Received: 3 December 2020 | Accepted: 5 February 2021

DOI: 10.1111/ijcp.14084

N O N - S Y S T E M AT I C R E V I E W
PRIMARY CARE

Non-­pharmacologic treatment of insomnia in primary care

settings

Laura Hrehová1 | Kamal Mezian2

1
Institute of General Practice, First Faculty
of Medicine, Charles University, Prague, Abstract
Czech Republic Introduction: Prevalence of insomnia is higher in females and increases with higher
2
Department of Rehabilitation Medicine,
age. Besides primary insomnia, comorbid sleep disorders are also common, accompa-
First Faculty of Medicine, Charles University
and General University Hospital in Prague, nying different conditions. Considering the possible adverse effects of commonly used
Prague, Czech Republic
drugs to promote sleep, a non-­pharmacologic approach should be preferred in most
Correspondence cases. Although generally considered first-­line treatment, the non-­pharmacologic ap-
Laura Hrehová, Institute of General Practice,
proach is often underestimated by both patients and physicians.
First Faculty of Medicine, Charles University,
Prague, Czech Republic. Objective: To provide primary care physicians an up-­to-­date approach to the non-­
Email: [email protected]
pharmacologic treatment of insomnia.
Methods: PubMed, Web of Science, and Scopus databases were searched for rel-
evant articles about the non-­pharmacologic treatment of insomnia up to December
2020. We restricted our search only to articles written in English.
Main message: Most patients presenting with sleep disorder symptoms can be ef-
fectively managed in the primary care setting. Primary care physicians may use phar-
macologic and non-­pharmacologic approaches, while the latter should be generally
considered first-­line treatment. A primary care physician may opt to refer the patient
to a subspecialist for refractory cases.
Conclusions: This paper provides an overview of current recommendations and
up-­to-­date evidence for the non-­pharmacologic treatment of insomnia. This article
emphasizes the importance of cognitive-­behavioral therapy for insomnia, likewise,
exercise and relaxation techniques. Complementary and alternative approaches are
also covered, eg, light therapy, aromatherapy, music therapy, and herbal medicine.

1 | I NTRO D U C TI O N also common complaints of shift workers. If not adequately treated,

insomnia can result in psychopathological conditions, hypertension,
International Classification of Sleep Disorders, 3rd edition (ICSD-­ and other serious health problems.7 Treatment options for insom-
3) distinct insomnia to acute and chronic (insomnia symptoms >3 nia cover pharmacological and non-­
pharmacological approaches.
1
nights per week for >3 months). Various symptoms of sleep disor- Commonly used agents are benzodiazepine receptor agonists, se-
ders comprise difficulty initiating sleep, difficulty maintaining sleep, dating antidepressants, sedating antihistamines, melatonin recep-
and non-­restorative sleep. 2 Prevalence of insomnia is alarming high tor agonists, and dual orexin receptor antagonists.7 However, all
as it affects 6%-­10% of the adult population.3 Insomnia is more prev- medications are associated with their potential side effects. Being
4
alent in females and older individuals. Besides primary insomnia, aware of the possible side effects of hypnotic/sedating drugs is
comorbid sleep disorders are also common accompanying different particularly important in elderly patients. Regarding geriatric pa-
diseases/conditions, eg, chronic pain, nocturia, chronic cough, pru- tients using hypnotic/sedating medication, an increased risk of
ritus, emotional disturbance, and pregnancy.5,6 Sleep difficulties are falls, physical dependence, and confusion have been documented.8

Int J Clin Pract. 2021;00:e14084. wileyonlinelibrary.com/journal/ijcp © 2021 John Wiley & Sons Ltd | 1 of 8
https://doi.org/10.1111/ijcp.14084
2 of 8 | HREHOVÁ and MEZIAN

