Practitioner’s Corner

Sleeping Without a Pill: Nonpharmacologic

Treatments for Insomnia

LARA KIERLIN, MD

Insomnia is a complaint of patients seen in many medical settings, but it is particularly prevalent in
patients who present to mental health practitioners. When choosing an intervention for insomnia,
physicians often turn to pharmacological management options as their primary strategy, with other
modalities only considered secondarily, if at all. Medications for insomnia, which include benzodi-
azepines, nonbenzodiazepines, and antihistamines, have been found to have both varying degrees of
efficacy as well as side-effect profiles that may limit their use. In recent years, the American Academy
of Sleep Medicine has studied nonpharmacologic interventions for insomnia and found evidence to
support their use in achieving sustained improvements in sleep parameters over time. Methods such
as cognitive-behavioral therapy, stimulus-control therapy, relaxation, paradoxical intention, and sleep
restriction are efficacious treatments that mental health practitioners can consider in the treatment
of insomnia. Researchers are only beginning to review evidence concerning complementary and alter-
native medicine therapies (CAM); however, given the preponderance of patients who may be employ-
ing these techniques for insomnia, it is important that clinicians be familiar with these approaches,
which merit further study. This article reviews nonpharmacologic treatments for insomnia that are
available to mental health practitioners as well as primary care providers, either via direct applica-
tion of the techniques or by referral. The evidence for each of these modalities is presented in an effort
to expand the treating physician’s armamentarium beyond sole use of the medications traditionally
used to treat insomnia. (Journal of Psychiatric Practice 2008;14:403–407)

KEY WORDS: insomnia, nonpharmacological therapies, medication, cognitive-behavioral therapy (CBT), stimulus-
control therapy, relaxation, paradoxical intention, sleep restriction

Insomnia, defined as the subjective experience of poor
sleep leading to impaired daytime functioning, is a com-
plaint voiced by patients who are seen by clinicians in a
variety of disciplines. While the overall prevalence of
insomnia has been reported to be 4%–33% in the gener-
al population, estimates of the prevalence of insomnia
among patients presenting in primary care settings
range from 50% to 69%.1,2 Mental health practitioners,
in particular, may need to address sleep complaints in
the majority of their patients, since insomnia may affect
80% of depressed patients and up to 90% of patients
with anxiety.1 Implicit in the definition of insomnia is
dysfunction. The Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision (DSM-IV-
TR)3 lists a number of different types of disorders
involving insomnia: primary insomnia; insomnia related
to another mental disorder; sleep disorder due to a gen-
eral medical condition, insomnia type; and substance-
induced sleep disorder, insomnia type. To make any of
these diagnoses, the criteria require that the sleep dis-
turbance or its daytime sequelae, such as fatigue, cause
“clinically significant distress or impairment in social,
occupational, or other important areas of functioning.”
However, the effects of insomnia are not only personal,
but also have far-reaching societal consequences.
Increased healthcare utilization, alcohol use, and
KIERLIN: UCLA Department of Psychiatry and Biobehavioral
Sciences at the David Geffen School of Medicine/Resnick Neuro-
psychiatric Hospital.
Copyright ©2008 Lippincott Williams & Wilkins Inc.
Please send correspondence and reprint requests to: Lara Kierlin,
MD, David Geffen School of Medicine/Resnick Neuropsychiatric
Hospital, 760 Westwood Plaza, Los Angeles, CA 90024.
lkierlin@mednet.ucla.edu
The author declares no conflict of interest.

