insomnia in adults. The aim is to provide clinicians with a standardized framework for the diagnosis and treatment of insomnia in adults. In the process of clinical practice, physicians should still make individualized treatment with reference to the specific conditions of patients in this guideline.
I. Criteria for classifying the recommended intensity of treatment regimens
This guideline mainly refers to the available evidence-based medical data and the clinical operability under the existing conditions in China when recommending the treatment plan. For the treatment methods commonly used in China but not validated by the effective evidence-based medical model, we recommend them with reference to their efficacy assessment, risk estimation, economic burden and practicality, etc., and reach a consensus after expert discussion. The strength of the recommendation is divided into 4 levels (I is the strongest and IV is the weakest): I recommendation: based on evidence-based medicine level 1 evidence or most recognized level 2 evidence, if there is no contraindication can be used directly in clinical practice; II recommendation based on evidence-based medicine level 2 evidence or highly consistent expert consensus, can be applied when the evidence is sufficient; III recommendation: based on evidence-based medicine level 3 evidence or expert consensus, can be used after discussion with patients Level IV recommendation: optional program, patients need to be informed of the potential risks, not used for patients without indications.
II. Definition and classification of insomnia
Insomnia is usually defined as a subjective experience of unsatisfactory sleep duration and/or quality that affects daytime social functioning. Insomnia is characterized by difficulty in falling asleep (more than 30 min), sleep maintenance disorder (≥2 awakenings throughout the night), early awakening, decreased sleep quality and reduced total sleep time (usually less than 6 h), accompanied by daytime dysfunction. Insomnia is classified according to its duration: acute insomnia (duration ≥ 1 month); subacute insomnia (duration ≥ 1 month, < 6 months) and chronic insomnia (duration ≥ 6 months). Insomnia can be divided into two categories: primary and secondary, according to the etiology. Primary insomnia usually lacks a clear etiology or remains after the exclusion of possible causes of insomnia, and mainly includes three types of psychophysiological insomnia, idiopathic insomnia and subjective insomnia. The diagnosis of primary insomnia lacks specific indicators and is mainly an exclusionary diagnosis. When the possible causes of insomnia have been excluded or cured, insomnia symptoms are still left behind, primary insomnia can be considered. Secondary insomnia includes insomnia caused by physical diseases, mental disorders, substance abuse, and insomnia related to sleep disordered breathing and sleep movement disorders. Insomnia often occurs together with other diseases, and it is sometimes difficult to determine the causal relationship between these diseases and insomnia, so the concept of comorbidinsomnia has been proposed in recent years to describe insomnia that is accompanied by other diseases.
Clinical assessment and diagnosis of insomnia
(A) Clinical assessment
1. History taking: Clinicians need to take a careful medical history, including specific sleep conditions, medication history and possible substance dependence, physical examination and psychiatric assessment. The specifics of sleep status information acquisition include insomnia manifestations, resting patterns, sleep-related symptoms, and the impact of insomnia on daytime functioning. History information can be collected by a variety of means, including self-assessment scale tools, home sleep records, symptom screening forms, psychiatric screening tests, and family member statements. The recommended history collection process (l-7 are required assessment items and 8 are recommended assessment items) is as follows: (1) clarify the presence of neurological, cardiovascular, respiratory, digestive, and endocrine disorders through systematic review, and also rank the presence of various other types of somatic disorders, such as pruritus and chronic pain; (2) clarify the presence of mood disorders, anxiety disorders, and memory disorders through interviewing the patient. (3) review the history of drug or substance application, especially antidepressants, central excitatory drugs, analgesics, sedatives, theophyllines, steroids, and psychoactive substance abuse such as alcohol; (4) review the overall sleep status in the past 2-4 weeks, including the sleep