Moreover, current evidence supports the risk of cognitive decline

development in association with long-­term benzodiazepine therapy.9
Review criteria
Considering the above-­mentioned agents' possible adverse effects,
This review was conducted by a focused PubMed, Scopus,
a non-­pharmacologic approach should be preferred in most cases.10
and Web of Science search of the English language litera-
Importantly, general practitioners should evaluate their patients who
ture up to December 2020. We included articles referring
present with insomnia complaints about psychiatric comorbidities,
to the non-­pharmacologic treatment of insomnia. We con-
as these may warrant a referral to a psychiatrist or clinical psycholo-
11 sidered original research and systematic review articles.
gist. In this regard, otherwise, healthy patients presenting with
Editorials, letters to the editor, and case series/reports
insomnia symptoms generally do not require sleep specialist refer-
were excluded.
ral initially and can be managed by general practitioners.12 Notably,
in relation to the COVID-­19 pandemic, 43.5% of sleep departments
Message for the clinic
in the Czech Republic and Slovakia completely interrupted their
service. In similar situations, primary care physicians may need to • The non-­pharmacologic approach should be generally
manage insomnia symptoms even in more complicated cases. 13 considered the first-­line treatment for insomnia.
Multicomponent behavioral therapy and psychotherapy are con- • Hypnotic/sedating medication should be reserved for
sidered first-­line treatment according to guidelines of the American selected cases.
College of Physicians, European Sleep Research Society, and British • A primary care physician may consider referral to a sub-
Association for Psychopharmacology.14-­16 The non-­pharmacological specialist for refractory cases or if the diagnosis is in
treatment components are cognitive-­behavioral therapy for insom- doubt.
nia (CBT-­i), sleep hygiene, stimulus control, sleep restriction, psy-
chotherapy and relaxation techniques, exercise, complementary and
alternative approaches, eg, phototherapy, massage, music therapy,
aromatherapy, herbal medicine, acupuncture/acupressure. provide quantitative information about the subjective quality of
sleep. The self-­rated questionnaire widely used in chronic insomnia
for assessing quality and patterns of sleep over the last month in
2 | M E TH O DS either scientific research or daily clinical practice is the Pittsburgh
Sleep Quality Index (PSQI). The PSQI consists of 19 individual items,
2.1 | Literature search measuring seven areas (components): habitual sleep efficiency, sleep
latency, sleep duration, sleep disturbances, use of sleep-­promoting
This narrative review was conducted by a focused PubMed, Scopus, medications, daytime dysfunction, and subjective sleep quality.17
and Web of Science hand search of the English language literature Importantly, the cross-­cultural adaptation of the Czech version of
up to November 2020. We included articles referring to the non-­ the PSQI has already been conducted.18 Some centers use differ-
pharmacologic treatment of insomnia. The following eligibility cri- ent assessment tools, eg, Epworth Sleepiness Scale, Sleep Disorders
teria were determined in advance. We considered original research, Questionnaire, Insomnia Severity Index.19 Sleep diaries provide
narrative, and systematic review articles. Editorials, letters to the patients and health care professionals important information for
editor, and case series/reports were excluded. Terms and keywords assessing sleep. There are hundreds of different self-­administered
used included the following: insomnia, sleep, cognitive-­behavioral sleep diaries. To solve this heterogeneity problem, the “Consensus
therapy, sleep hygiene, stimulus control, autogenic training, herbal Sleep Diary” was developed and published by sleep medicine ex-
medicine, phytotherapy, light therapy, acupuncture, acupressure, perts. 20 Besides classical paper diaries, modern sleep diaries nowa-
progressive muscle relaxation, hypnotherapy, exercise, yoga, Tai Chi, days in the form of an app provide several benefits (eg, improved data
music therapy, mindfulness, depression, sleep restriction, aroma- collection, automatic scoring, reducing the time for data entry). 21
therapy, and massage. The bibliographies of relevant articles were Furthermore, we consider adjusting/replacing medications that
searched for additional references. may disturb sleep (eg, corticosteroids and SSRI antidepressants). We
also make an effort to control symptoms of comorbid diseases (eg,
chronic pain, nocturia, chronic cough, pruritus). The first-­line treat-
2.2 | Authors' approach ment in our clinical practice is non-­pharmacologic, focusing on sleep
hygiene and stimulus control. In the author's opinion, most of these
The author's insomnia management approach includes a detailed patients do not require the initial subspecialist referral and can be
sleep history focusing on behavior around the bed and sleep, managed by general practitioners. A primary care physician may
stress, depression, and laboratory testing (including serum thyroid-­ consider referral to a sleep clinic or neurological assessment if the
stimulating hormone and free T3 and free T4). history suggests restless legs syndrome, obstructive sleep apnea,
Two commonly used tools for subjective sleep assessment are or new-­onset epileptic seizures in sleep, or if the diagnosis is in
sleep questionnaires and sleep diaries. The sleep questionnaires doubt. Sleep physicians may indicate paraclinical examinations such
HREHOVÁ and MEZIAN | 3 of 8

