Adjunct Interventions to Cognitive Behavioral Therapy for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) has been consistently demonstrated to be an efficacious treatment of insomnia1Trauer J.M. Qian M.Y. Doyle J.S. et al.Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis.Ann Intern Med. 2015; 163: 191-204Crossref PubMed Scopus (570) Google Scholar and is widely acknowledged as the first-line treatment for insomnia.2Morgenthaler T. Kramer M. Alessi C. et al.Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine Report.Sleep. 2006; 29: 1415-1419Crossref PubMed Scopus (651) Google Scholar,3Qaseem A. Kansagara D. Forciea M.A. et al.Clinical Guidelines Committee of the American College of PManagement of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2016; 165: 125-133Crossref PubMed Scopus (977) Google Scholar However, because CBT-I essentially consists of cognitive restructuring and behavior modification that require patient engagement and their active participation, it has inherent limitations. First, suboptimal adherence to CBT-I components is a known limitation and reduces its impact.4Matthews E.E. Arnedt J.T. McCarthy M.S. et al.Adherence to cognitive behavioral therapy for insomnia: a systematic review.Sleep Med Rev. 2013; 17: 453-464Crossref PubMed Scopus (102) Google Scholar Second, a considerable proportion of patients drop out, with attrition rates in sleep clinics ranging from 10% to 40%.5Ong J.C. Kuo T.F. Manber R. Who is at risk for dropout from group cognitive-behavior therapy for insomnia?.J Psychosom Res. 2008; 64: 419-425Crossref PubMed Scopus (96) Google Scholar Third, approximately 40% of patients that participate in randomized controlled trials of CBT-I achieves remission, which is a respectable success rate for a mental/behavioral health condition but still highly unsatisfying.6Wu J.Q. Appleman E.R. Salazar R.D. et al.Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis.JAMA Intern Med. 2015; 175: 1461-1472Crossref PubMed Scopus (323) Google Scholar,7Morin C.M. Vallieres A. Guay B. et al.Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.JAMA. 2009; 301: 2005-2015Crossref PubMed Scopus (547) Google Scholar Thus, adjunct interventions that overcome such limitations of CBT-I would be of paramount importance in clinical practice. This issue reviews behavioral (B), pharmacologic (P), and other (O) interventions that may complement and/or serve as an alternative option to CBT-I. Most interventions addressed in this issue serve as adjunct treatments to CBT-I, including paradoxical intention (B), circadian rhythm regulation (B and P), behavioral activation (B), exercise (B), intense sleep retraining (B), and acupuncture (O). Although hypnotic medications (P) are often used as an alternative treatment to CBT-I in clinical practice, given the clear superiority of CBT-I especially in the long term, they are reviewed in this issue as an adjunct treatment to CBT-I. Two interventions may serve as both adjunct and alternative treatments to CBT-I: mindfulness (B) and acceptance and commitment therapy (B). Last, partner alliance (O) is not a treatment per se but is addressed in this issue as a means to complement and enhance CBT-I. Out of the 11 interventions described in the issue, four are supported by a reasonable amount of largely consistent evidence: mindfulness, circadian rhythm regulation, exercise, and acupuncture. Several clinical trials exist that tested hypnotic medications as an adjunct treatment to CBT-I; however, the data are complex, requiring a careful interpretation. The other interventions reviewed in the issue have less-extensive or less-consistent evidence, while they are all based on robust theoretical rationales: partner alliance, paradoxical intention, behavioral activation, intense sleep retraining, acceptance and commitment therapy, and biofeedback.