latency (the time between going to bed and starting to sleep), the number of awakenings during sleep, the duration and total sleep time. It is important to note that the average estimate should be used when asking about the above parameters, and it is not appropriate to base the diagnosis on the sleep status and experience of a single night; (5) perform a sleep quality assessment with the help of a scale tool such as the PittsburghSleepQualityIndex (PSQJ) questionnaire; (6) assess daytime function by asking questions or with the help of a scale tool (6) Assessment of daytime function by consultation or with the aid of scale tools to exclude other disorders that impair daytime function; (7) EpworthSleepinessScale (ESS) assessment for patients with daytimesleepiness, combined with consultation to screen for sleep disordered breathing and other sleep disorders; (8) If possible, it is best to have the patient and family complete a 2-week assessment prior to the first systematic assessment. The patient and family members should assist in completing a 2-week sleep diary, recording the daily bedtime, estimating the sleep latency, recording the number of nighttime awakenings and the time of each awakening, recording the total bedtime between bedtime and waking, estimating the actual sleep time based on the morning awakening time, calculating the sleep efficiency (i.e., actual sleep time/bedtime × 100%), recording abnormal nocturnal symptoms (abnormal breathing, behavior, movement, etc.), and recording the daily sleep efficiency. The actual sleep efficiency (i.e., actual sleep time/bedtime × 100%) was calculated, and abnormal nighttime symptoms (abnormal breathing, behavior, movement, etc.), the extent to which daytime energy and social functioning were affected, and lunch breaks were recorded. Daytime medication use and self-experience.
2. Scale assessment: including self- and other-assessed insomnia-related scales: (1) ESS; (2) Insomnia Severity Index; (3) PSQI; (4) Beck Depression Inventory; (5) StateTraitAnxietyInventory (STAI); (6) Fatigue Severity Scale ( FatigueSeverityScale); (7) Quality of Life Questionnaire (SF-36); (8) Sleep Beliefs and Attitudes Questionnaire.
3.Objective assessment: Compared with healthy people, insomnia patients are more prone to bias in their self-assessment of sleep status due to neuropsychological or cognitive-behavioral changes, and need to be screened by objective assessment tools when necessary. The polysomnogram (PSG) is mainly used for the assessment and differential diagnosis of sleep disorders. PSG assessment can be performed for the differential diagnosis of patients with chronic insomnia. The multiplesleep latency test (MSLT) is used for the diagnosis and differential diagnosis of episodic sleep disorders and excessive daytime sleepiness (EDS). Somatic motion recording (actigraph) can be used as an alternative means to assess a patient’s total nighttime sleep time and sleep patterns when PSG monitoring conditions are not available. Neurofunctional imaging opens up a new field for the diagnosis and differential diagnosis of insomnia, but due to the expensive equipment, it cannot be promoted in clinical practice yet.
(ii) Diagnosis
The diagnosis of insomnia must meet the following conditions:
1. The presence of one of the following symptoms: difficulty falling asleep, sleep maintenance disorder, early awakening, decreased sleep quality or non-restorativesleep in the morning after waking up from daily sleep.
2.The above symptoms occur despite the condition of sleep and the environment is suitable for sleep
3. The patient complains of at least one of the following sleep-related impairments in daytime functioning: (1) fatigue or general malaise; (2) decreased attention, attention maintenance, or memory; (3) decreased ability to learn, work, and/or socialize; (4) mood swings or irritability; (5) daytime sleepiness; (6) decreased interest or energy; (7) increased tendency to make mistakes at work or while driving; (8) nervousness, headache, dizziness, or other symptoms related to sleep. headache, dizziness, or other somatic symptoms associated with sleep deprivation; (9) excessive concern about sleep.
IV. Treatment of insomnia
(I) Overall goal
To clarify the etiology as much as possible and to achieve the following objectives: (1) to improve sleep quality and/or increase effective sleep time: (2) to restore social function and improve patients’ quality of life; (3) to reduce or eliminate the risk of somatic diseases associated with insomnia or co-morbidities with somatic diseases; (4) to avoid the negative effects of pharmacological interventions.