Journal of Psychiatric Practice Vol. 14, No. 6 November 2008 403

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PRACTITIONER’S CORNER
adverse consequences due to excessive daytime sleepi-
ness, such as auto accidents and work-related injuries,
have been attributed to insomnia in several studies.4
Insomnia has also been implicated in higher rates of
morbidity and mortality due to direct cardiovascular
and psychiatric sequelae in those who suffer from this
condition.5
Once thought to be a minor complaint that could be
treated with a glass of warm milk (or perhaps some-
thing more potent), insomnia is now well recognized as
a healthcare problem with social, physical, and emo-
tional consequences. The negative consequences of
insomnia, while often related to the primary disorder,
can also arise as a result of methods used to treat it.
Medications in the sedative-hypnotic class, which
include benzodiazepine receptor agonists, are frequent-
ly used by practitioners who feel that some intervention
is needed to help patients achieve restorative sleep.
Other medications, such as the antihistamine diphen-
hydramine (Benadryl) or the antidepressant trazodone,
may be used in low doses to achieve sleep onset, and
many patients do report some success with these
agents, particularly in the short term.6 However, these
medications can produce side effects, ranging from
morning “hangover-like” sedation, to amnesia, cognitive
deficits, and behavioral disinhibition.7 It is also possible
for at-risk patients to develop tolerance and subsequent
dependence when treated with benzodiazepines. The
makers of non-benzodiazepine hypnotics such as zolpi-
dem (Ambien), the most commonly-prescribed sleep aid
today, claim these agents have fewer side effects than
longer-half-life benzodiazepines such as lorazepam and
temazepam. However, given the recent introduction of
this class of medications, uncertainty about the extent
of their side effects will remain until further long-term
studies are performed.8 Recent reports have implicated
zolpidem in the genesis of behaviors labeled “sleep relat-
ed eating disorders” by researchers who have observed
nocturnal binging by patients taking this medication,
with the patients later being amnestic regarding the
experience.9
Side effects notwithstanding, the efficacy of many
medications that are currently used to treat insomnia
has been called into question. Several researchers have
challenged whether subjective reports of improved sleep
are consistent with meaningful objective data support-
ing these reports. Several benzodiazepine agonists,
including temazepam, have demonstrated variable
effects on sleep onset, maintenance, and total sleep time
in randomized controlled trials.10 Even in trials that
have demonstrated efficacy, improvements in sleep
404 November 2008
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
parameters have been found to diminish after several
weeks of use.11 Of the nonbenzodiazepine hypnotics,
zolpidem has shown efficacy in improving measures of
sleep onset, but has been found to be less effective for
sleep maintenance.12 Contrary to what is widely
believed, surveys have found that difficulty with main-
taining sleep is a more common complaint than difficul-
ty with sleep initiation,13 lending support to the
stipulation that the most effective treatment for insom-
nia should address both of these dimensions.
While the current explosion of research in the field of
sleep medicine has led investigators to evaluate multi-
ple approaches to the treatment of insomnia, it is only
recently that findings have begun to emerge comparing
the effectiveness of nonpharmacologic treatment meth-
ods with that of medications in the long-term manage-
ment of insomnia. In 1999, the American Academy of
Sleep Medicine (AASM) performed a meta-analysis of
available data on the use of non-pharmacologic treat-
ments.6 An update of this research was published in
2006.14 The authors of these meta-analyses found sup-
port for the hypothesis that psychological and behav-
ioral interventions for insomnia provide sustained
improvements in sleep over time. They reported statis-
tically significant evidence that supported the efficacy of
the following methods: stimulus-control therapy, relax-
ation, paradoxical intention, sleep restriction, and cog-
nitive-behavioral therapy (CBT).15
Cognitive-Behavioral Therapy
The effect of CBT on various sleep parameters has been
studied in several randomized controlled trials in recent
years. When used in the treatment of insomnia, CBT
involves identifying and challenging a person’s often
negative perceptions regarding sleep, which can lead to
heightened anxiety and arousal, states that themselves
impede sleep onset. In one trial, CBT, used in conjunc-
tion with mild sleep restriction, stimulus control, and
relaxation, was compared with pharmacotherapy, a com-
bination of CBT and pharmacotherapy, and placebo.16
This study found that, of these interventions, CBT had
the greatest effect on sleep-onset latency (time until
sleep) and sleep efficiency (percentage of time spent
sleeping compared with total amount of time spent in
bed) and that it provided the most lasting effect at long-
term follow-up 12 months later.16 Subjects who received
CBT experienced a near-normalization of sleep-onset
latency (normal value generally considered to be 30
minutes or less), and sleep efficiency (normal value gen-
erally considered to be 85% or more of time in bed spent
Journal of Psychiatric Practice Vol. 14, No. 6

