Abstract
Sleep disorders are common globally. In the United States, as many as 70 million people suffer from sleep disorders, with approximately 30% suffering from short-term insomnia and 10% from chronic insomnia, according to the American Sleep Association. 1 Fortunately, an integrative approach in the treatment of insomnia includes therapies that address the common underlying causes of disrupted sleep and also helps people experience an increased state of relaxation and mindfulness. Clinicians and researchers suggest that complementary therapies such as mind–body practices, acupuncture, and listening to music can help improve sleep quantity and sleep quality.
The Problem
Chronic insomnia is a condition to be taken seriously by clinicians, as it is a significant risk factor for accidents/injuries, cardiovascular disease, myocardial infarction, infections, depression and anxiety, and other conditions. Chronic insomnia is “disrupted sleep that occurs at least three nights per week and lasts at least three months,” according to the National Sleep Foundation. 2
Many factors contribute to insomnia, including increasing age, medical conditions, stressful living, poor sleeping environments, menopause, medication, addiction/substance abuse, and more. A thorough history, including a sleep history, physical exam, and appropriate laboratory testing may all be essential in making a clear diagnosis. A diagnosis and treatment plan is important. As one author on the topic of insomnia pointed out, “Sleep disorders including insomnia are under-recognized and undertreated.” 3
Once a diagnosis of insomnia is determined, a search for underlying causes and comorbidity is important, as is managing and improving conditions such as pain, blood sugar abnormalities, urinary frequency, and many other chronic problems that can keep people awake at night. Comorbid conditions commonly occurring with insomnia include substance abuse/dependence, depression, anxiety, and post-traumatic stress disorder (PTSD), all of which need to be addressed when approaching the management of insomnia. Of course, regular exercise and following a healthy dietary pattern are essential steps toward improved sleep, with alcohol and caffeine taken in moderation or avoided if necessary.
Medication is commonly prescribed for insomnia, and while medication can be an important initial therapy in the short-term treatment of insomnia, it is not always the best long-term treatment option. This is particularly true in older patients and in people taking multiple medications, as the risks of poly-pharmacy increase. Non-pharmacologic approaches may be considered along with medication, but they should also be considered as first-line therapies. The authors of one article, for example, pointed out, “Use of a mind–body intervention can be combined with pharmacotherapy in the treatment of insomnia.” 4 They added: “Deciding which treatment to initiate first, or whether to run treatments concurrently, depends on factors such as the nature of the insomnia, treatment history, co-morbid conditions, and acceptability of treatment to the patient and treatment cost or availability.” 4
Complementary Therapies to Consider
People suffering from insomnia often do not consider how the quality of their daytime choices significantly affects the quality of their nighttime experience. One of the most important ways to address sleep disorders, and especially insomnia, is to improve the quality of daytime living, habits, and choices. For example, if a patient suffering from insomnia is living a high-adrenaline life during the day, it may be difficult to lie down in peace at night. Taming the tempo of the day is an important step, and mindfulness practices are a clear and effective way to help in this area. Complementary therapies are also proven to be effective at addressing many underlying causes of insomnia, which in turn help people rest.
The American Academy of Sleep Medicine reported that three main factors contribute to insomnia, which they describe as the “3 P's of Insomnia”: predisposing factors characterized by a state of hyperarousal; precipitating triggers such as stressful life events or intense emotions; and perpetuating factors such as repetitive behaviors that contribute to poor sleep hygiene and poor sleeping environments. 5 Complementary therapies are particularly amenable to helping people attenuate a state of hyperarousal and also in helping people deal with strong emotions and learn stress management and relaxation techniques. Such complementary therapies that target these areas are well suited as part of a long-term relief strategy. The following are four complementary therapies for clinicians to consider when creating an integrative approach to treating insomnia:
1. Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is established as one of the most effective non-pharmacologic treatments for primary insomnia. In one systematic review and meta-analysis on the effectiveness of CBT for insomnia (CBT-i), analysis of sleep diary outcomes showed that among >1000 participants, the CBT-i groups had significant improvements in sleep onset latency, wake after sleep onset, and sleep efficiency compared to control groups. 6 The CBT-i treatments included a combination of cognitive therapy, stimulus control, sleep restriction, and sleep hygiene and/or relaxation techniques. The authors stated: “Our meta-analysis shows cognitive behavioral therapy for insomnia to be a highly effective treatment for non-co-morbid chronic insomnia, producing clinically meaningful responses.” 6 They added that CBT-i “should be used as the initial intervention for chronic insomnia when possible.” 6 There are many CBT-i practitioners throughout the United States, and clinicians can work with behavioral medicine and sleep specialists to identify practitioners or groups in their area.
