Nonpharmacological sleep interventions reduce anxiety
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Nonpharmacological sleep interventions were effective in reducing anxiety and sleep-related thought processes, and these benefits were more substantial in patients with anxiety, according to a recent meta-analysis.
Prior to the pandemic, data from the National Institute of Mental Health showed that 19.1% of all U.S. adults had an anxiety disorder, with prevalence of these conditions more common in women than men (23.4% vs. 14.3%). Also, 31.9% of all U.S. adolescents have had an anxiety disorder, with a higher prevalence among girls than boys (38% vs. 26.1%). In a meta-analysis conducted during the early days of the pandemic — late 2019 until August 2020 — the pooled prevalence of anxiety among adults and children worldwide was 47% and 20.5%, respectively.
Sleeping difficulties are also common, with about one-third of adults in Western countries experiencing a sleep problem at least once a week, Alex Catherine Staines, DClinPsy, MSc, of the department of clinical psychology at the Norwich Medical School at the University of East Anglia in the United Kingdom, and colleagues wrote. They noted that previous research efforts examining sleep interventions have limited their scope to cognitive behavioral therapy-insomnia (CBT-I).
These earlier meta-analyses also “often included measures of both anxiety and co-related anxiety processes such as worry or stress, and effects were not investigated for those from a mental health population,” they wrote in the Journal of Sleep Research.
Staines and colleagues reviewed 43 randomized clinical trials, 12 of which were conducted in the U.S., with 5,945 patients. The trials examined nonpharmacological sleep interventions such as:
- CBT-I, either alone or in combination with mindfulness therapy;
- face-to-face or telehealth appointments with a health care professional;
- computer programs, either self-taught or by a health care professional;
- exposure to bright light;
- sleep hygiene;
- bibliotherapy;
- hypnotherapy for insomnia; and
- brief behavioral therapy for insomnia.
Reflective of the previously established bi-directional relationship that exists among individuals of all ages between sleep problems and emotional difficulties such as stress and anxiety, the trials contained representatives from all age groups except children. The studied trials also had to include resolution of anxiety symptoms as an outcome.
According to Staines and colleagues, the combined effect size of nonpharmacological sleep interventions on anxiety symptoms was moderate, which signified a reduction in symptoms. Subgroup analyses found a moderate effect of these interventions among trial participants with additional physical or mental health difficulties and for those with elevated levels of anxiety at baseline. A secondary meta-analysis showed that nonpharmacological sleep interventions had a large effect on sleep-related thought processes.
“This review did not examine specific anxiety disorders or disorder-specific questionnaires; therefore, our results may have clinical implications for treating other disorders where anxiety may be high,” Staines and colleagues wrote. “These findings suggest sleep interventions may be offered in accessible cost-effective modalities. Clinically, this could improve access and waiting times in psychological services.”
References:
Deng J, et al. Ann NY Acad Sci. 2021;doi:10.1111/nyas.14506.
National Institute of Mental Health. Any anxiety disorder. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder. Accessed Sept. 1, 2021.
Staines AC, et al. J Sleep Res. 2021;doi:10.1111/jsr.13451.
Perspective
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This meta-analysis includes data from 43 different studies that studied how treating insomnia with psychotherapies like CBT-I can improve symptoms of anxiety, even though anxiety is not directly targeted with the insomnia treatments. It’s nice to see large-scale analyses that support what we see in clinical practice.
Patients who don’t sleep well often feel more anxious and people who struggle with anxiety often have a hard time sleeping. One thing I see frequently in my practice is that the benefits of treating insomnia extend far beyond better sleep. People often feel more hopeful, more in control of their lives, and report better relationships with the people around them.
One of the interesting points in this article is that changing the way people think might be an important part of how improving sleep might reduce anxiety symptoms. Many people with chronic insomnia problems worry and ruminate about sleep itself, and learning skills to cope with and change their way of thinking about sleep may generalize to other daytime worries. The findings also show that people with other conditions (physical or mental health problems in addition to insomnia) also experience reduced anxiety.
CBT-I is a brief psychological treatment for chronic insomnia disorder. The American Academy of Sleep Medicine clinical practice guidelines suggest it has the strongest evidence to support its use, even in people with co-occurring mental health problems like anxiety. When providers talk to patients about CBT-I and similar treatments, they can share the hopeful message that even if a person has struggled with insomnia for a long time, and even if the patient has tried to improve basic “sleep hygiene” in the past, CBT-I can still help. Patients with insomnia, with or without anxiety, should reach out to an American Academy of Sleep Medicine Accredited Sleep Disorders Center and ask for information about specialists in their area who can provide CBT-I or access the Society for Behavioral Sleep Medicine website and search for a provider in their area who can provide the treatment in person or via telemedicine.
Board-certified behavioral sleep medicine specialist, the American Board of Sleep Medicine
Professor of medicine, David Geffen School of Medicine, University of California at Los Angeles
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