(II) Intervention modalities
The interventions for insomnia mainly include pharmacological and non-pharmacological treatments. For patients with acute insomnia, early application of pharmacological treatment is appropriate. For patients with subacute or chronic insomnia, whether primary or secondary, pharmacological treatment should be complemented by psychobehavioral treatment, even for those who have been taking sedative-hypnotic drugs for a long time. The main effective psycho-behavioral therapy for insomnia is cognitivebehavioral therapy for insomnia (CBT-I). At present, there is a relative lack of professional resources to engage in psycho-behavioral therapy in China, and not many people are certified in this field, and the use of CBT-I alone may also face compliance problems, so pharmacological interventions still dominate the treatment of insomnia. Non-pharmacological treatments other than psycho-behavioral therapy, such as diet therapy, aromatherapy, massage, homeopathy, and light therapy, lack convincing controlled studies with large samples. Traditional Chinese medicine has a long history of treating insomnia, but it is limited by the special individualized medical model, which is difficult to be evaluated by modern evidence-based medical model. The importance of sleep health education should be emphasized, i.e., psycho-behavioral treatment, pharmacological treatment and traditional medicine treatment on the basis of establishing good sleep hygiene habits
(C) Pharmacological treatment of insomnia
Although there is a wide variety of drugs with hypnotic effects, the main purpose of most of them is not to treat insomnia. The main drugs currently used in clinical treatment of insomnia include benzodiazepine receptor agonists (BZRAs), melatonin receptor agonists, and antidepressants with hypnotic effects. Although antihistamines (e.g., diphenhydramine), melatonin, and valerian extract have hypnotic effects, the available evidence from clinical studies is limited and they should not be used as routine medications for insomnia. Alcohol (ethanol) cannot be used dry to treat insomnia.
1.BZRAs: divided into traditional benzodiazepines (benzodiazepinedrugs, BZDs) and new non-benzodiazepinedrugs (non-benzodiazepinedrugs, non-BZDs). BZDs, which have been used since the 1960s, can non-selectively agonize the γ-aminobutyric acid receptor A (GABAA Since the 1960s, non-BZDs, represented by zolpidem, have been used in the clinical treatment of insomnia. Since they are more selective for the α1 subunit on GABAA, they mainly exert hypnotic effects.
(1)BZDs: there are more types, such as estazolam, flurazepam, quazepam, temazepam, triazolam, alprazolam, chlordiazepoxide, diazepam, and diazepam. diazepam, lorazepam and midazolam, the first five of which are approved by the FDA for the treatment of insomnia. It should be noted that in China, triazolam is managed as a Class I psychotropic drug and is not recommended for the treatment of insomnia, while the other listed BZDs are managed as Class II psychotropic drugs. These BZDs can shorten the sleep latency and increase the total sleep time of insomniacs. Adverse effects include daytime sleepiness, dizziness, hypotonia, falls, and cognitive impairment. The use of BZDs in elderly patients is particularly important to note the muscle relaxing effects of the drug and the risk of falls. The use of medium- and short-acting BZDs for insomnia has the potential to cause rebound insomnia. Withdrawal symptoms may occur upon discontinuation of BZDs after continued use. The potential risk of substance abuse needs to be considered in insomnia patients with a history of substance abuse. BZDs are contraindicated in women who are pregnant or lactating, in those with hepatic or renal impairment, in those with obstructive sleep apnea syndrome, and in those with severe ventilatory deficits.
(2) non-BZDs: These include zolpidem, zolpidem controlled release (zolpidem-CR), zopiclone, eszopiclone, and zaleplon, which have similar hypnotic efficacy to BZDs. Due to the short half-life of non-BZDs, the residual effect of the next day is minimized, generally does not produce daytime sleepiness, the risk of drug dependence is lower than traditional BZDs, the treatment of insomnia is safe and effective, long-term use without significant adverse drug reactions, but there is a possibility of a transient rebound of insomnia after sudden discontinuation of the drug.
