2006AASM失眠症心理及行为治疗实践参数.pdf

SLEEP,Vol.29,No.11,200614151.0 INTRODUCTIONINSOMNIA IS A COMMON CONDITION,REPORTED TO OCCUR IN ONE THIRD OF THE ADULT POPULATION.1 CHRONIC INSOMNIA IS ASSOCIATED WITH A reduced quality of life,impaired daytime functioning,increased loss of time from work and higher health costs.Chronic insomnia is also associated with an increased risk of depression and chronic use of hypnotic medication.2-4 The diagnosis of insomnia is based on subjective complaints of difficulty falling asleep or staying asleep,or non-restorative sleep associated with marked distress or significant daytime im-pairment.5,6 Insomnia-related complaints may include reports of daytime fatigue,problems with memory and concentration and mood disturbance.Insomnia can be a primary disorder,as in pri-mary insomnia(e.g.psychophysiological insomnia,paradoxical insomnia,idiopathic insomnia,physiological insomnia-unspeci-fied,etc.),or(what we term here as)secondary insomnia,where insomnia is a symptom of or associated with other conditions in-cluding medical or psychiatric illness,substance abuse disorder or another sleep disorder.5-7 It is often difficult to distinguish the cause of insomnia in patients with concurrent medical disorders.However,insomnia,whether primary or secondary to a comor-bid illness,merits attention.Indicators of the severity of insomnia Practice Parameters for the Psychological and Behavioral Treatment of Insomnia:An Update.An American Academy of Sleep Medicine ReportAn American Academy of Sleep Medicine ReportStandards of Practice Committee of the American Academy of Sleep Medicine1Timothy Morgenthaler,MD;2Milton Kramer,MD;3Cathy Alessi,MD;4Leah Friedman,MA,PhD;5Brian Boehlecke,MD;6Terry Brown,DO;7Jack Coleman,MD;8Vishesh Kapur,MD;9Teofilo Lee-Chiong,MD;10Judith Owens,MD;11Jeffrey Pancer,DDS;12Todd Swick,MD1Mayo Clinic,Rochester,MN;2New York Medical Center,New York,NY,3VA Greater Los Angeles Healthcare System-Sepulveda and University of California,Los Angeles,CA;4Stanford University School of Medicine,Stanford,CA;5University of North Carolina,Chapel Hill,NC;6St.Joseph Memorial Hospital,Murphysboro,IL;7Murfreesboro Medical Center,Murfreesboro,TN;8University of Washington,Seattle,WA;9National Jewish Medical and Research Center,Denver,CO;10 Rhode Island Hospital,Providence,RI;11Toronto,Canada;12Houston Sleep Center,Houston,TXPractice Parameter PaperMorgenthaler et alPRACTICE PARAMETERAbstract:Insomnia is highly prevalent,has associated daytime conse-quences which impair job performance and quality of life,and is asso-ciated 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 Stan-dards 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).Stimu-lus 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,imag-ery 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).Keywords:Practice guidelines,practice parameters,insomnia primary,insomnia secondary,treatment,behavioral,psychological,non-pharma-cological,stimulus control therapy,relaxation training,sleep restriction,cognitive behavior therapy,multicomponent therapy,paradoxical inten-tion,sleep hygiene education.Citation:Morgenthaler 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(11):1415-1419.Disclosure StatementThis was not an industry supported study.Dr.Morgenthaler has received research support from Itamar Medical,LTD.and ResMed,Inc.Dr.Alessi is a consultant for Prescription Solutions,Inc.Dr.Coleman is on the medical advisory board of Influent Medical;and is a consultant and speaker/instructor for Acclarent.Dr.Kapur has received research support from the Washington Technology Center and Pro-tech Services,Inc.;and has received research equipment from Respironics.Dr.Owens has received research support from Cephalon,Lilly,and Sepracor;is a consultant for Lilly,Cephalon,and Shire;and is a speaker for Johnson&Johnson,Cephalon,and Lilly.Dr.Swick has received research support from Sanofi-Aventis,Takeda Pharmaceuticals,Merck,Jazz Pharmaceuticals,Pfizer,Somaxon,Astellas-Pharmaceuticals,and Cephalon;and is a member of the speakers bureau for GlaxoSmith-Kline,Jazz Pharmaceuticals,Sepracor,Cephalon,and Boehringer Ingel-heim.Drs.Kramer,Friedman,Boehlecke,Brown,Lee-Chiong,and Pancer have indicated no financial conflicts of interest.Submitted for publication April 20,2006Accepted for publication April 30,2006Adress correspondence to:Timothy I.Morgenthaler,MD,Mayo Sleep Disor-ders Center,Mayo Clinic,200 First