as polysomnography and actigraphy in those patients. We consider TA B L E 1 Inadequate sleep hygiene: adapted according to ICSD
psychiatric/psychological evaluation in patients with depression and diagnostic criteria26

anxiety symptoms, particularly if there is no response to our therapy. • Naps during day at least two times each week.
• Unsettled bedtime or wake-­up times.
• Frequent periods (more than two times per week) of extended
amounts of time spent in bed.
3 | N O N - ­P H A R M ACO LO G I C TH E R A PI E S • Routine use of caffeine, alcohol, or tobacco before bed.
• Performing high-­intensity exercise right before bed.
3.1 | Cognitive-­behavioral therapy for insomnia • Engaging in exciting or emotionally upsetting activities too close
to bedtime.
• Frequent use of the bed for non-­sleep-­related activities (eg,
CBT-­i is an effective non-­pharmacologic multimodal combination of television watching, reading, studying, snacking, etc).
treatments for coping with sleep problems. It can either be effec- • Sleeping on an uncomfortable bed (poor mattress, inadequate
tively done by trained therapists face-­to-­face or as a telemedicine-­ blankets, etc).
• Allowing the bedroom to be too bright, too stuffy, too cluttered,
based internet-­delivered therapy. 22 CBT-­i aims to change thoughts
too hot, too cold, or in some way not conducive to sleep.
that negatively interfere with sleep quality and improve sleep be- • Performing activities demanding high levels of concentration
haviors and unhealthy habits. CBT-­
i encompasses cognitive and shortly before bed.
behavioral interventions and relaxation training. For treatment suc- • Allowing mental activities, such as thinking, planning, reminiscing,
cess, good compliance of the patient is a prerequisite. Along with the etc to occur in bed.

motivation, patients also need to include the sleep diary as part of

their daily routine. hygiene,” a set of recommendations to alleviate the negative impact
Cognitive interventions as a form of psychotherapy aim to rec- of blue light exposure on sleep quality. The evening exposition to
ognize and change the patient´s maladaptive beliefs about sleep. artificial light disrupts both NREM (non-­rapid eye movement) and
The first step is the identification of the stressors, which are subse- REM (rapid eye movement) sleep cycles. 27 The wavelengths in the
quently replaced with an alternative interpretation. Quite common blue part of the spectrum (400-­490 nm) significantly suppress mel-
are unrealistic expectations about sleep duration. These thoughts atonin secretion. 28 Interestingly, Smotek and coworkers reported
create tension, impair the ability to sleep, and cause a vicious cycle. an alerting effect for selected variables after exposure to a short-­
This sleep misperception (discrepancy between self-­perceived and wavelength (blue) light. 29 Further, increased body temperature and
objective sleep parameters) among insomniacs ranges up to 50%, de- heart rate have also been documented after exposure to short-­
pending on the methodology/outcome measures used. 23 Education wavelength light (460 nm).30 These non-­image forming effects are
of patients about realistic expectations from sleep may reduce anx- believed to be mediated by intrinsically photosensitive retinal gan-
iety and hyperarousal associated with insomnia. The therapist can glion cells (ipRGCs) with particular sensitivity to blue light spectrum
even advise the patient to make an active effort to stay awake, which from 460 to 480 nm wavelength. As such, blue light in the evening
may help relieve the anxiety linked to the pressure to fall asleep. The causes decreased sleepiness and phase delay, therefore delaying
described technique is known as paradoxical intention. sleep onset (not only on the day of exposure but also the following
Behavioral interventions emphasize the change in the patient´s day), and that is why one of the recommendations is to avoid blue
maladaptive behavior. Therapy for insomnia should involve at least light in the evening or use blue-­light blockers to better consolidate
one intervention session. Individual or group format therapy aims the dim light melatonin onset (DLMO).31,32 Patients presenting with
at the development of new behavioral patterns. The intervention insomnia symptoms may be advised to limit the use of blue light-­
can easily be delivered in the office setting by a general practitioner, emitting devices (eg, TVs, laptops, tablets, smartphones) 90 min-
who advises the patient to maintain a sleep diary and is instructed utes before bedtime.33 Also, appropriate daylight exposure, night
on sleep hygiene, stimulus control, and sleep restriction therapy. exposure, timing, and cumulative length are to be considered when
Commonly used individual components comprise sleep hygiene, speaking about “light hygiene.”
stimulus control, sleep restriction, paradoxical intention, and relax- Stimulus control therapy aims to (re)associate the bedroom with
ation training. sleep and set a regular sleep-­wake cycle.34 Specific recommenda-
Sleep hygiene was initially introduced in 1977 by Peter Hauri, who tions include a set of behavior modifications (eg, only going to bed
developed a concept of sleep-­promoting recommendations. 24 Sleep when feeling sleepy, using the bed and bedroom for sleep and sex
hygiene consists of a set of behavior and environmental factors only, keeping a fixed wake time in the morning). Together with sleep
modifications (eg, avoiding naps during the day, avoiding physical hygiene, stimulus control education is recommended as an initial in-
exercise close to bedtime, limiting caffeine consumption, bedroom tervention for all adults with insomnia.35
temperature) that may improve sleep quality. 25 The International Sleep restriction may be beneficial for patients who spend a long
Classification of Sleep Disorders (ICSD) introduced a diagnostic time in bed, not sleeping. The initial goal is to achieve mild sleep
category called “Inadequate Sleep Hygiene.”26 The sleep habits deprivation by limiting the number of sleeping hours. The physi-
that contribute to inadequate sleep hygiene, according to the ICSD, cian advises the patient to limit time in bed to the number of hours
are presented in Table 1. In recent years, attention is paid to “light spent sleeping, while this time should not be less than five hours.36
4 of 8 | HREHOVÁ and MEZIAN