2, melatonin and melatonin receptor agonists: melatonin is involved in regulating the sleep-wake cycle and can improve symptoms caused by jet lag changes, delayed sleep phase syndrome and circadian rhythm dysregulation sleep disorder, but melatonin is not recommended for use as a hypnotic drug because there is no consistent conclusion on clinical application. Melatonin receptor agonists include remelteon (ramelteon), tesimelteon (in phase III clinical, tasimelteon), and agomelatin (agomelatin). Remelteon is a melatonin receptor MT1 and MT2 agonist currently in clinical use, which can shorten sleep latency, improve sleep efficiency, and increase total sleep time, and can be used to treat insomnia with difficulty falling asleep as the main complaint and circadian rhythm disorder sleep disorders. In addition, Ramelteon is safe and effective for insomnia patients with combined sleep breathing disorders. It has been approved for the long-term treatment of insomnia because it has no drug dependence and does not produce withdrawal symptoms. Agomelatine is both a melatonin receptor agonist and a 5-hydroxytryptamine receptor antagonist, and thus has both antidepressant and hypnotic effects, improving insomnia associated with depressive disorders, shortening sleep latency, and increasing sleep continuity. Unlike BZDs, melatonin receptor agonists can be used as an alternative treatment for patients who cannot tolerate the aforementioned hypnotic drugs as well as for patients who have developed drug dependence.
3, antidepressants: some antidepressants have hypnotic sedative effect, in insomnia accompanied by depression, anxiety state of mind when the application is more effective. (1) tricyclic antidepressants: Amitriptyline can shorten sleep latency, reduce awakenings during sleep, increase sleep time and improve sleep efficiency, but it also reduces slow-wave sleep and reduces REM sleep to varying degrees, and has many adverse effects, such as dry mouth, accelerated heart rate and difficulty in urination caused by anticholinergic effects. Therefore, it is not used as the drug of choice for insomnia. Small doses of doxepin (3-6mg/d) can improve the sleep status of adult and elderly chronic insomnia patients because of the specific antihistamine mechanism, with the characteristics of good clinical tolerance delivery and no withdrawal effect, which has been used as one of the recommended drugs for insomnia treatment abroad in recent years. (2) Selective 5-tryptamine reuptake inhibitors (SSRIs): Although they have no clear hypnotic effect, they can improve insomnia symptoms by treating depression and anxiety disorders. Some SSRIs prolong sleep latency, increase awakenings during sleep, decrease sleep duration and sleep efficiency, reduce slow-wave sleep, and may increase periodic limb movements and eye activity during NREM sleep. Some patients may even aggravate their insomnia symptoms when taking them; therefore, SSRIs are generally recommended to be taken during the daytime. (3) 5-hydroxytryptamine and norepinephrine reuptake inhibitors (SNRIs): These include venlafaxine and duloxetine. Improves insomnia by treating depressive and anxiety states. The deficiencies are almost identical to those of SSRIs. (4) Other antidepressants: small doses of mirtazapine (15-30mg/d) can relieve insomnia symptoms; small doses of trazodone (25-100mg/d) have a sedative effect and can be used to treat insomnia and insomnia rebound after discontinuation of hypnotic drugs. (5) Combination of antidepressants and BZRAs: chronic insomnia often coexists with depressive symptoms, and the simultaneous combination of short-acting BZRAs at the beginning of treatment with antidepressants is beneficial to improve insomnia symptoms as soon as possible and improve patient compliance. For example, the combination of zolpidem and some SSRIs (paroxetine, etc.) can rapidly relieve insomnia symptoms and improve quality of life, while synergistically improving depression and anxiety symptoms.
4. Specific recommendations for pharmacotherapy: The key to pharmacotherapy is to grasp the balance of benefits and risks. When selecting intervention drugs, we need to consider the specificity of the symptoms, the response to previous medication, the general condition of the patient, the interaction of current medication, adverse drug reactions, and other diseases of the current patient. Therapeutic principles need to be followed along with the principles of individualization.