2. Mindfulness-Based Practices
Mindfulness-based practices and mindfulness-based stress reduction (MBSR) are widely recognized in the integrative medicine community as effective in helping people manage and improve their experiences with a wide variety of conditions such as chronic pain, depression, breast cancer, addictions/substance abuse, PTSD, and others. These are the very conditions that often contribute to insomnia, and improving the symptoms that accompany these issues can also improve sleep. Meditative skills that encompass learning to manage reactions and expectations along with breath work and other relaxation techniques are the cornerstones of programs offering these practices.
In an article about mindfulness-based therapies for insomnia (MBT-I), Ong and Smith reported that mindfulness-based therapies for insomnia help by: “1) increasing awareness of the mental and physical states that arise when experiencing insomnia symptoms, 2) shifting mental processes to reduce sleep-related arousal, and 3) promoting a mindful stance to respond when symptoms of insomnia arise.” 7 They pointed out that research suggests that not everyone responds fully to CBT and that learning these mindfulness-based skills may help certain individuals. More research is needed regarding who is best served by which therapies. Ong and Sholtes emphasized that regular mindfulness meditation practice is necessary for change and that “this approach might be more acceptable to patients who are looking for non-pharmacological treatments for insomnia and are willing to make lifestyle changes.” 8
A recent small randomized controlled trial explored the effects of a low-cost community-accessible mind–body intervention known as mindful awareness practices (MAPs) for daily living compared to a structured sleep hygiene and education (SHE) program on moderate sleep disturbances in older adults. 9 Results showed that the MAPs intervention led to superior improvements in sleep quality at immediate post intervention compared with the SHE intervention. The authors stated: “The findings from our study suggest that mindfulness meditation may be introduced to older adults as a short-term solution to remediate their moderate sleep disturbances.” 9 They added: “Given that standardized mindfulness programs are readily delivered in many communities, dissemination efforts do not serve as a barrier in this instance. Therefore, older adults often have immediate access to these programs, which are offered at low cost.” 9
3. Acupuncture
Clinicians and researchers have found that acupuncture may be an effective complementary therapy for insomnia. In particular, clinicians observe that acupuncture helps restore people to better sleep, especially when the treatment is being used for underlying problems such as chronic pain. Jamie Starkey, LAc, Traditional Chinese Medicine Manager and Lead Acupuncturist, Cleveland Clinic Wellness Institute, Cleveland, Ohio, stated that in her clinical experience, acupuncture treatments most often help improve insomnia by treating issues that disrupt sleep such as pain, stress, anxiety, and/or hot flashes. She stated: “For example, if patients are experiencing chronic pain, acupuncture may help alleviate their pain, which indirectly improves their sleep because the pain no longer wakes them up at night.” She added: “Patients should consider the risk versus the benefits. Acupuncture has a very safe track record, so it is certainly worth exploring the potential use of either auricular or whole-body point systems.”
