Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report

Abstract

Insomnia is highly prevalent, has associated daytime consequences which impair job performance and quality of life, and is associated with increased risk of comorbidities including depression. These practice parameters provide recommendations regarding behavioral and psychological treatment approaches, which are often effective in primary and secondary insomnia. These recommendations replace or modify those published in the 1999 practice parameter paper produced by the American Sleep Disorders Association. A Task Force of content experts was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the scientific literature since 1999 and to grade the evidence regarding non-pharmacological treatments of insomnia. Recommendations were developed based on this review using evidence-based methods. These recommendations were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Psychological and behavioral interventions are effective in the treatment of both chronic primary insomnia (Standard) and secondary insomnia (Guideline). Stimulus control therapy, relaxation training, and cognitive behavior therapy are individually effective therapies in the treatment of chronic insomnia (Standard) and sleep restriction therapy, multicomponent therapy (without cognitive therapy), biofeedback and paradoxical intention are individually effective therapies in the treatment of chronic insomnia (Guideline). There was insufficient evidence to recommend sleep hygiene education, imagery training and cognitive therapy as single therapies or when added to other specific approaches. Psychological and behavioral interventions are effective in the treatment of insomnia in older adults and in the treatment of insomnia among chronic hypnotic users (Standard).

Therapeutic rationale for low dose doxepin in insomnia patients

“…No incidence of withdrawal syndrome or rebound insomnia after discontinuing doxepin 3 mg or 6 mg [25][26][27] . 6. Use of low dose doxepin is not associated with tolerance, and anti-cholinergic side effect.…”

“…[4,6,13] . The current mainstay for the pharmacotherapy of insomnia is as below [4][5][6][7][8][9]13,14] :…”

“…This produces hypnotic action. Thus low dose of doxepin (1,3,6 mg) can produce selective H1 blockade [19,20,23,24,] .…”

“…Efficacy Doxepin 1, 3, and 6 mg is widely studied in both adult and elderly patients with difficulty in sleep onset and sleep maintenance insomnia. There were 1 423 subjects, with chronic insomnia (n=858) or transient (n=565) insomnia participated in 6 randomised, double-blind studied. These studies were up to 3 months in duration and included patients of both sex between 18 and 93 years of age.…”

The FIBRO System: a rapid strategy for assessment and management of fibromyalgia syndrome

“…If FMS patients have difficulty falling asleep, FDA approved pharmacologic therapies should be considered after patients fail psychological and behavioral insomnia treatment modalities [Morgenthaler et al 2006]. While benzodiazepines have historically been the mainstay of insomnia therapy, due to their detrimental effects on sleep architecture, cognition, and addiction, potential use in FMS patients is not recommended.…”