(1) Mode of administration:BZRAs are generally administered at night before bedtime and taken l times per night, called drug continuity. For chronic insomnia patients, intermittent treatment of non-BZDs is advocated from the perspective of safety and compliance with medication, i.e., choosing to take the medication several nights a week instead of taking it every night continuously. The frequency of intermittent treatment is not conclusive, but the recommended frequency of intermittent dosing is 3-5 times per week. Which night is more appropriate? Based on the results of clinical trials of pizotam, it is recommended that patients should take it on an “as needed” basis according to their sleep needs (Class II recommendation). The specific decision of “on-demand” can be referred to the following criteria: (1) when sleep is expected to be difficult: take it 5-10 min before going to bed; (2) according to the needs of night sleep: take it 30 min after going to bed and still cannot fall asleep; (3) if you wake up during the night and cannot fall asleep again, and the expected time to wake up is more than 5h, can be taken (only suitable for the use of short half-life drugs); ④ according to the needs of daytime activities (the next day when there are important work or business), taken at bedtime. Antidepressants with hypnotic effects and melatonin receptor agonists are taken at bedtime. Due to different pharmacological mechanisms, antidepressants are generally not administered intermittently or on demand. Whether melatonin receptor agonists can be administered intermittently or on demand requires further study.
(2) Duration of treatment:The duration of pharmacological treatment for insomnia is not clearly defined and the dose and maintenance time should be adjusted according to the patient’s condition. Continuous treatment can be chosen for pharmacological interventions of less than 4 weeks, while pharmacological interventions of more than 4 weeks need to be re-evaluated and, if necessary, the intervention protocol changed or intermittent treatment used when appropriate according to the patient’s sleep improvement status (Class II recommendation).
(3) Change of medication: The indications for change of medication include (i) ineffectiveness of the recommended therapeutic dose; (ii) development of tolerance; (iii) serious adverse reactions; (iv) interaction with drugs used to treat other diseases; (v) use for more than 6 months; (vi) high-risk groups (patients with a history of addiction). See sequential treatment plan for the choice of drug change.
(4) Discontinuation of treatment: When the patient feels able to self-control sleep, gradual discontinuation of the drug can be considered. If insomnia is associated with other disorders (e.g., depressive disorders) or life events, discontinuation of sedative-hypnotic drugs should also be considered when the cause is removed. Recommended discontinuation principles: ① Avoid abrupt termination of medication to reduce insomnia rebound (level II recommendation); ② Discontinuation should be gradual, sometimes taking weeks to months, and if severe or persistent psychiatric symptoms occur during discontinuation, the patient should be re-evaluated (level II recommendation); ③ Commonly used methods of dose reduction are gradual reduction of nighttime medication and/or changing continuous treatment to intermittent treatment (level III recommendation).
(5) Treatment when drug therapy is ineffective: Some insomnia patients have limited response to drug therapy, or can only obtain transient sleep improvement. In addition, some insomnia patients suffer from multiple diseases at the same time, and the simultaneous application of multiple drugs may interfere with the therapeutic effect due to drug interactions. Cognitive-behavioral interventions are recommended as an add-on or alternative treatment when satisfactory results cannot be obtained with standard medication (level I recommendation).
(6) Recommended insomnia drug treatment strategies (⑤-⑧ can be regarded as sequential programs): ① When insomnia is secondary to or associated with other diseases, the primary or concomitant disease should be treated simultaneously; ② The drug treatment should be accompanied by helping the patient to establish healthy sleep habits; ③ The patient’s response to treatment should be monitored and evaluated after the drug treatment is started. Long-term, refractory insomnia should be treated under the guidance of a specialist; ④If available, cognitive-behavioral therapy should be performed along with pharmacological interventions (Class I recommendation); ⑤Short-acting BZRAs such as pyrazolam, zopiclone, dezopiclone and zaleplon are preferred for primary insomnia (Class II recommendation); ⑥If the preferred drug is ineffective or non-compliant, replace it with another short- to medium-acting BZRAs or melatonin receptor agonists (Class II recommendation); (vii) add antidepressants with sedative effects (e.g., doxepin, trazodone, mirtazapine, or paroxetine), especially for insomnia with anxiety and depressive symptoms (Class II recommendation); (viii) BZRAs or melatonin receptor agonists can be combined with antidepressants (Class II recommendation); (ix) non-BZDs or melatonin receptor agonists (level II recommendation), ⑩ antihistamines, antiallergic drugs and other sleep-assisting over-the-counter drugs are not suitable for the treatment of chronic insomnia; (11) for chronic insomnia patients with long-term application of sedative-hypnotic drugs, continuous drug treatment is not advocated, and intermittent treatment or on-demand medication is recommended (see below), while an assessment every 4 weeks is recommended (level III recommendation).
