Mind and Body Practices
Relaxation techniques include progressive relaxation, guided imagery, biofeedback, self-hypnosis, and deep breathing exercises. The goal is similar in all: to consciously produce the body’s natural relaxation response, characterized by slower breathing, lower blood pressure, and a feeling of calm and well-being. Relaxation techniques are also used to induce sleep, reduce pain, and calm emotions.
Evidence suggests that using relaxation techniques before bedtime can be helpful components of a successful strategy to improve sleep habits. Other components include maintaining a consistent sleep schedule; avoiding caffeine, alcohol, heavy meals, and strenuous exercise too close to bedtime; and sleeping in a quiet, cool, dark room.
Strength of the Evidence Base
- The evidence base from many studies on the effects of relaxation techniques for insomnia is of sufficient size and quality to permit independent systematic reviews and meta-analyses, and inclusion of specific recommendations in independent clinical practice guidelines.
- A 2006 systematic review of 37 studies found evidence that psychological and behavioral therapies, including relaxation techniques, produced reliable changes in several sleep parameters of participants with primary insomnia or insomnia associated with medical and psychiatric conditions. Relaxation was one of five treatments that met criteria for empirically-supported psychological treatments for insomnia. This review was conducted by a task force commissioned by the American Academy of Sleep Medicine (AASM) in order to update its practice parameters on psychological and behavioral therapies for insomnia.
- The accompanying 2006 practice parameter report published by the AASM concluded that several psychological and behavioral interventions, including relaxation training, stimulus control therapy, and cognitive behavioral therapy are effective, and recommended inclusion of at least one in initial treatment strategies for chronic primary and comorbid (secondary) insomnia.
- A 2009 meta-analysis of five randomized controlled trials evaluating the efficacy of music-assisted relaxation for sleep quality in adults found that music-assisted relaxation had moderate benefits.
- Relaxation techniques are generally considered safe. There have been rare case reports of worsening of symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.
- Relaxation techniques are generally used as components of a treatment plan, and not as the only approach for potentially serious health conditions.
Other Mind and Body Practices
Other mind and body practices which have been studied for their effects on insomnia and other sleep disorders include mindfulness-based stress reduction, yoga, massage therapy, and acupuncture. Current evidence of these therapies is either too preliminary or inconsistent to draw conclusions about whether they are helpful for sleep disorders.
Strength of the Evidence Base
- The current evidence base on efficacy of mindfulness-based stress reduction (a type of meditation), yoga, and massage therapy is limited to clinical trials reports, most from small preliminary studies.
- While there have been many studies of acupuncture for insomnia, the evidence base suffers from trials of poor methodological quality, and high levels of publication bias and heterogeneity in study design.
- A 2011 randomized trial involving 30 adults with primary chronic insomnia reported initial evidence that mindfulness-based stress reduction was comparable in effectiveness to a prescription drug (eszopicolone) by a variety of measures. The authors concluded that mindfulness-based stress reduction is a viable treatment for chronic insomnia.
- A 2013 randomized controlled trial evaluated the effect of mindfulness-based stress reduction on sleep quality in 336 Danish women with breast cancer. The investigators reported a small statistically significant improvement in sleep quality just after the intervention, but no long-term effect. An earlier uncontrolled study involving people with different types and stages cancer reported similar findings.
- A small 2012 trial evaluated the effects of yoga, passive stretching, or standard care on insomnia in 44 postmenopausal women in Brazil. The investigators found that participants in the yoga group had significantly lower post-treatment scores for insomnia, compared to the other two groups. They also reported significantly improved post-treatment scores for severity of climacteric symptoms, quality of life, and resistance phase of stress in the yoga group compared to control.
- A small 2011 study compared the effects of Chinese therapeutic massage (Tui na), passive movement, or control (not specified) in 44 postmenopausal women with insomnia in Brazil. The investigators reported evidence of improvements in subjective insomnia scores, as well as scores for anxiety, depression, and quality of life in the group of women treated with massage, compared to those in a passive movement or a control (treatment not specified) group.
- A 2012 Cochrane systematic review considered the evidence from 33 randomized trials of needle acupuncture, electroacupuncture, and acupressure for insomnia. The investigators found evidence that needle acupuncture (but not electroacupuncture) as an adjunct to other treatment might marginally increase the proportion of people with improved sleep quality. Overall they concluded that current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia.
- Meditation is considered to be safe for healthy people. There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched. People with physical limitations may not be able to participate in certain meditative practices involving physical movement. Individuals with existing mental or physical health conditions should speak with their health care providers prior to starting a meditative practice and make their meditation instructor aware of their condition.
- Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. However, injuries from yoga, some of them serious, have been reported in the popular press. People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.
- Massage therapy appears to have few risks when performed by a trained practitioner. However, massage therapists should take some precautions with certain health conditions. In some cases, pregnant women should avoid massage therapy. Forceful and deep tissue massage should be avoided by people with conditions such as bleeding disorders or low blood platelet counts, and by people taking anticoagulant medications such as warfarin (also known as blood thinners). Massage should not be done in any potentially weak area of the skin, such as wounds. Deep or intense pressure should not be used over an area where the patient has a tumor or cancer, unless approved by the patient’s health care provider.
- Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Reports of serious adverse events related to acupuncture are rare, but include infections and punctured organs.
Melatonin is a hormone known to shift circadian rhythms. Current evidence suggests that melatonin may be useful in treating several sleep disorders, such as jet lag, delayed sleep phase disorder, and sleep problems related to shift work.
Strength of the Evidence Base
- The evidence base from many studies on the effects of melatonin supplements for certain sleep disorders such as jet lag, delayed sleep phase disorder, shift work disorder, and insomnia is of sufficient size and quality to permit independent systematic reviews and meta-analyses, and inclusion of recommendations in independent clinical practice guidelines.
- A 2007 practice parameter report issued by the American Academy of Sleep Medicine (AASM) includes the recommendation of melatonin supplements to promote daytime sleep among night shift workers. Studies that support this recommendation found that melatonin administration prior to daytime sleep after night work shifts improved daytime sleep quality and duration, and caused a shift in circadian phase in some but not all participants. It did not enhance alertness at night.
- The AASM guidelines also include the recommendation of melatonin supplements to reduce symptoms of jet lag and improve sleep following travel across multiple time zones. A 2009 Cochrane review supporting this recommendation assessed the effectiveness of oral melatonin for alleviating jet lag after air travel across several time zones, and concluded that melatonin is remarkably effective in preventing or reducing jet lag, and that occasional short-term use appears to be safe.
- Adults and teens with delayed sleep disorder have trouble falling asleep before 2 a.m. and have trouble waking up in the morning. In a 2007 review, the authors suggested that a combination of melatonin supplements, a behavioral approach to delay sleep and wake times, and reduced evening light may even out sleep cycles in people with this disorder.
- A 2013 meta-analysis of 19 randomized placebo-controlled trials involving 1863 participants with primary sleep disorders found evidence of small but statistically significant improvements in sleep onset latency, total sleep time, and overall sleep quality with melatonin use. These effects do not appear to dissipate with continued melatonin use. The investigators concluded that although the absolute benefit of melatonin compared to placebo is smaller than other pharmacological treatments for insomnia, melatonin may have a role in the treatment of insomnia given its relatively benign side-effect profile compared to these agents.
- A 2007 study of 170 participants with insomnia, aged 55 years or older, found that prolonged-release melatonin significantly improved quality of sleep and behavior following wakefulness (BFW), compared with placebo. The authors concluded that the improvements in quality of sleep and BFW were strongly correlated, suggesting a beneficial treatment effect on the restorative value of sleep.
- The evidence base regarding treatment of childhood sleep disturbances with melatonin is more limited. Two recent literature reviews concluded that available research suggests benefit with minimal side effects in healthy children as well as children and adolescents with attention-deficit hyperactivity disorder, children and youth with autism, and several other special populations. The author noted, however, that all studies have involved small numbers of subjects and address only short-term use of melatonin. There are no good data concerning the safety and efficacy of long-term melatonin use.
- Melatonin supplements appear to be relatively safe for short-term use, although modest adverse effects on mood were seen with melatonin use in elderly people (most of whom had dementia) in one study. The long-term safety of melatonin supplements has not been established.
L-tryptophan and 5-hydroxytryptophan (5-HTP)
Dietary supplements containing chemical precursors of melatonin—L-tryptophan and 5-hydroxytryptophan (5-HTP)—have also been researched as sleep aids, but they have not been shown to be effective for insomnia.
Strength of the Evidence Base
- The evidence base for L-tryptophan and 5-HTP consists of only a few small clinical trials, all with limitations in design or quality.
- Studies of L-tryptophan supplements as an insomnia treatment have had inconsistent results. Evidence that 5-HTP supplements are useful in insomnia is lacking at present.
- The use of L-tryptophan supplements has been linked to eosinophilia-myalgia syndrome (EMS), a complex, potentially fatal disorder with multiple symptoms including severe muscle pain. The exact cause is unknown, but some evidence suggests it was related to contamination of L-tryptophan products. Until more is known it is reasonable to regard L-tryptophan as possibly unsafe.
Herbal and Homeopathic Medicines
Various herbs such as valerian, chamomile, and kava, and homeopathic medicines sometimes used as sleep aids have not been shown to be effective for insomnia, and important safety concerns have been raised about a few.
Strength of the Evidence Base
- The strongest evidence concerning efficacy of the herb valerian for insomnia consists of several meta-analyses and systematic reviews.
- Very little research has been done on the effects of chamomile, kava, and other herb formulations for this condition.
- A 2010 meta-analysis of 18 randomized placebo-controlled trials of valerian preparations failed to find quantitative or objective evidence of improvement in insomnia.
- A 2007 systematic review of valerian as a sleep aid found that, overall, the evidence does not support the clinical efficacy of valerian as a sleep aid for insomnia.
- There is insufficient evidence to make determinations about the efficacy of chamomile, kava, or other herbal formulations for insomnia.
- A 2010 systematic review concluded that current evidence does not demonstrate significant effects of homeopathic medicines for insomnia.
- Although few people have reported negative side effects from valerian, it is uncertain whether this herb is safe for long-term use.
- Some people, especially those who are allergic to ragweed or related plants, may have allergic reactions to chamomile.
- More importantly, kava supplements have been linked to a risk of severe liver damage.