In an article about acupuncture and insomnia, Hayhoe stated: “Acupuncture is observed clinically to improve sleeping in chronic pain patients, but reviews are unable firmly to recommend acupuncture for insomnia as many trials are methodologically inadequate, despite most being positive for acupuncture. However, there is strong evidence for benefit from acupuncture in several chronic pain problems and improvement in these is likely also to restore normal sleeping.” 10 Hayhoe added: “Bearing in mind the high level of safety inherent in acupuncture or acupressure therapy, the lack of formal trial evidence should not be considered a bar to clinical use, particularly if it can be incorporated easily into the overall treatment strategy for a chronic pain problem.” 10
A recent meta-analysis on the use of auricular acupuncture for people suffering from primary insomnia found that auricular acupuncture was beneficial for primary insomnia sufferers in terms of both sleep quality and quantity. 11 While further high-quality research is needed in this area, the study authors commented: “Auricular acupuncture has been extensively adopted in Asian countries. With minimal consumption of medical resources, auricular acupuncture could be integrated into routine care for insomnia without difficulty in a wide range of clinical settings.” 11
4. Listening to Music
Listening to music at bedtime is a widespread practice among people who have difficulty sleeping. In fact, studies suggest that listening to music enhances relaxation, reduces cortisol levels, and can help to regulate heart rate and blood pressure and decrease sympathetic arousal. 12 A Cochrane review included six studies and 314 participants in an analysis of the effects of listening to prerecorded music daily. 12 Participants in the various studies listened to music for 25–60 minutes for a period of three days to five weeks. Results showed that listening to music may improve sleep quality in adults with insomnia symptoms compared to music alone or with standard care to standard care alone or no treatment. The authors concluded: “The intervention is safe and easy to administer. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia.” 12
Another survey of the general public looked at why people believe that music helps them sleep and what music they preferred. 13 Results showed that 62% of 651 participants said they used music to help them sleep, and 14 musical genres of 545 musical artists were reported. The most common reason for listening to music as a sleep aid was to help them fall asleep more quickly. Among participants who listened to music as a sleep aid, >95% agreed with the statement that music helped them relax mentally, and >80% agreed that music helped them relax physically. More than half agreed that music helped them fall asleep more quickly and reduced the amount of time spent in bed before falling asleep. The survey authors stated: “The need for a non-pharmaceutical, low cost sleep aid within our modern society is clear due to the economic, physical and psychological costs of sleep loss, which are increasingly widespread.” 13 They added: “Music's potential for successful use in therapeutic and clinical settings makes it a viable, low cost, side-effect free option in the treatment of sleep loss. The results of this population survey suggest that many individuals are already intuitively using diverse types of music to fight sleep difficulties.” 13
These are four important complementary therapies that clinicians can bring to mind when addressing sleep disorders and particularly insomnia in their patients. Today, CBT, MBSR, and other mindfulness practices are often available in hospitals and outpatient settings, as well as community centers and churches, for example. There are a variety of settings that also offer these therapies specifically related to insomnia treatment. Experts point out that utilizing health-care professionals that are well trained and experienced in these specific areas is important for beneficial outcomes. Other non-pharmacologic therapies, including nature therapy, relaxation techniques, and online programs, can help a person wind down for the evening to rest on a more regular basis. Fortunately, today, such therapies are becoming increasingly accessible to more people, and hopefully this trend will continue with innovative and inclusive efforts.
Conclusion
Being aware and mindful of the above complementary therapies and their potential effects on patients' sleep is one step toward being prepared to provide an integrative approach in the management of insomnia. It is important to point out that chronic insomnia is rarely cured overnight. Learning to improve sleep is generally a process—a process that requires structured direction, support, and also follow-up by clinicians. Particularly in the case of insomnia, practice makes better. Simply learning or experiencing new techniques is not enough. Consistency is important. These points should be emphasized when working with patients suffering from insomnia. Insomnia is not quickly addressed on the patient or the clinician side. Treating insomnia can be time intensive, and clinicians should feel comfortable referring to sleep and/or behavioral medicine specialists, as well as clinics and settings offering the above programs, to help bring relief to their patients. ■