5. Pharmacological treatment for patients with special types of insomnia.
(l) Elderly patients:Non-pharmacological treatments, such as sleep hygiene education, are preferred for elderly insomnia patients, with particular emphasis on receiving CBT-I (Class I recommendation). When treatment for the primary disease does not relieve insomnia symptoms or when non-pharmacological treatment cannot be complied with, pharmacological treatment may be considered. Non-BZDs or melatonin receptor agonists are recommended for elderly patients with insomnia (Class II recommendation). Caution should be exercised when using BZDs if necessary, and in case of ataxia, confusion, paradoxical movements, hallucinations. In case of ataxia, confusion, paradoxical movements, hallucinations, respiratory depression, immediate discontinuation of the drug and proper treatment are required, and attention should be paid to the possibility of accidental injuries such as falls caused by reduced muscle tone due to the use of BZDs. The dose of drug therapy for elderly patients should start from the minimum effective dose, short-term application or intermittent therapy, not to advocate high dose administration, the process of drug administration should be closely observed adverse drug reactions.
(2) Pregnant and lactating patients: There is a lack of information on the safety of sedative-hypnotic drugs in women during pregnancy. Since zolpidem has no teratogenic effect in animal experiments, it can be taken for a short time if necessary (Grade IV recommendation). Caution is needed in the application of sedative-hypnotic drugs as well as antidepressants during lactation to avoid the effect of drugs on the infant through breast milk, and non-pharmacological interventions are recommended for the treatment of insomnia (Class I recommendation).
(3) Perimenopausal and menopausal patients: For perimenopausal and menopausal women with insomnia, common diseases affecting sleep in this age group, such as depressive disorders, anxiety disorders and sleep apnea syndrome, should be identified and treated first, and necessary hormone replacement therapy should be given according to symptoms and hormone levels.
(4) Patients with respiratory diseases: BZDs are used with caution in patients with chronic obstructive pulmonary disease (COPD) and sleep apnea hypoventilation syndrome due to their adverse effects such as respiratory depression. Adverse reactions have not been reported, but the efficacy of zaleplon in insomniacs with respiratory disease has not been established. Elderly patients with sleep apnea can have insomnia as the main complaint, and the number of people with complex sleep apnea [complexsleepapnea) is increasing. Short-acting sleep-promoting drugs such as zolpidem alone can reduce the occurrence of central sleep apnea, and their simultaneous application with noninvasive ventilator therapy can improve compliance and reduce the possibility of inducing obstructive sleep apnea. BZDs are contraindicated in patients with acute exacerbation of CDPD with significant hypercapnia and in the decompensated phase of restrictive ventilatory dysfunction, and may be applied and closely monitored alongside mechanical ventilation support (invasive or noninvasive) if necessary. The melatonin receptor agonist ramelteon can be used to treat patients with sleep apnea combined with insomnia, but further studies are needed.