Using the sleep diary, the patient is instructed to gradually increase 58.3% reported hypnosis benefit on sleep quality. The incidence of
35
sleep time as sleep quality improves. One important flaw of this adverse events was reported to be low.54
approach is an increased risk of daytime drowsiness.
Evidence shows CBT's consistent effectiveness in improving
sleep problems across multiple outcomes37-­39 and seems to be the 3.3 | Exercise
14,16
optimal first-­
line treatment. Notably, no specific adverse ef-
fects were reported.40 After 6-­week of the CBT-­i program, Janků Sleep and exercise bound a reciprocal relationship involving physical
and colleagues reported a significant reduction of total sleep time and psychical pathways. Multiple explanations of how regular exer-
discrepancy. On the other hand, change in wake after sleep onset cise affects sleep comprise endocrine effects on the hypothalamic
41
discrepancy was not observed. level,55 the interaction with circadian rhythm, metabolic and im-
mune responses, and thermoregulatory.56 In the last years, specific
attention has been paid to exercise-­related hippocampal neurogen-
3.2 | Relaxation techniques esis with the integration of newly born neurons. Although exercise-­
induced neurogenesis mechanisms are not yet clearly understood,
Autogenic training is a technique of passive autosuggestion described this form of morphological and functional plasticity is believed to
in 1932 by a German psychiatrist Johannes Heinrich Schultz. The bear the potential to maintain brain function and to promote brain
technique involves a series of mental exercises used to induce a plasticity. In their RCT, Erickson and coauthors documented an im-
state of relaxation. In their systematic review and meta-­analysis, Seo provement in cognitive functions, eg, spatial memory after seven
and Kim concluded that autogenic training is effective for adults' weeks of an aerobic exercise program.57 Importantly, exercise-­
stress management as it decreased anxiety and depression in 11 related hippocampal neurogenesis seems to be linked to the antide-
studies that were analyzed.42 In 2011, Ann Bowden and coauthors pressant effects of exercise. Besides neurogenesis, physical activity
published a study of the effectiveness of autogenic training, and 112 exerts multiple physiological effects on improving well-­being, eg,
subjects with sleep-­related problems reported an improvement in increased plasma β-­endorphin concentrations.
several sleep patterns, including sleep onset latency and feeling of Resistance exercise, aerobic training, and stretching. In 2018,
sleep refreshment. The program consisted of 8-­week training, with Kovacevic and colleagues conducted a systematic review to determine
no specific focus on sleep.43 the acute and chronic effects of resistance exercise on sleep quality.
Progressive muscle relaxation (PMR) is a deep muscle relaxation Regular resistance exercise significantly improved sleep quality, with
method developed by American physician Edmund Jacobson in additional benefits of a combination with aerobic exercise. On the other
1938.44 The goal of PMR is to reduce somatic tension and cognitive hand, the evidence of the acute effects of resistance exercise on sleep
arousal that negatively affects sleep quality. The effectiveness of quality was low and inconsistent.58 In 2019, D'Aurea et al conducted
PMR in improving sleep quality has been proven in several clinical a study comparing the effects of moderate-­intensity resistance exer-
conditions, eg, cancer, prenatal anxiety, and COVID-­19.45-­47 cise training and stretching on chronic insomnia. The authors found
Mindfulness meditation is rooted in Buddhist philosophy and is both approaches to be similarly effective in objective and subjective
based on emotional detachment with non-­judgmental awareness sleep parameters. Compared with controls, either resistance exercise
in the present moment.48 Focusing on calming and slowing down and stretching were effective.59 In their study, Bullock and cowork-
breathing is often used to achieve an emotionally and mentally clear ers compared the influence of different exercise intensities on sleep
and stable state. In 2019, Rush and colleagues conducted a system- quality in older poor sleepers. Their results suggest that high-­intensity
atic review and meta-­analysis of the effect of mindfulness meditation interval training (HIIT) was the least effective for optimizing sleep in
on sleep quality in 18 randomized controlled trials (RCT's), including poor sleepers compared with moderate and low (stretching) intensity
1654 patients. Their preliminary findings suggest that mindfulness exercise.60 According to sleep hygiene, people should not perform ex-
meditation may improve some aspects of poor sleep quality, eg, im- ercise before bedtime. On the other hand, Buman and coauthors did
49,50
provement in sleep-­related daytime impairment. Referring to the not find an association between evening exercise and worse sleep.61
study by Liu and Rice, patients less experienced in meditation prefer To this end, regular exercise seems to be a good alternative treatment
background sounds without a distinct melody during mindfulness option for poor sleepers.
meditation.51 Tai Chi Chuan, an internal Chinese martial art, is nowadays also
Hypnotherapy is performed by professionals who received train- very popular in the Western world. A systematic review with a
ing in hypnosis. The alternated state of consciousness, called the meta-­analysis conducted in 2014 showed the potential to enhance
hypnotic trance, allows for relaxation, increased suggestibility, and older adults' cognitive function who practice Tai Chi.62 A favorable
posthypnotic suggestion. Hypnosis has been reported as an effec- impact of Tai chi on the occurrence of falls, cardiovascular fitness,
tive therapy for several clinical conditions, eg, relieving cancer treat- and flexibility was also reported.63,64 In 2010, Wang and coworkers,
52,53
ment side effects, and pain management. In 2018, Chamine and in their systematic review, documented the effects of Tai Chi on im-
coauthors published a systematic review of 24 articles describing provement in psychological well-­being, including mood, decreased
hypnosis interventions on sleep quality. From the analyzed studies, stress, and anxiety.65 Two recently published systematic reviews
HREHOVÁ and MEZIAN | 5 of 8

