Tools for Practice


#188 Trouble Sleeping: Spend less time in Bed?


CLINICAL QUESTION
For people with primary insomnia (not related to other conditions), can sleep restriction therapy improve outcomes?

BOTTOM LINE
Sleep restriction therapy (SRT) improves time to fall asleep by 12 minutes and time asleep while in bed by 5-10%. Sleep restriction will improve sleep for one in every two to six patients compared to sleep hygiene alone.  


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EVIDENCE
Two systematic reviews: Missed studies and not combined.1,2   
  • Seven Randomized Controlled Trials (RCTs):3-9 20-179 patients (overall 35% male, mean age 62), follow-up 4-24 weeks, mostly compared to sleep hygiene4-6,8,9 and mostly self-reported outcomes. Findings: 
    • Sleep efficiency (time asleep while in bed): In four of six studies, SRT statistically significantly improved over control: 
      • Attained 79-87% with SRT versus 68-79% with control. 
    • Sleep latency (delay getting to sleep): In three of six studies, SRT statistically significant:  
      • Falling asleep 6-19 minutes faster than control. 
    • Other outcomes: 
      • Total time asleep generally not statistically different from control,3,4,6 but may be slightly lower with SRT in first eight weeks.9   
      • Response, remission or “better” (variably defined):3-5,8 Number Needed to Treat (NNT)=2 for any improvement8 to NNT=6 for remission.3 
      • Stopping hypnotic medications:6 53% with SRT versus 15%, NNT=3.   
      • Adverse events not reported.  
      • Benefits persisted 6-12 months.3,4,6  
  • Best RCT (highest quality and used primary care patients): All 97 patients got sleep hygiene advice and half randomized to SRT.4  
    • SRT included sleep prescription from general practitioner given with one follow-up (then self-administered).   
    • Results similar to above, plus:  
      • Sleep quality score (0-21, mean 10.4): SRT improved score 3.9 versus 2.2 (clinically meaningful difference=3).   
      • Improved fatigue score 18% more than control.   
      • Harms: Accidents 14% SRT versus 29% control, not statistically different.   
  • Multiple issues (examples): Studies underpowered,5-9 many outcomes analyzed,3,4,6-9 baseline characteristics unbalanced.3,8,9  
Context: 
  • Self-reported outcomes are frequently worse than results from actigraphy.3,4   
  • Cognitive Behavioral Therapy (CBT) (with multi-components) is highly effective for insomnia.10  
    • For example: CBT improves sleep efficiency 10%. 
      • Comparing indirectly, z-drugs11 improve sleep efficiency ~5%. 
  • SRT trims time in bed to time asleep. Full details are available in hand-outs for patients12,13 or for practitioners to complete with them.13-15  

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Author(s):

  • G. Michael Allan MD CCFP
  • Jobin Varughese MD CMD CCFP (COE)

1. Kyle SD, Aquino MR, Miller CB, et al. Sleep Med Rev. 2015; 23:83-8.

2. Brasure M, MacDonald R, Fuchs E, et al. AHRQ Publication No.15(16)-EHC027-EF. Rockville, MD: Agency for Healthcare Research and Quality. December 2015. Available at: https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2164 . Last accessed: April 19, 2017.

3. Epstein DR, Sidani S, Bootzin RR, et al. Sleep. 2012; 35:797-805.

4. Falloon K, Elley CR, Fernando A 3rd, et al. Br J Gen Pract. 2015; 65:e508-15.

5. Fernando A, Arroll B, Falloon K. J Prim Health Care. 2013; 5(10):5-10.

6. Taylor DJ, Schmidt-Nowara W, Jessop CA, et al. J Clin Sleep Med. 2010; 6:169-75.

7. Lichstein KL, Riedel BW, Wilson NM, et al. J Consult Clin Psychol. 2001; 69:227-39.

8. Edinger JD, Sampson WS. Sleep. 2003; 2:177-82.

9. Friedman L, Benson K, Noda A, et al. J Geriatr Psychiatry Neurol. 2000; 13:17-27.

10. Trauer JM, Qian MY, Doyle JS, et al. Ann Intern Med. 2015; 163:191-204.

11. Lindblad A, Allan GM. Tools for Practice. Available at: https://www.acfp.ca/wp-content/uploads/tools-for-practice/1416848644_z-drugsfv.pdf. Last accessed: April 6, 2017.

12. Sleep restriction therapy. Kaiser Permanente Thrive. Available at: https://thrive.kaiserpermanente.org/care-near-you/northern-california/sanjose/wp-content/uploads/sites/7/2015/10/sleep-restriction-rev2_tcm28-557887.pdf. Last accessed: March 7, 2017.

13. Insomnia management toolkit: Bedtime restriction therapy. Drug and Alcohol Services South Australia. Available at: https://www.sahealth.sa.gov.au/wps/wcm/connect/b4ccb7004033fe2599bcbbd30eb2c8cd/7+-+Bedtime+Restriction+Therapy-DASSA-April2014.pdf?MOD=AJPERES&CACHEID=b4ccb7004033fe2599bcbbd30eb2c8cd. Last accessed: March 7, 2017.

14. Sleep restriction hand-out. Available at: http://supp.apa.org/books/Pediatric-Sleep-Problems/Sleep_Restriction.pdf. Last accessed: March 7, 2017.

15. Gofreed DL. Sleep restriction hand-out. Arlington Sleep Medicine. Available at: http://www.arlingtonsleepmedicine.com/pdf_files/ASM%20Sleep%20Restriction%20Therapy.pdf. Last accessed: March 7, 2017.

Authors do not have any conflicts of interest to declare.