By Cindy Gross
Do you often lie in bed unable to fall asleep? Do you regularly wake up in the middle of the night or too early in the morning? If so, you are not alone. About 1 out of every 10 adults has chronic insomnia. Insomnia causes daytime problems like feeling fatigued or being unable to concentrate. Insomnia is associated with accidents, low productivity and serious health problems. It is also an important risk factor for depression. The most common treatment for chronic insomnia is sleeping pills. People regularly take these pills for years, despite troublesome side effects, and without addressing the underlying problems that cause or perpetuate their insomnia. Our findings published in the March/April 2001 issue of EXPLORE (Gross et al., 2011) indicate that mindfulness training may be an effective treatment for chronic insomnia, providing sleep benefits comparable to medication, without the side effects.
Mindfulness, paying attention to the present moment in particular way, is hypothesized to improve sleep by calming the body and stopping mind-racing. The impact of mindfulness training on arousal and poor sleep habits is discussed in Full Catastrophe Living by Jon Kabat-Zinn, the text which introduced the Mindfulness-based stress reduction (MBSR) program. Approaches to improve sleep through mindfulness include establishing a mindful pre-sleep routine, not spending time awake in bed (e.g., getting up and doing yoga or something enjoyable if unable to sleep), and switching attention from wakefulness by focusing on the breath or practicing a meditation technique. In this way, mindfulness is hypothesized to facilitate disengagement from the concerns of the day, and enable falling asleep. Although studies by our group and others have frequently shown that mindfulness training improves sleep quality, the impact of MBSR training on patients with insomnia had not been tested. Therefore, we decided to conduct a small clinical trial to investigate MBSR’s potential as a treatment for chronic insomnia.
The purpose of our study was to determine if mindfulness training would enable adults with chronic insomnia to obtain clinically meaningful improvements in sleep, comparable to the sleep benefits they might have obtained using an FDA-approved sedative. Thirty adults with primary chronic insomnia were randomized 2:1 into two groups: MBSR or pharmacotherapy. Mindfulness training was provided by a skilled MBSR teacher, Terry Pearson, in the standard format of 8 weekly two-and-half hour classes plus a retreat. The pharmacotherapy group was prescribed 3mg of eszopiclone (LUNESTATM) nightly for 8 weeks, followed by 3 months of use as needed. A 10-minute sleep hygiene presentation (i.e., do not watch television in bed, keep the bedroom dark at night, etc. ) was given to all participants by study staff at the start of the study, and staff contacted everyone weekly so they could report any side effects.
Sleep was measured three ways. First, sleep patterns were objectively measured by actigraphy, a wristwatch-like device that measures movement. Second, participants kept daily entries in a log book called a sleep diary. Third, participants completed questionnaires containing widely-used, validated sleep scales including the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. Sleep measures were obtained before the interventions, and at two and five month follow-ups. The study participants were 21 to 65 years old (mean age 49) and mostly women (73%). Most (66%) had been using sleeping pills prior to enrolling in this trial. Twenty-seven out of 30 patients completed their assigned treatment.
By the end of the 8 week program, MBSR participants significantly reduced the time it took them to fall asleep (-8.9 minutes), as measured by actigraphy. Based on sleep diaries, they fell asleep an average of 22 minutes sooner, and increased their total sleep time by about 34 minutes a night by 5 month follow-up. All standardized sleep scales showed large, statistically significant improvements from before MBSR to all follow-ups. No significant differences were found between the sleep outcomes of the MBSR and pharmacotherapy groups, although our sample size was not sufficient to establish that treatment effects were equal.
To evaluate clinical importance, rates of recovery from insomnia were examined. Before treatment, all participants met criteria for insomnia and poor sleep on the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. By month five, half of the patients randomized to MBSR met stringent criteria for recovery from insomnia. Moreover, none reported adverse events and treatment satisfaction scores were high (averaged 8.8 on a 1 to 10 scale). Although patients in the pharmacotherapy group obtained similar benefits to sleep outcomes, their treatment satisfactions scores were not high (average 6.1), most continued using sleeping pills to the end of trial, and several reported adverse events. Although sleep outcomes following MBSR compared favorably with conventional pharmacotherapy, the fact that only half of the patients in this study met criteria for recovery at follow-up suggests that there is still room for improvement in insomnia treatments.
This study provides initial evidence of the efficacy of mindfulness training as a treatment for chronic insomnia. Strengths included a randomized design and verification of the diagnosis of primary insomnia by psychiatric screening and examination by a sleep physician. Given the absence of side effects and the positive potential benefits of mindfulness that extend beyond sleep, we encourage people with chronic insomnia, particularly those unable or unwilling to use sleep medications, to consider mindfulness training with MBSR.
Funding was provided by a UMN AHC Faculty Development grant to Cynthia Gross and colleagues .
Reference: Gross CR, Kreitzer MJ, Reilly-Spong M, Wall M, Winbush NY, Patterson R, Mahowald M, Cramer-Bornemann M. Mindfulness-Based Stress Reduction vs. pharmacotherapy for primary chronic insomnia: A pilot randomized controlled clinical trial. Explore: The Journal of Science & Healing. Explore. 7(2): 76-87, 2011. PMID: 21397868