with meta-­analyses have reported sleep quality improvement via Tai light intensity was 4800 lux.80 With coauthors in their systematic
66,67
Chi training. review with meta-­analysis, Van Maanen reported light therapy to
Yoga, in its ancient spiritual concept, originated in the Indian sub- be effective for insomnia symptoms and recommended it as a com-
continent more than 5000 years ago, comprises meditation, breath- plementary method to insomnia management.80 On the other hand,
ing exercises, lifestyle advice, and body positions. The Western light therapy can be questionable in patients with photosensitivity
version, known as “modern postural yoga” consists mainly of pos- and epilepsy.
tures usually connected by flowing sequences.68 Cramer et al, in Music therapy is the therapeutic use of music to promote pa-
their systematic review from 2013, documented moderate evidence tients' mental and bodily health. Listening to music is a complicated
for short-­term effects of yoga on symptom relief in patients with process accompanied by the activation of different brain parts with
69
depression. Considering women with sleep problems, Wang and a complex response, eg, cognitive and emotional. Särkämö and col-
coworkers reported that yoga intervention could be beneficial in the leagues, in poststroke patients listening to music of their own choice,
long-­term.70 Furthermore, yoga practice has also been reported to reported mood improvement and cognitive enhancement.81 Nilsson
be helpful in primary insomnia,71 and it was shown to improve sleep documented stress reduction in patients who underwent cardiac
72 73
in elderly people, cancer patients, and women with menopausal surgery after 30 minutes of listening to soft and relaxing melodies
symptoms.74 However, European guidelines for the diagnosis and with a volume of 50-­60 dB.82 In their systematic review from 2017,
14
treatment of insomnia do not recommend yoga for the treatment Feng et al documented that listening to relaxing music improves
of insomnia because of poor evidence. sleep onset latency and overall sleep quality in primary insomniacs.83
Aromatherapy is based on the usage of concentrated essential
oils extracted from fragrant floral parts to improve mental and phys-
3.4 | Complementary and alternative approaches ical health. Aromatherapy is usually administered by either inhala-
tion or skin application.84 A possible explanation for aromatherapy's
European guidelines for diagnosing and treating insomnia14 do not efficacy ranges from subjective psychological to direct biological
recommend Valerian and other phytotherapeutics, acupuncture, action.85 Some essential oils contain terpenes that cross the blood-­
aromatherapy, and foot reflexology to treat insomnia because of brain barrier and possess cholinergic activity or act on gamma-­
poor evidence. Notably, these approaches and products are popu- aminobutyric acid receptors.86 Certain odors, eg, linalool and linalyl
lar worldwide and have been increasingly studied over the past two acetate extracted from lavender, may induce sedation and relax-
decades to treat sleep disorders. ation.87 In their systematic review from 2019, Lin and coauthors also
Light therapy is the use of light in the treatment of physical or highlighted the results' limitations and documented that aromather-
mental illnesses. Different light sources analyzed in studies are (a) apy can be effectively used to improve sleep quality.88 The study
monochromatic (single wavelength), (b) narrow-­
bandwidth with mentioned above is in line with Hwang and colleagues' previously