asleep). In addition, CBT alone was found to be superi-
or to combination therapy involving CBT plus zolpidem.
The investigators hypothesized that the combination
treatment was not as effective because the participants
who were also receiving medication might have been
less committed to behavioral treatment than those
receiving CBT alone. The CBT that was found to be
effective in this study involved four 30-minute sessions
and one telephone session with a pre-doctoral or post-
doctoral psychologist. The authors of this study posited
that a CBT intervention such as this may be more cost-
effective than long-term medication use, depending on
the psychological treatment resources available to the
patient. Given the findings described above, more
research is needed to compare the use of combination
therapy to each of the modalities alone, with special
attention paid to the real-world variability in access to
behavioral care and its associated costs. Until such data
are available, clinicians should take into account the
individual patient's situation and preferences in select-
ing the most appropriate approach.
Progressive Relaxation
Progressive relaxation is a technique used to achieve
sleep onset in patients when nighttime anxiety is a com-
ponent of their insomnia. In progressive relaxation, the
subject begins to sense gradual resolution of tension,
first in distal extremities and then in proximal areas of
the body. This technique may be taught in guided ses-
sions facilitated by a therapist, or an instructional
recording may be used. The subject is instructed to focus
on a particular part of the body and the sensations in
that body part and is then told to allow that area to
relax; the process then moves to the next limb, joint, or
muscle. When used correctly, this technique has been
demonstrated to be an effective relaxation tool in
patients with sleep-onset anxiety. Repeated studies
have confirmed that relaxation methods produce posi-
tive outcomes, including decreased sleep latency, fewer
nocturnal arousals, increased restorative slow-wave
sleep, and an improved subjective sense of having expe-
rienced restful sleep.17 Data also support the efficacy of
progressive relaxation for use by patients being tapered
off sedative/hypnotic medications. In one study, partici-
pants who used these methods reduced their use of
sleep medication by 80%, reported an improved quality
of sleep, experienced better sleep efficiency, and had an
overall reduction in withdrawal symptoms.18 Progres-
sive relaxation is a treatment that is relatively easy to
learn, and its efficacy for insomnia, when used alone or
Journal of Psychiatric Practice Vol. 14, No. 6
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PRACTITIONER’S CORNER
in combination with other therapeutic modalities, is
supported in the literature.
Stimulus Control Therapy (Sleep Hygiene)
CBT and progressive relaxation are frequently aug-
mented by stimulus control therapy, which is a treat-
ment for patients who have been conditioned to
associate the bed, or sleep in general, with a negative
response. Such a negative association may have devel-
oped after a triggering event, such as a medical or psy-
chiatric illness, or a psychosocial stressor. In the
literature, the term “stimulus control” is sometimes
used interchangeably with the concept of sleep hygiene.
The intervention involves having patients actively take
steps to control their sleep environment. Examples of
such environmental modifications include using the bed
for sleep or sex only, not for activities such as reading or
watching television; waking up at the same time every
morning, including on weekends; retiring to bed only
when sleepy and when there is a high likelihood that
sleep will occur; leaving the bed and beginning an activ-
ity in another location if sleep does not result in a rea-
sonably brief period of time after getting into bed;
reducing the subjective effort and energy expended try-
ing to fall asleep; avoiding exposure to bright light dur-
ing nighttime hours, and eliminating daytime naps.19
Stimulus control therapy is included as a standard
treatment method in the most recent “Practice
Parameters for the Psychological and Behavioral
Treatment of Insomnia” published by the AASM.20
Advantages of this technique are its intuitive nature,
simplicity, and low cost for the patient. In fact, strate-
gies related to sleep hygiene are often discussed in the
popular press and do not differ substantially from the
techniques used in research settings, which supports
the applicability of stimulus control therapy to real-
world settings.
Sleep Restriction
One of the components of stimulus control therapy is
sleep restriction, a technique developed by Spielman in
1987 that seeks to match time spent in bed with actual
time spent asleep.21 This technique involves having the
patient maintain a strict sleep-wake schedule, staying
awake and arising at specified periods that are suffi-
cient to induce a mild sleep deprivation condition. A full
course of treatment usually lasts for up to 3 weeks and
involves calculating an individual minimum sleep time
(using sleep diaries), allowing only that minimum
November 2008 405
