Preface: Adjunct Interventions to Cognitive Behavioral Therapy for Insomnia xiii
Joshua Hyong-Jin Cho
Partner Alliance to Enhance Efficacy and Adherence of CBT-I 1
Jason Gordon Ellis, Robert Meadows, Pamela Alfonso-Miller, and Célyne H. Bastien
Cognitive behavioral therapy for insomnia (CBT-I) is now widely recognized as the first-line management strategy for insomnia, both for insomnia in its “pure” form, and when comorbid with a physical or psychological illness. However, there is a definite need to develop and test both alternative and adjunct interventions to CBT-I, before implementing them into routine practice. The aim of this article is to provide a narrative review of the literature with regard to what is known about the influence of partners on sleep, insomnia, and its management.
Paradoxic Intention as an Adjunct Treatment to Cognitive Behavioral Therapy for Insomnia 9
Markus Jansson-Fröjmark, Christina Sandlund, and Annika Norell-Clarke
Paradoxic intention (PI) was one of the first psychological interventions for insomnia. Historically, PI has been incorporated in cognitive behavioral therapy for insomnia (CBT-I) or delivered as a sole intervention for insomnia. PI instructions have varied over the years, but a common denominator is the instruction to try to stay awake in bed for as long as possible. This article reviews and discuss treatment rationales and theoretic frameworks for PI, the current evidence base for PI, its clinical relevance, and considerations needed when PI is used as an adjunct treatment to CBT-I, or as a second-line intervention for insomnia.
Circadian Interventions as Adjunctive Therapies to Cognitive-Behavioral Therapy for Insomnia 21
Leslie M. Swanson and Greta B. Raglan
The circadian system plays a key role in the sleep-wake cycle. A mismatch between the behavioral timing of sleep and the circadian timing of sleepiness/alertness can contribute to insomnia. Patients who report primarily difficulty falling asleep or early morning awakenings may benefit from circadian interventions administered adjunctively to cognitive-behavioral therapy for insomnia. Specific circadian interventions that clinicians may consider include bright light therapy, scheduled dim light, blue-blocking glasses, and melatonin. Implementation of these interventions differs depending on the patient’s insomnia subtype. Further, careful attention must be paid to the timing of these interventions to ensure they are administered correctly.
Behavioral Activation as an Adjunct Treatment to CBT-I 31
Behavioral activation (BA) has long been long understood to be a particularly effective treatment for depression. Elements of BA are also to be found in components of insomnia treatment such as sleep restriction, stimulus control, and the setting of a morning routine. Although little research exists that examines the independent contribution of BA to the treatment of insomnia, it is reasonable to apportion some of the effect of cognitive-behavioral treatment of insomnia (CBT-I) to the implementation of BA whether that implementation is simply incidental to standard practice or more extensively deployed.
Exercise as an Adjunct Treatment to Cognitive Behavior Therapy for Insomnia 39
Giselle Soares Passos, Shawn D. Youngstedt, and Marcos Gonçalves Santana
The question that guided this review is whether exercise can add to the improvements in insomnia in patients treated with cognitive behavioral therapy for insomnia (CBT-I). CBT-I has long been recommended as the first-line treatment of chronic insomnia. However, CBT-I is not effective for as many as 30% to 40% of patients with insomnia. There is accumulating evidence for positive effects on insomnia following acute and chronic exercise. However, to the best of our knowledge, the effects of CBT-I combined with exercise have not been explored in clinical trials. In this article, we develop a rationale for combining CBT-I with exercise.