short, medium, or long wavelengths, (c) polychromatic, or (d) spe- published work, which documented aromatic oils extracted from lav-
cific bandwidth-­
enriched polychromatic spectra. Particularly, the ender and bergamot to be most commonly studied.89
blue part of the light spectrum (from 460 to 480 nm) seems to play Massage is a thousands of years old technique involving me-
31
a crucial role in circadian rhythm synchronization. Importantly, as chanical contact on the patient's body, commonly used in medicine,
reported by Vandewalle and colleagues, 20 minutes of exposure sports-­related regeneration, and wellness. More than one hundred
to monochromatic light (470 nm) modulated the activity of similar massage types are known. In the literature, the influence of massage
brain areas as exposure to the bright white light of equal duration therapy on the improvement of depression and anxiety was docu-
75
but composed of 100 times more photons. The fact that light in- mented.90 A possible massage therapy mechanism for stress relief
hibits the secretion of melatonin and that the hypothalamus through is decreased cortisol levels, and an increase in active neurotrans-
the retinohypothalamic tract controls circadian rhythms provides mitters, such as serotonin and dopamine91 Hachul and colleagues
better insight into how light therapy can be used to treat sleep dis- reported improved sleep in postmenopausal women with insomnia
76,77
orders. When natural sunlight is not appropriate, light therapy symptoms after massage therapy.92
boxes mimicking outdoor light might provide an alternative to ad- Acupuncture and acupressure arise from traditional Chinese
just normal circadian rhythm. “Dawn simulation” is a form of light medicine, characterized by the insertion of metallic needles into or
therapy, commonly studied in the treatment of winter depression. through the skin or applying mechanical pressure at specific sites.
Down simulators are artificial light sources that gradually increase The techniques mentioned above are believed to restore the proper
in brightness just before the anticipated wake time.78 A relatively flow of vital energy, known as qi. The study by Jinhuan and coau-
new concept/method is called “biodynamic lighting”, where an arti- thors has shed more light on the effects of acupuncture for insom-
ficial light source follows a daylight curve in terms of intensity and nia. They analyzed fifteen studies involving 1108 patients and found
spectrum for improving circadian rhythm. Some commercially avail- acupuncture superior to placebo in treating insomnia.93 On the other
able wearable devices use light sources of lower intensity of specific hand, in 2019, He and coworkers published an overview of 34 sys-
wavelengths showing promising preliminary results for shifting cir- tematic reviews assessing acupuncture to treat insomnia. They rec-
cadian timing.79 In studies of insomnia therapy, the mean reported ommended a cautious interpretation of the promising results, as the
6 of 8 | HREHOVÁ and MEZIAN

included studies' quality was generally low.94 Regarding existing evi- DATA AVA I L A B I L I T Y S TAT E M E N T
dence of the acupressure effect on sleep quality, one systematic re- No datasets were generated or analyzed during the current study.
view with meta-­analysis reported an improvement in the Pittsburgh
Sleep Quality index compared with sham treatment. However, the ORCID
authors also identified a high risk of bias because of the absence of Laura Hrehová https://orcid.org/0000-0002-8173-6487
95
blinding patients.
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