A Summary of Research on Insomnia Treatments' Efficacy

Summary

Cognitive Behavioral Therapy seems like the most effective treatment. App/website based programs for sleep are available (see the bottom of the document).

Excerpts from research

Other treatments

No good evidence for Chinese herbal medicine
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0051096/

“The study suggests that a brief course of evening bright-light therapy can be an effective treatment for early-morning awakening insomniacs who have relatively phase advanced circadian rhythms.”
http://www.journalsleep.org/Articles/280510.pdf

“Due to poor methodological quality, high levels of heterogeneity and publication bias, the current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia.”
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013489/

Cognitive behavioral therapy for insomnia, Relaxation therapy, Stimulus control therapy, "Sleeping pills"

Large effect size using Cognitive Behavioral Therapy in insomnia for early morning awakening, small for total sleep time
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/

“Low to moderate grade evidence suggests CBT-I has superior effectiveness to benzodiazepine and non-benzodiazepine drugs in the long term, while very low grade evidence suggests benzodiazepines are more effective in the short term.”
https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-13-40

“However, adequate trials of combined behavior therapy and pharmacotherapy are the best course of management.”
“stimulus control therapy and relaxation and cognitive therapies have the best effect sizes”
“The evidence for [cognitive therapy] intervention is the strongest”
What is relaxation therapy?
“Relaxation-based interventions are based on the observation that insomnia patients often display high levels of arousal (physiological and cognitive), both at night and during daytime.[33] Relaxation methods are used to deactivate the heightened arousal system, and the selection of a specific technique varies depending on whether physiological or cognitive arousal is targeted for treatment. Progressive muscle relaxation and biofeedback techniques seek to reduce somatic arousal, whereas attention focusing procedures such as imagery training and thought stopping are intended to lower presleep cognitive arousal (e.g., intrusive thoughts, racing mind). Additional relaxation therapies (e.g., abdominal breathing, meditation, hypnosis) have also been advocated, but currently there is no evidence to support their use in the clinical management of insomnia with less than modest effect sizes ranging from 0.81 to 0.83 for sleep latency, 0.25 to 0.52 for total sleep time, and 0.06 for wake after sleep onset.[31,32] As is the premise for most self-management skills, all these relaxation techniques require regular practice over a period of several weeks, and professional guidance is often necessary in the initial stage of training.”

What is cognitive behavior therapy for insomnia?
“Cognitive therapy seeks to alter faulty beliefs and attitudes about sleep.[34] For example, insomniacs "often display a great deal of apprehension about bedtime and performance anxiety in their attempt to control the process of sleep onset; some even entertain catastrophic thinking about the potential consequences of insomnia, all of which may heighten their affective response to poor sleep." The objective of cognitive therapy is to cut short the vicious cycle of insomnia, emotional distress, dysfunctional cognitions, and further sleep disturbances. Examples of treatment targets for cognitive therapy include having unrealistic sleep expectations (e.g., "I must get 8 hours of sleep every night"), misconceptions about the causes of insomnia (e.g., "my insomnia is entirely due to chemical imbalances in my body"), amplifications of its consequences (e.g., "I am going to fail after a poor night's sleep"), and performance anxiety resulting from excessive attempts at controlling the sleep process.[35]”

What is stimulus control therapy?
“Stimulus control therapy is based on the premise that insomnia is a conditioned response to temporal (bedtime) and environmental (bed/bedroom) cues that are usually associated with sleep.[28] Accordingly, the main objective of stimulus control therapy is to train the patient to "re-associate the bed and bedroom with rapid sleep onset by curtailing sleep-incompatible activities (overt and covert) that serve as cues for staying awake and by enforcing a consistent sleep-wake schedule." Stimulus control therapy consists of the following instructional procedures[29] consisting of going to bed only when feeling sleepy, using the bed and bedroom only for sleep and sex and nothing else like watching TV, getting out of bed and going into another room whenever unable to fall asleep or returning to sleep within 15–20 minutes and returning to bed only when sleepy again, maintaining a regular rising time in the morning regardless of sleep duration the previous night, and avoiding daytime napping.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924526/

Mean effect sizes (ESM) for each variable calculated from sleep diaries ranged from medium to large with regard to SOL (ESM = 0.67), TWT (ESM = 1.09), WASO (ESM = 0.70), EMA (ESM = 0.74), TIB (ESM = 0.80), and SE (ESM = 0.89)
ACT, actigraphic evaluation; CI, confidence interval; EMA, early morning awakening; ESM, mean effect size; FU, follow-up; k, number of studies; PSG, polysomnogram; SE, sleep efficiency; SOL, sleep onset latency; TST, total sleep time; TWT, total wake time; WASO, wake after sleep onset.
TIB, time in bed
https://www.researchgate.net/profile/Isa_Okajima/publication/229920149_A_meta-analysis_on_the_treatment_effectiveness_of_cognitive_behavioral_therapy_for_primary_insomnia/links/54082a5f0cf2bba34c24a2c3.pdf

“Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia. (Standard)
    These treatments are effective for adults of all ages, including older adults, and chronic hypnotic users. (Standard)
    These treatments should be utilized as an initial intervention when appropriate and when conditions permit. (Consensus)
Initial approaches to treatment should include at least one behavioral intervention such as stimulus control therapy or relaxation therapy, or the combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy—otherwise known as cognitive behavioral therapy for insomnia (CBT-I). (Standard)”
http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf

“These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia.”
“In most measures, CBT was the most sleep effective intervention; it produced the greatest changes in sleep-onset latency and sleep efficiency, yielded the largest number of normal sleepers after treatment, and maintained therapeutic gains at long-term follow-up.”
CBT was better than drugs!
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/217394

For info on how to do relaxation, stimulus control, etc: http://www.uptodate.com/contents/treatment-of-insomnia-in-adults

Exercise, CBT and relaxation therapy have 'A' strength evidence.
http://www.aafp.org/afp/2007/0815/p517.html#afp20070815p517-b4

“Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%).”
https://www.ncbi.nlm.nih.gov/pubmed/24865869

“There were no statistically significant differences between sleep efficiency, total sleep time, and insomnia severity index for internet-delivered versus in-person therapy with a trained therapist.”
“In conclusion, internet-delivered cognitive behavioral therapy is effective in improving sleep in adults with insomnia.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750912/

“In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.”
https://www.ncbi.nlm.nih.gov/pubmed/26615572

Exercise and Sleep

“Compared with controls (C), subjects in the exercise training condition (E) showed significant improvement in the PSQI global sleep score at 16 weeks (baseline and posttest values in mean [SD] for C=8.93 [3.1] and 8.8 [2.6]; baseline and posttest values for E=8.7 [3.0] and 5.4 [2.8]; mean posttest difference between conditions=3.4; P<.001; 95% confidence interval, 1.9-5.4), as well as in the sleep parameters of rated sleep quality, sleep-onset latency (baseline and posttest values for C=26.1 [20.0] and 23.8 [15.3]; for E=28.4 [20.2] and 14.6 [13.0]; net improvement=11.5 minutes), and sleep duration baseline and posttest scores for C=5.8 [1.1] and 6.0 [1.0]; for E=6.0 [1.1] and 6.8 [1.2]; net improvement=42 minutes) assessed via PSQI and sleep diaries (P=.05).”
http://jamanetwork.com/journals/jama/article-abstract/412611

“The late evening exercise with the strength of 50-60% VO2max of 1 h has the effect of getting better subjective sleep feeling in the morning and the effect of the decreased daytime sleepiness.”
https://www.ncbi.nlm.nih.gov/pubmed/9628115

“The results indicate that vigorous late-night exercise does not disturb sleep quality.”
https://www.ncbi.nlm.nih.gov/pubmed/20673290

“Epidemiologic studies have generally shown positive associations of exercise with sleep. On the other hand, experimental studies have failed to demonstrate substantial sleep-promoting effects of either acute or chronic exercise. However, many experimental studies have been limited to good sleepers with little room for improvement because of ceiling/floor effects. The limited research on people with insomnia has yielded more promising results. Better-controlled research with objective sleep measures is needed to verify these findings. There are strong theoretical rationales for examining the efficacy of exercise sleep problems secondary to anxiety, depression, or circadian malsynchronization. Evidence of exercise as an effective treatment for RLS should also be expanded.”
https://www.ncbi.nlm.nih.gov/pubmed/15892929

“Athough only moderate effect sizes have been noted, meta-analytical techniques have shown that exercise increased total sleep time and delayed REM sleep onset (10 min), increased slow-wave sleep (SWS) and reduced REM sleep (2–5 min). The sleep-promoting efficacy of exercise in normal and clinical populations has yet to be established empirically.”
http://www.sciencedirect.com/science/article/pii/S1087079200901102

“Methodological quality ranged from 36%-64% while quality of evidence was very low to low. Statistically significant improvements (P≤0.05) were observed for the apnea-hypopnea index (AHI), overall sleep quality, global score, subjective sleep, and sleep latency.”
“Exercise improves selected sleep outcomes in adults. To increase public health reach, a large, well-designed, and more inclusive meta-analysis is needed.”
https://www.ncbi.nlm.nih.gov/pubmed/28276627

Best CBT programs