PRACTITIONER’S CORNER
amount of time for sleep each day, and then gradually
increasing this amount as the body resets its internal
sleep clock. Bright light therapy, which is often
employed to help patients with early morning awaken-
ings reset their natural sleep cycle, can also be used in
the early stages of those receiving sleep restriction ther-
apy to reinforce a new wake schedule. Although difficult
to apply with consistency, this form of therapy can have
a positive effect on insomnia in motivated patients.
Paradoxical Intention
Paradoxical intention is a cognitive reframing technique
in which the insomnia sufferer, rather than attempting
to fall asleep at night, instead makes every effort to stay
awake. To this end, the subject divorces subjective con-
trol of sleep from the outcome. One theory that may
explain the effectiveness of this method is that elimi-
nating voluntary effort may, in turn, relieve perform-
ance anxiety that is sleep-prohibitive. Researchers
found that subjects with insomnia who used this tech-
nique showed a reduction in sleep effort and perform-
ance anxiety and a trend toward a lower subjective
assessment of sleep-onset latency compared with con-
trols.22 One potential use for this method is to treat
patients who exhibit higher levels of performance anxi-
ety related to sleep in the pre-treatment phase. Other
studies have found that paradoxical intention can
reduce overestimation of the sleep deficit, a quality
found in many individuals with insomnia.23
Complementary and Alternative Medicine
Strategies
While the use of prescription medications to treat sleep
disorders is certainly growing (a record 43 million pre-
scriptions for sleep aids were filled in 2005),24 interest
in complementary and alternative medicine (CAM)
strategies has increased among both patients and
healthcare practitioners. Such strategies, which include
spiritual health techniques, yoga, Chinese and
Ayurvedic medicine, biofeedback, and other modalities,
have been studied for their effectiveness in mood disor-
ders, anxiety, and, recently, sleep disturbance.
Researchers recently reviewed randomized controlled
trials of CAM treatments for sleep problems in older
adults and found that 77% of those studies showed pos-
itive effects for CAM interventions in sleep disturbance,
with the evidence for mind-body interventions and acu-
pressure suggesting particular benefit in this older pop-
ulation.25 Evidence notwithstanding, a recent survey
406 November 2008
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
revealed that over 1.6 million Americans already use
some form of CAM to treat insomnia, with herbal reme-
dies, mind-body therapies, and relaxation the modalities
most often used.26 Although these CAM strategies may
be outside the realm of traditional Western medicine, it
is clear that they are gaining acceptance and being used
by many insomnia sufferers, who may not readily
divulge this use to their primary care providers.
Therefore, it is important that clinicians familiarize
themselves with these therapies.
Conclusion
Despite evidence for the nonpharmacological approach-
es described in this article, many practitioners continue
to use medications as the first-line treatment for insom-
nia. This is especially true in primary care settings,
where physicians may lack the expertise and/or the time
necessary to provide more behaviorally based treat-
ment. To address this legitimate concern, techniques
have been developed to facilitate use of CBT methods in
the primary care setting. Primary care physicians may
not consider themselves sleep experts per se, but they do
have the authority to challenge false beliefs about sleep
that might be expressed by their patients. For example,
physicians may allay fears of patients who feel that they
must conform to some particular norm regarding num-
ber of hours slept. Providing simple reassurance that
there is no “perfect” number of hours of sleep required
and that people function within a range of sleep times
can challenge patient misconceptions that contribute to
insomnia. In at least one study, CBT methods tailored to
the time constraints present in a brief office visit have
been demonstrated to be effective.14 In addition, the
AASM now provides accreditation not only for formal
behavioral sleep medicine fellowships, but also for 4-
week mini-fellowships targeted to physicians, psycholo-
gists, and advanced practice nurses in an effort to
improve behavioral treatment of patients with insomnia
who present in the primary care setting (information on
these programs is available on the AASM website at
www.aasmnet.org). Although data support use of behav-
ioral interventions for insomnia, patients may not have
much choice about which treatment they receive if phar-
macologic management is more easily accessible.
Therefore, with research increasingly validating behav-
ioral techniques for insomnia, it would be beneficial for
medicine and its allied fields to incorporate such strate-
gies into their treatment regimens.
Insomnia is a medical condition that, whether self-
limited or chronic, has the potential to cause significant
Journal of Psychiatric Practice Vol. 14, No. 6