Street SW,Rochester,MN,55905;Tel:[phone];Fax[phone];Email:morganthaler.timothymayo.eduSLEEP,Vol.29,No.11,20061416include intensity,frequency and duration of the sleep difficulty.Insomnia is said to be persistent if it lasts from 1 to 6 months,and chronic if it lasts more than six months.The present paper replaces the previous practice parameters8 for the non-pharmacologic treatment of chronic insomnia.These updated recommendations are based on the accompanying re-view paper2 prepared by a taskforce appointed by the Standards of Practice Committee(SPC)of the American Academy of Sleep Medicine(AASM).2.0 METHODS A task force of content experts was appointed by the AASM in January,2004 to review and grade evidence in the peer-reviewed scientific literature regarding the behavioral and psychological treatment of insomnia,including both primary and secondary in-somnia.Recommendations are based on evidence from studies evaluated in this literature review.The Board of Directors of the AASM approved these recom-mendations.All members of the AASM SPC and Board of Direc-tors completed detailed conflict-of-interest statements and were found to have no conflicts of interest with regard to this subject.These practice parameters define principles of practice that should meet the needs of most patients in most situations.These guidelines should not,however,be considered inclusive of all proper methods of care or exclusive of other methods of care rea-sonably expected to obtain the same results.The ultimate judg-ment regarding appropriateness of any specific therapy must be made by the clinician and patient,in light of the individual cir-cumstances presented by the patient,available diagnostic tools,accessible treatment options,resources available and other rel-evant factors.The AASM expects these guidelines to have a beneficial im-pact on professional behavior,patient outcomes,and,possibly,health care costs.These practice parameters reflect the state of knowledge at the time of publication and will be reviewed,up-dated,and revised as new information becomes available.This practice parameter paper is referenced,where appropriate,using square-bracketed numbers to the relevant sections and tables in the accompanying review paper,or with additional references at the end of this paper.As described in the accompanying review paper,reviewed articles were assigned an evidence classification based on criteria listed in Table 1.Definitions for varying levels of recommendations(reflecting the strength of the available evi-dence)used by the AASM appear in Table 2.For some parameters there were no studies meeting inclusion criteria that specifically addressed the clinical issue.In these cases(Parameters 3.10-3.13)the parameter is provided since we believe it refers to an impor-tant clinical question,but no specific recommendation level is provided.3.0 RECOMMENDATIONS Although the focus of the prior practice parameters8 were pri-marily limited to the effectiveness of specific individual thera-pies in the treatment of chronic primary insomnia in adults,these updated parameters will also address use of behavioral therapies in secondary insomnia,and in special populations.New recom-mendations,as well as those that are the same as,similar to,or an expansion of recommendations in the prior practice parameters are noted in the text.The recommendations in this paper are sup-ported by Level I to Level V evidence.Each of the 37 articles presented in Table 2 of the accompany-ing review paper11 was evaluated using the evidence-based ap-proach outlined by the SPC in Table 1 of this paper.Recommen-dations were developed by the SPC and the level of supporting evidence(Standard,Guideline,or Option)assigned according to the scheme shown in Table 2.The following are recommendations of the SPC approved by the Board of Directors of the AASM.RECOMMENDATIONS ACCORDING TO TYPE OF INSOMNIA3.1 Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary insomnia.4.2(Standard)This is a new recommendation that was implied,but not spe-cifically stated in the prior practice parameters.There were 17 studies identified in the current review that evaluated the effects of treatment for primary insomnia,including 5 randomized con-trolled trials with Level I evidence that demonstrated the effec-tiveness of psychological and behavioral interventions.12-16 Practice Parameter PaperMorgenthaler et alTable 1AASM Classification of