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National Center for Complementary and Integrative Health

NCCIH Clinical Digest

for health professionals

Psychological and Physical Approaches for Sleep Disorders: What the Science Says

March 2024

Clinical Guidelines, Scientific Literature, Info for Patients: 
Psychological and Physical Approaches for Sleep Disorders

Woman sleeping

Cognitive Behavioral Therapy for Insomnia (CBT-I)

Current clinical practice guidelines from the American Academy of Sleep Medicine (2021) recommend psychological and behavioral interventions in the treatment of chronic insomnia disorder in adults. 

  • The American Academy of Sleep Medicine guidelines state: “We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia (CBT-I) for the treatment of chronic insomnia disorder in adults (strong recommendation). We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults (conditional recommendation).” The authors of the guidelines also noted that there were fewer than three studies meeting their inclusion criteria for the use of cognitive therapy, paradoxical intention, mindfulness, biofeedback, and intensive sleep retraining; as a result, no recommendations were made about these treatments.

What Does the Research Show?

  • Clinical practice guidelines issued by the American Academy of Sleep Medicine in 2021 recommend psychological and behavioral interventions for the treatment of chronic insomnia disorder in adults. The guidelines state: “We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia (CBT-I) for the treatment of chronic insomnia disorder in adults (strong recommendation).”
  • A 2018 analysis of pooled data from 4 randomized controlled trials of 546 peri- and postmenopausal women with insomnia and bothersome vasomotor symptoms found that CBT-I produced the greatest reduction in Insomnia Severity Index (ISI) from baseline compared to an education control. 
  • A 2014 randomized controlled trial examined the comparative efficacy of cognitive behavioral therapy, tai chi, and a sleep seminar education control in 123 older adults with chronic and primary insomnia. The study found that cognitive behavioral therapy performed better than tai chi and sleep seminar education in remission of clinical insomnia. The cognitive behavioral therapy group also showed greater improvement in sleep quality, sleep parameters, fatigue, and depressive symptoms than the tai chi and sleep seminar education groups.

Safety

  • CBT-I is considered safe.

Relaxation Techniques

There is a small amount of low-quality evidence that relaxation techniques by themselves can help with chronic insomnia.  Relaxation techniques may be recommended in certain situations, depending on individual preferences, health provider qualifications, and treatment availability. 

Current clinical practice guidelines from the American Academy of Sleep Medicine (2021) conditionally recommend relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. 

What Does the Research Show?

  • Clinical guidelines from the American Academy of Sleep Medicine (2021) made a conditional recommendation to use relaxation therapy as a single-component therapy based on “a small body of low-quality evidence from five studies showing clinically meaningful improvements in one critical outcome, consideration that some patients prefer relaxation therapy, the fact that mental health providers are trained to deliver this form of treatment, and the potential for relaxation therapy to require only limited resources.”
  • A 2018 systematic review looked at 27 studies of psychological interventions to try to improve sleep. The studies involved 2,776 college students who ranged from healthy sleepers to those with a diagnosed sleep disorder. About 22 percent of the studies investigated “relaxation, mindfulness, hypnotherapy” treatments. This review recommended cognitive behavioral therapy to improve sleep in college students. The review also found that relaxation approaches helped somewhat with sleep quality and sleep problems but especially with mental health. The authors recommended that “relaxation, mindfulness, hypnotherapy” treatments be combined with cognitive behavioral therapy as a way to enhance mental health benefits.

Safety

  • Relaxation therapies for insomnia are considered safe.

Yoga

Yoga has been shown to be helpful for sleep in several studies of cancer patients, women with sleep problems, and older adults and in individual studies of other population groups, including people with arthritis and women with menopause symptoms. However, a 2019 clinical practice guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense said there was insufficient evidence to recommend for or against yoga for treating insomnia.

What Does the Research Show?

  • A 2020 systematic review and meta-analysis of 19 studies involving a total of 1,832 participants found positive effects of yoga in 16 randomized controlled trials, compared with the control group, in improving sleep quality among women using Pittsburgh Sleep Quality Index (PSQI); however, 2 studies revealed no effects of yoga compared to the control group in reducing insomnia among women using ISI. Seven studies revealed no evidence for effects of yoga compared with the control group in improving sleep quality for women with breast cancer using PSQI, while four studies revealed no evidence for the effects of yoga compared with the control group in improving the sleep quality for peri/postmenopausal women using PSQI.
  • A 2020 secondary analysis of a randomized controlled trial involving 320 adults with chronic low-back pain and poor sleep quality prior to the intervention found modest but statistically significant improvements in sleep quality in the yoga (12 weekly yoga classes) and physical therapy groups.
  • A 2019 systematic review of 11 studies that evaluated the use of yoga to manage stress and burnout in health care workers concluded that yoga is effective in improving physical problems and quality of sleep, as well as reducing stress levels and burnout. However, the authors of the review noted that it would be necessary to broaden the subject further and acquire more robust scientific evidence by designing and implementing research studies equipped with a solid methodological structure on bigger sample groups.
  • A 2013 multicenter, randomized controlled trial evaluated the effect of yoga on sleep quality in 410 cancer survivors suffering from moderate or greater sleep disruption between 2 and 24 months after surgery, chemotherapy, and/or radiation therapy. The study found that compared with standard care, yoga participants demonstrated greater improvements in global sleep quality and subjective sleep quality, daytime dysfunction, wake after sleep onset, sleep efficiency, and medication use at postintervention.
  • A 2022 randomized controlled trial investigated the effects of yoga (duration of 20 weeks) on menopausal symptoms and sleep quality across menopause statuses in 208 women. Based on participant responses to questionnaires, the study found that yoga decreased menopausal symptoms, with the strongest effects noted in postmenopausal women, followed by perimenopausal women. In addition, yoga significantly improved sleep quality in postmenopausal and perimenopausal women after controlling for social support, depression, anxiety, stress, and menopausal symptoms; however, yoga did not affect sleep quality in premenopausal women.

