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In recent posts, I remarked on the limited effectiveness and unresolved safety problems associated with benzodiazepines and other prescription medications widely used to treat insomnia, and provided concise reviews of evidence for acupuncture and other complementary and alternative (CAM) approaches. In this post, I briefly review evidence for beneficial effects of relaxation and mind-body practices for individuals with insomnia.
Different mind-body approaches have been investigated in controlled trials of insomnia, including progressive muscle relaxation, massage, meditation, desensitization, guided imagery, autogenic training, and hypnosis. Progressive muscle relaxation and sustained deep breathing are especially effective at reducing the time needed to fall asleep in an individual with chronic insomnia. Listening to relaxing music soon before bedtime can help individuals with insomnia fall asleep quicker. In my own clinical practice, I have found that patients who have trouble falling asleep because of anxiety or work stress frequently benefit from listening to relaxing imagery that contains nature sounds starting 30 minutes before their regular bedtime.
There is evidence that individuals who have difficulty falling asleep because of chronic pain or other medical problems respond better to progressive muscle relaxation, and those who stay awake because of chronic worrying are more likely to sleep better with guided imagery (Titlebaum, 1996). Relaxation probably works by increasing parasympathetic activity (i.e., the part of the autonomic nervous system that slows the heart and calms the mind), and decreasing overall sympathetic activity (i.e. the part of the autonomic nervous system that increases heart rate and enhances wakefulness), hence increasing the threshold for arousal during sleep.
Cognitive approaches for relaxation such as meditation and guided imagery are probably more effective than progressive muscle relaxation for mild or situational insomnia, but are of little benefit for severe insomnia (National Institutes of Health Technology Assessment Panel, 1996). Individuals with chronic pain disorders such as fibromyalgia or arthritis report significant increases in the duration of sleep and reduced pain with regular massage therapy (Field, Diego, Cullen, Hernandez-Reif, Sunshine, & Douglas, 2002). Individuals with chronic insomnia who consistently practice a cognitive-behavioral technique alone or in combination with a benzodiazepine or other sedative-hypnotic drug report that non-pharmacologic or combined approaches are more effective than medications alone. Further, improved sleep is sustained longer in individuals who use non-pharmacologic or integrative approaches compared with medication only (Morin et al., 1999). A meta-analysis of 66 studies (including approximately 2000 patients) of relaxation and mind-body approaches for insomnia concluded that all interventions examined resulted in “reliable and durable benefits” that were superior to placebo, including improved quality of sleep and reduced time needed to fall asleep (Murtagh & Greenwood, 1995). A separate meta-analysis found that although non-pharmacologic treatments of chronic insomnia are initially more expensive and require more time compared with conventional drug therapy, in the long run they are reliable, result in sustained benefits, and are more cost-effective than drugs alone (Morin et al., 1994).
In view of adverse effects and the potential for abuse with prolonged use of benzodiazepines and other sedative-hypnotic drugs, especially in the elderly and in substance-abusing patients, practitioners should encourage all patients with insomnia--whether or not they are taking a prescription sedative-hypnotic--to use relaxation, guided imagery or a mind-body practice on a regular basis.
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