distress in those who suffer from it. For years, pharma-
cological intervention has been the treatment of choice,
due to moderate efficacy, ease of administration, and
provider familiarity. However, a growing body of evi-
dence supports the use of nonpharmacologic methods
involving behaviorally based approaches such as CBT,
stimulus-control therapy, progressive relaxation, and
others, for their potential long-term efficacy in the treat-
ment of insomnia. Efforts are underway to educate
healthcare providers about the potential benefits of and
the practical application of these techniques. With this
knowledge, medicine and its allied fields can make pos-
itive changes in the lives of their patients, who may
already be taking advantage of nonpharmacologic treat-
ments for insomnia. Psychology stands poised to make
its contribution to the field of sleep medicine, and the
world may rest easier as a result.
References
1. Ohayon MM. Epidemiology of insomnia: What we know and
what we still need to learn. Sleep Med Rev 2002;6:97–111.
2. Smith MT, Perlis ML, Park A, et al. Comparative meta-analy-
sis of pharmacotherapy and behavior therapy for persistent
insomnia. Am J Psychiatry 2002;159:5–11.
3. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders, 4th edition, text revision.
Washington, DC: American Psychiatric Association; 2000.
4. Grunstein R. Insomnia. Diagnosis and management. Aust Fam
Physician 2002;31:995–1000.
5. NIH state-of-the-science conference statement on manifesta-
tions and management of chronic insomnia in adults. NIH
Consens State Sci Statements 2005;22:1–30.
6. Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treat-
ment of chronic insomnia. An American Academy of Sleep
Medicine review. Sleep 1999;22:1134–56.
7. Nelson J, Chouinard G. Canadian Society for Clinical Pharma-
cology. Guidelines for the clinical use of benzodiazepines:
Pharmacokinetics, dependency, rebound and withdrawal. Can
J Clin Pharmacol 1999;6:69–83.
8. Kales A. Benzodiazepine hypnotics and insomnia. Hosp Pract
(Off Ed) 1990;25:7–21.
9. Najjar M. Zolpidem and amnestic sleep related eating disorder.
J Clin Sleep Med 2007;3:647–8.
10. Rosenberg RP. Sleep maintenance insomnia: Strengths and
weaknesses of current pharmacologic therapies. Ann Clin
Psychiatry 2006;18:49–56.
11. Mendelson WB, Roth T, Cassella J, et al. The treatment of
chronic insomnia: Drug indications, chronic use and abuse lia-
bility. Summary of a 2001 New Clinical Drug Evaluation Unit
Journal of Psychiatric Practice Vol. 14, No. 6
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PRACTITIONER’S CORNER
meeting symposium. Sleep Med Rev 2004;8:7–17.
12. Saletu-Zyhlarz G, Anderer P, Brandstatter N, et al. Placebo-
controlled sleep laboratory studies on the acute effects of zolpi-
dem on objective and subjective sleep and awakening quality
in nonorganic insomnia related to neurotic and stress-related
disorder. Neuropsychobiology 2000;41:139–48.
13. National Sleep Foundation: 2002 Sleep in America Poll.
Washington, DC: National Sleep Foundation; 2002:1–43.
14. Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and
behavioral treatment of insomnia: Update of the recent evi-
dence (1998–2004). Sleep 2006;29:1398–414.
15. Edinger JD, Sampson WS. A primary care “friendly” cognitive
behavioral insomnia therapy. Sleep 2003;26:177–82.
16. Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behav-
ior therapy and pharmacotherapy for insomnia: A randomized
controlled trial and direct comparison. Arch Intern Med
2004;164:1888–96.
17. Engel RR, Knob B, Albus M. Relaxation versus activity train-
ing for chronic insomnia: A long-term, EEG controlled study of
therapeutic effects and mechanisms of change. In: Koella WP,
Ruther E, Schulz H, eds. Sleep ‘84: Proceedings of the Seventh
European Congress on Sleep Research, Munich, September
3–7, 1984. Stuttgart, Germany: Gustav Fischer Verlag;
1985:136–8.
18. Lichstein KL, Peterson BA, Riedel BW, et al. Relaxation to
assist sleep medication withdrawal. Behav Modif 1999;23:
379–402.
19. Dollman WB, Le Blanc VT, Roughead EE. Managing insomnia
in the elderly—what prevents us using non-drug options? J
Clin Pharm Ther 2003;28:485–91.
20. Morgenthaler T, Kramer M, Alessi C, et al. Practice parame-
ters for the psychological and behavioral treatment of insom-
nia: An update. An American Academy of Sleep Medicine
Report. Sleep 2006;29:1415–9.
21. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic
insomnia by restriction of time in bed. Sleep 1987;10:45–56.
22. Broomfield NM, Espie CA. Initial insomnia and paradoxical
intention: An experimental investigation of putative mecha-
nisms using subjective and actigraphic measurement of sleep.
Behav Cognit Psychother 2003;31:313–24.
23. Harvey AG. A cognitive model of insomnia. Behav Res Ther
2002;40:869–93.
24. Consumer News Service. Americans may be relying too heavi-
ly on sleeping pills. Available at www.consumeraffairs.com
/news04/2006/08/cu_sleeping_pills.html, accessed September
27, 2008.
25. Meeks TW, Wetherell JL, Irwin MR. Complementary and alter-
native treatments for late-life depression, anxiety, and sleep
disturbance: A review of randomized controlled trials. J Clin
Psychiatry 2007;68:1461–71.
26. Pearson NJ, Johnson LL, Nahin RL. Insomnia, trouble sleep-
ing, and complementary and alternative medicine: Analysis of
the 2002 National Health Interview Survey data. Arch Intern
Med 2006;66:1775–82.
November 2008 407