(5) Patients with co-morbid psychiatric disorders:Insomnia symptoms are often present in patients with psychiatric disorders and should be treated and controlled by a licensed psychiatrist according to specialist principles for the primary disorder, along with treatment of insomnia symptoms. Depressive disorders are often co-morbid with insomnia and should not be treated in isolation to avoid entering a vicious circle of dilemma. The recommended combination treatments include: ① CBT-I for insomnia along with the application of antidepressants with hypnotic effects (such as doxepin, amitriptyline, mirtazapine or paroxetine); ② antidepressants (monotherapy or combination) plus sedative-hypnotic drugs (such as non-BZDs drugs or melatonin receptor agonists ( Level III recommendation). It is important to note that the use of antidepressants and hypnotic drugs has the potential to exacerbate sleep apnea syndrome and periodic leg movements. When insomnia is present in patients with anxiety disorders, anxiolytic medications are the mainstay, with sedative-hypnotic medications added at bedtime if necessary. When insomnia exists in patients with schizophrenia, antipsychotic medication should be chosen as the main treatment, supplemented with sedative-hypnotic medication for insomnia if necessary.
(iv) Psychological-behavioral treatment of insomnia
The essence of psychobehavioral treatment is to change the patient’s belief system, to exert their self-efficacy, and thus to improve insomnia symptoms. To accomplish this goal, the involvement of a medical professional is often required. Psychobehavioral treatments are effective for primary and secondary insomnia in adults and often include sleep hygiene education, stimulus control therapy, sleep restriction therapy, cognitive therapy, and relaxation therapy. These approaches are used either independently or in combination for the treatment of primary or secondary insomnia in adults.
1. Sleep hygiene education:Most insomnia patients have poor sleep habits that disrupt the normal sleep pattern and form a wrong concept of sleep, which leads to insomnia. Sleep hygiene education is mainly to help insomnia patients understand the important role of bad sleep habits in the occurrence and development of insomnia, analyze and find the reasons for forming bad sleep habits, and establish good sleep habits. In general, sleep hygiene education needs to be carried out simultaneously with other psychological and behavioral treatments, and it is not recommended to carry out sleep hygiene education as an isolated intervention.
The content of sleep hygiene education includes:
(1) Avoid stimulants (coffee, strong tea, or smoking, etc.) several hours before bedtime (usually after 4:00 p.m.);
(2) Do not drink alcohol before bedtime, as alcohol can interfere with sleep;
(3) regular physical exercise, but before bedtime should avoid strenuous exercise;
(4) do not eat and drink or eat indigestible food before bedtime;
(5) at least 1h before bedtime do not do mental work or watch books and movies that can easily cause excitement;
(6) bedroom environment should be quiet, comfortable, light and temperature appropriate;
(7) to maintain a regular rest and rest time.
2, relaxation therapy: stress, tension and anxiety are common factors that induce insomnia. Relaxation therapy can alleviate the adverse effects of the above factors, so it is the most commonly used non-pharmacological treatment for insomnia, the purpose of which is to reduce the alertness when lying in bed and reduce nighttime awakenings. Technique training to reduce arousals and promote nighttime sleep includes progressive muscle relaxation, guided imagery, and abdominal breathing exercises. Patients planning relaxation training should practice consistently 2-3 times a day in a neat and quiet environment, initially under professional supervision. Relaxation therapy can be used as an independent intervention for insomnia treatment (Level I recommendation).
Stimulation control therapy: Stimulation control therapy is a set of behavioral interventions to improve the interaction between sleep environment and sleep tendency (sleepiness), to restore the function of bed as a sleep-inducing signal, so that patients can easily fall asleep and rebuild the sleep-wake biorhythm. Stimulus control therapy can be applied as a stand-alone intervention (Level I recommendation). Details: (1) go to bed only when you feel like sleeping; (2) if you cannot fall asleep in bed for 20 min, get up and leave the bedroom, engage in some simple activities, and return to the bedroom to sleep when you feel like sleeping; (3) do not do activities in bed that are not related to sleep, such as eating, watching TV, listening to the radio, and thinking about complex problems; (4) maintain a regular waking time regardless of the length of sleep the night before (5) Avoid naps during the day.
4, sleep restriction therapy: many insomnia patients attempt to increase the opportunity to sleep by increasing the time of bed rest, but often contrary to expectations, but the quality of sleep further decline. Sleep restriction therapy increases the drive to sleep by shortening the time spent awake in bed to improve sleep efficiency.