EvidenceEvidence Study DesignLevelsI Randomized well-designed trials with low alpha and beta error*II Randomized trials with high alpha and beta error*III Nonrandomized concurrently controlled studiesIV Nonrandomized historically controlled studiesV Case seriesAdapted from Sackett9*Alpha(type I error)refers to the probability that the null hypothesis is rejected when in fact it is true(generally acceptable at 5%or less,or p0.05).Beta(Type II error)refers to the probability that the null hypothesis is mistakenly accepted when in fact it is false(generally trials accept a beta error of 0.20).The estimation of Type II error is generally the result of a power analysis.The power analysis takes into account the variability and the effect size to determine if sample size is adequate to find a difference in means when it is present(Power generally acceptable at 80-90%).Table 2AASM Levels of RecommendationsTerm DefinitionStandard This is a generally accepted patient-care strategy,which reflects a high degree of clinical certainty.The term stan-dard generally implies the use of Level I Evidence,which directly addresses the clinical issue,or overwhelming Level II Evidence.Guideline This is a patient-care strategy,which reflects a moderate degree of clinical certainty.The term guideline implies the use of Level II Evidence or a consensus of Level III Evidence.Option This is a patient-care strategy,which reflects uncertain clinical use.The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.Adapted from Eddy10SLEEP,Vol.29,No.11,200614173.2 Psychological and behavioral interventions are effective and recommended in the treatment of secondary insomnia.4.3,4.4(Standard)This is a new recommendation(evidence relating to secondary insomnia was not included in the earlier review).There were 11 studies identified in the current review that evaluated the effects of treatment for insomnia associated with another medical or psy-chiatric disorder,including four randomized controlled trials with either Level I15,17 or Level II18,19 evidence demonstrating the ef-fectiveness of psychological and behavioral interventions.RECOMMENDATIONS FOR SPECIFIC THERAPIES3.3 Stimulus control therapy is effective and recommended therapy in the treatment of chronic insomnia.4.3,4.4,4.5(Standard)This recommendation is unchanged from the prior practice pa-rameter.Since the prior review,there was 1 additional randomized controlled trial(Level II)supporting the effectiveness of stimulus control therapy.20 The objective of stimulus control therapy is to train the insomnia patient to re-associate the bed and bedroom with sleep and to re-establish a consistent sleep-wake schedule.3.4 Relaxation training is effective and recommended therapy in the treatment of chronic insomnia.4.6(Standard)This recommendation represents a change from the prior prac-tice parameter.Since the prior review,there were 4 additional ran-domized controlled trials,including 3 Level I12,21,22 and 1 Level II studies19 strengthening the support regarding the effectiveness of relaxation training.Relaxation training involves methods aimed at reducing somatic tension(e.g.,progressive muscle relaxation,autogenic training)or intrusive thoughts at bedtime that interfere with sleep.3.5 Sleep restriction is effective and recommended therapy in the treatment of chronic insomnia.4.2,4.4,4.6(Guideline)This recommendation is a change from the prior practice pa-rameter.Since the prior review,there have been 2 additional ran-domized controlled trials,including 1 Level I21 and 1 Level II23 study strengthening the support regarding the effectiveness of sleep restriction therapy.This form of therapy involves curtail-ing the amount of time in bed to the actual amount of time spent asleep,thereby creating a mild sleep deprivation,and then length-ening sleep time as sleep efficiency improves.3.6 Cognitive behavior therapy,with or without relaxation therapy,is effective and recommended therapy in the treatment of chronic insomnia.4.2,4.6(Standard)This recommendation is a change from the prior practice pa-rameter.Since the prior review,there have been 5 additional ran-domized controlled trials,including 4 Level I studies12,16,24,25 and 1 Level II study26 strengthening the support regarding the effective-ness of cognitive behavior therapy.In addition,there have been 7 additional randomized controlled trials supporting the effective-ness of cognitive behavior the