 

Safety

  • Yoga is generally considered a safe form of physical activity for healthy people when performed properly, under the guidance of a qualified instructor. However, as with other forms of physical activity, injuries can occur. 
  • The most common injuries are sprains and strains, and the parts of the body most commonly injured are the knee or lower leg. Serious injuries are rare. The risk of injury associated with yoga is lower than that for higher impact physical activities.
  • Hot yoga has special risks related to overheating and dehydration.
  • Pregnant women, older adults, and people with health conditions should talk with their health care providers and the yoga instructor about their individual needs. They may need to avoid or modify some yoga poses and practices. 

Tai Chi

Results of several studies, using objective and subjective measures, have shown that tai chi may be helpful for people with sleep problems. However, a 2019 clinical practice guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense said there was insufficient evidence to recommend for or against using tai chi to treat insomnia.

What Does the Research Show?

  • A 2020 systematic review and meta-analysis of 20 randomized controlled studies from 5 countries involving a total of 1,703 patients found that compared with nontherapeutic and other active treatments, tai chi has a positive effect on improving sleep quality. An in-depth analysis showed that 24-form and 8-form Yang-style tai chi had significant positive effects on sleep quality, as assessed by the Pittsburgh Sleep Quality Index (PSQI).
  • A 2021 randomized controlled trial assigned 320 participants 60 years or older and with chronic insomnia to three groups: 12-week tai chi training, 12-week conventional exercise, and no intervention control. The study found that compared with the control group, the exercise and tai chi groups showed improved sleep efficiency, reductions of wake time after sleep onset, and reduced awakenings as measured by actigraphy. However, there were no significant differences between the exercise and tai chi groups.

Safety

  • Tai chi appears to be safe. A 2019 meta-analysis of 24 studies (1,794 participants) found that the frequency of adverse events was similar for people doing tai chi, another active intervention, or no intervention. 

Meditation and Mindfulness Practices

A 2019 clinical practice guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense said there was not enough evidence to know whether mindfulness meditation is helpful for people with insomnia, and a 2021 clinical practice guideline from the American Academy of Sleep Medicine said there was not enough evidence to make recommendations on using mindfulness by itself for insomnia. 

What Does the Research Show?

  • A 2022 review of 20 studies and 2,890 participants found that mindfulness-based stress reduction might be ineffective for improving sleep quality in people with insomnia, but the authors noted that the studies were small and showed bias.
  • A  2019 systematic review and meta-analysis of 18 studies (1,654 total participants) found that mindfulness meditation practices improved sleep quality more than education-based treatments. However, the effects of mindfulness meditation approaches on sleep quality were no different than those of evidence-based treatments such as cognitive behavioral therapy and exercise.
  • Results from a 2015 randomized controlled trial involving 60 adults aged 75 years and over with chronic insomnia suggest that the mindfulness-based stress reduction program could be a useful treatment for chronic insomnia for this age group. 

Safety

  • Meditation and mindfulness practices usually are considered to have few risks. 

Music-Based Interventions

A 2022 review of 13 studies with 1,007 adult participants found that listening to music may lead to improved reports of sleep quality among people with insomnia. However, there was not enough good-quality evidence to determine the effect of listening to music on the severity of insomnia or the number of times a person wakes up. 

What Does the Research Show?

  • A 2022 review of 13 studies with 1,007 adult participants found that listening to music may lead to improved reports of sleep quality among people with insomnia. However, there was not enough good-quality evidence to determine the effect of listening to music on the severity of insomnia or the number of times a person wakes up. The results showed that listening to music may slightly improve sleep-onset latency, sleep duration, sleep efficiency, and daytime effects.

Safety

  • In general, research studies of music-based interventions do not show any negative effects. However, listening to music at too high a volume can contribute to noise-induced hearing loss. 
  • Because music can be associated with strong memories or emotional reactions, some people may be distressed by exposure to specific pieces or types of music.

Acupuncture

A 2019 clinical practice guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense said there was not enough evidence to recommend for or against using acupuncture for insomnia, except for a weak recommendation for auricular acupuncture, which involves specific points on the outer ear. Results from some studies suggest that auricular acupuncture may help improve insomnia; however, many of the studies conducted on acupuncture for sleep disorders are small and are of low quality.

What Does the Research Show?

  • A 2021 review of 11 studies and 775 participants suggested that acupuncture may help improve insomnia, but the studies were small, differed from each other in many ways (e.g., treatment dosage, acupoint selection), and judged to be low quality. 
  • A 2019 clinical practice guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense said there was not enough evidence to recommend for or against using acupuncture for insomnia, except for a weak recommendation for auricular acupuncture, which involves specific points on the outer ear. 
  • A 2020 evaluation of 7 systematic reviews (10,001 participants) on auricular acupuncture for insomnia found that the reviews suggested auricular acupuncture may be beneficial, but the quality of most of the reviews was low or critically low and the quality of the studies within the reviews was poor.

Safety

  • Relatively few complications from using acupuncture have been reported.  However, complications have resulted from use of nonsterile needles and improper delivery of treatments.  When not delivered properly, acupuncture can cause serious adverse effects, including infections, punctured organs, and injury to the central nervous system. 

References

NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

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