The recommended sleep restriction therapy is as follows (Level II recommendation): (1) reduce bedtime to match actual sleep time and increase bedtime by 15-20 min only if sleep efficiency exceeds 85% for 1 week; (2) reduce bedtime by 15-20 min when sleep efficiency is below 80%, and keep bedtime the same when sleep efficiency is between 80% and 85%; (3) keep bedtime the same when sleep efficiency is below 80%. (3) Avoid daytime naps and keep regular waking time.
5.CBT-I: Insomnia patients are often afraid of insomnia itself, overly concerned about the adverse consequences of insomnia, and often feel nervous and worried about sleeping well when they are close to sleep, these negative emotions make sleep further deteriorate, and the aggravation of insomnia in turn affects the patient’s mood, forming a vicious circle between the two. The purpose of cognitive therapy is to change the patient’s cognitive bias about insomnia and to change the patient’s irrational beliefs and attitudes about sleep problems. Cognitive therapy is often used in combination with stimulus control therapy and sleep restriction therapy to form the CBT-I for insomnia.
Basic components of cognitive-behavioral therapy:
(1) Maintain reasonable sleep expectations;
(2) Don’t blame all your problems on insomnia;
(3) Maintain natural sleep and avoid overly subjective sleep intentions (forcing oneself to sleep);
(4) Don’t focus too much on sleep;
(5) Don’t get frustrated because you didn’t get a good night’s sleep;
(CBT-I is usually a combination of cognitive therapy and behavioral therapy (stimulus control therapy, sleep restriction therapy), and can be overlaid with relaxation therapy and supplemented with sleep hygiene education.CBT-I is the core of psychobehavioral treatment for insomnia (Level I recommendation).
(E) Integration of insomnia in prognosis
The short-term efficacy of pharmacological interventions for insomnia has been proven in clinical trials, but long-term application still entails potential risks such as adverse drug reactions and addiction. CBT-I not only has short-term efficacy, but its efficacy can be maintained in the long term in follow-up observations. CBT-I can be combined with non-BZDs to gain additional advantages, and the latter can be changed to intermittent treatment to optimize the effect of this combination treatment.
The recommended combination therapy (level II recommendation): CBT-I and non-BZDs (or melatonin receptor agonists) combination therapy is preferred, with gradual discontinuation of non-BZDs if short-term symptom control is achieved, otherwise non-BZDs are changed to intermittent medication and CBT-I intervention is maintained throughout the treatment (level II recommendation).
(vi) Traditional Chinese medicine treatment
Insomnia is called “sleeplessness” in Chinese medicine. According to Chinese medicine, the qi of heaven and earth is connected with the qi of human body, and the changes of yin and yang in nature also have the law of day and night, that is, the theory of “the unity of heaven and man”. The theory of the unity of heaven and man is the essence of Chinese medicine, which theoretically explains the coordination between nature and human sleep rhythm. Normal sleep requires the coordination of the body’s yin and yang qi and blood, and the normal functioning of the internal organs. Chinese medicine treats insomnia with the guiding idea of “holistic concept and evidence-based treatment”, and considers the human being as a whole and takes a macroscopic view of the disease. Therefore, insomnia is usually classified as “liver stagnation and fire”, “phlegm-heat internal disturbance”, “yin deficiency and fire”, “deficiency of both heart and spleen”, “heart and gall bladder qi”, and “heart and spleen qi”. Therefore, insomnia is usually classified into different types of symptoms, such as “liver stagnation and fire”, “phlegm-heat internal disturbance”, “yin deficiency and fire”, “heart and spleen deficiency”, “heart and gallbladder deficiency”, “heart and kidney disconnection”, etc. Different treatment rules and prescriptions are used, which fully reflect the characteristics of individualized treatment in traditional medicine. Commonly used medicines include sour date palm, cypress seeds, ling, Yuan Zhi, Wu Wei Zi, Shou Wu Teng, Yu Jin, mast, half summer, lily, longan, etc. In addition to the internal use of Chinese medicine, there are also acupuncture, tui-na and external treatment methods.