Wearable Device-Delivered Intensive Sleep Retraining as an Adjunctive Treatment to Kickstart Cognitive-Behavioral Therapy for Insomnia 49
Darah-Bree Bensen-Boakes, Tara Murali, Nicole Lovato, Leon Lack, and Hannah Scott
Intensive Sleep Retraining is a behavioral treatment for sleep onset insomnia that produces substantial benefits in symptoms after a single treatment session. This technique involves falling asleep and waking up shortly afterward repeatedly: a process that is thought to retrain people to fall asleep quickly when attempting sleep. Although originally confined to the sleep laboratory, recent technological developments mean that this technique is feasible to self-administer at home. With multiple randomised controlled trials required to confirm its efficacy, Intensive Sleep Retraining may serve as an adjunctive treatment to cognitive-behavioral therapy for insomnia, improving short-term efficacy by kick-starting treatment gains.
Mindfulness as an Adjunct or Alternative to CBT-I 59
Jason C. Ong and David A. Kalmbach
Mindfulness-based interventions (MBIs) are programs that teach mindfulness concepts through guided meditation and self-regulation practices. MBIs have been found to improve sleep and reduce cognitive arousal, which are central to the development and perpetuation of insomnia. In this article, we review theoretic frameworks and clinical trial effectiveness data supporting MBIs for insomnia. Based on this review, we provide suggestions for using MBIs as an adjunct or alternative treatment option to CBT-I with regard to how, when, and for whom. We conclude with an agenda for future directions that can clarify the use of mindfulness as a treatment option for insomnia.
Acceptance and Commitment Therapy as an Adjunct or Alternative Treatment to Cognitive Behavioral Therapy for Insomnia 73
Kathryn S. Saldaña, Sarah Kate McGowan, and Jennifer L. Martin
Although cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment of insomnia, difficulties exist with adherence to recommendations and premature discontinuation of treatment does occur. The current article aims to review existing research on acceptance and commitment therapy (ACT)-based interventions, demonstrate differences and similarities between ACT for insomnia and CBT-I, and describe treatment components and mechanisms of ACT that can be used to treat insomnia disorder.
Biofeedback as an Adjunct or Alternative Intervention to Cognitive Behavioral Therapy for Insomnia 85
Stephanie Kremer and Tanecia Blue
Insomnia is highly prevalent and comorbid with many disorders. However, insomnia is underdiagnosed and undertreated in many populations. Cognitive behavioral therapy for insomnia (CBT-I) is not appropriate or sufficient for some individuals. Biofeedback has demonstrated efficacy in a range of disorders, including insomnia. The authors discuss the history and rationale for the use of biofeedback in the treatment of insomnia and other comorbid disorders. The article also presents current research on biofeedback for insomnia and comorbid disorders with recommendations for using biofeedback as an adjunct or alternative intervention to CBT-I.
Hypnotic Medications as an Adjunct Treatment to Cognitive Behavioral Therapy for Insomnia 95
Paul Barkopoulos and Joshua Hyong-Jin Cho
Cognitive behavioral therapy for insomnia (CBT-I) is the universally recommended treatment of choice for insomnia disorder based on its safety and posttreatment durability of benefit. However, CBT-I does not help all patients achieve remission. The second most evidence-based treatment, hypnotic pharmacotherapy (PCT), does not resolve perpetuating factors of insomnia, resulting in potential waning of benefit and dependence. This article presents a rationale that supports consideration of hypnotic augmentation of CBT-I (COMB), along with a review of select randomized controlled trials relevant to clinical decision-making.
Acupuncture as an Adjunct Treatment to Cognitive-Behavioral Therapy for Insomnia 113
Samlau Kutana, Jun J. Mao, and Sheila.N. Garland
Cognitive-behavioral therapy for insomnia (CBT-I) is the main recommended treatment for patients presenting with insomnia; however, the treatment is not equally effective for all, and several factors can contribute to a diminished treatment response. The rationale for combining CBT-I treatment with acupuncture is explored, and evidence supporting its use in treating insomnia and related comorbidities is discussed. Practical, regulatory, and logistical issues with implementing a combined treatment are examined, and future directions for research are made. Growing evidence supports the effectiveness of acupuncture in treating insomnia and comorbid conditions, and warrants further investigation of acupuncture as an adjunct to CBT-I.