***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This study explores the usefulness of relaxation and gradual medication withdrawal in weaning insomniacs from sleep ( hypnotic ) medication . We recruited 40 volunteers from the community who had insomnia , half of whom were chronic users of hypnotics while the other half were nonmedicated . Half of all participants ( 10 medicated and 10 nonmedicated ) received progressive relaxation . All medicated participants received a st and ard gradual drug withdrawal program . Medicated participants reduced sleep medication consumption by nearly 80 % . Participants who received relaxation obtained additional benefits in sleep efficiency , rated quality of sleep , and reduced withdrawal symptoms . Medicated and nonmedicated participants attained comparable , improved sleep by posttreatment and follow-up . Hypnotic withdrawalwas accompanied by serious worsening of insomnia , but this dissipated by the end of the withdrawal period . The psychological treatment of hypnotic-dependent insomnia has high potential for making an important clinical contribution Forty-five adults with primary insomnia received cognitive-behavioral therapy ( CBT ) implemented in a group therapy format , in individual face-to-face therapy or through brief individual telephone consultations . The results indicate that CBT was effective in improving sleep parameters with all 3 methods of treatment implementation , and there was no significant difference across methods of implementation . All 3 treatment modalities produced improvements in sleep that were maintained for 6 months after treatment completion . These results suggest that group therapy and telephone consultations represent cost-effective alternatives to individual therapy for the management of insomnia Patients with primary insomnia overestimate their sleep onset latency ( SOL ) and underestimate their total sleep time ( TST ) . The present study aim ed to test the utility of a novel behavioural experiment design ed to correct distorted perception of sleep among patients diagnosed with primary insomnia . Individuals with primary insomnia were asked to wear an actigraph and keep a sleep diary for three nights . On the following day , half were shown the discrepancy between the data recorded on the actigraph and their sleep diary ( Shown-Discrepancy Group ) , the other half were not shown the discrepancy ( No-Demonstration Group ) . Participants were then asked to wear the actigraph and keep a sleep diary for three further nights . Following the behavioural experiment , the Shown-Discrepancy Group estimated their SOL more accurately and reported less anxiety and preoccupation about sleep compared to the No-Demonstration Group . The theoretical and clinical implication s of these findings are discussed Objective : To compare treatment outcomes associated with combined pharmacologic and non-pharmacologic treatments for psychophysiological insomnia . Background : Treatments for insomnia have included a variety of pharmacotherapy and cognitive-behavioral interventions , although few studies have investigated the combined efficacy of drug and non-drug therapy . Methods : Forty-one patients with primary insomnia were r and omly assigned to one of three treatment groups : ( i ) estazolam + muscle relaxation , ( ii ) estazolam + guided imagery , and ( iii ) estazolam + sleep education . After 4 weeks of active treatment , subjects were withdrawn from medication and followed for an additional 6 months . Results : Significant improvements were observed in self-report measures of total sleep time , sleep efficiency , and wakefulness after sleep onset in the combined drug and relaxation groups , compared to a significant improvement in total sleep time only in the educational control group . At follow-up , all three groups showed significant improvements across the major sleep measures . Positive changes were also observed in quality of life measures , including mood state and self- ratings of daytime arousal . Conclusions : These findings provide support for the value of combined pharmacotherapy and relaxation training in the treatment of psychophysiological insomnia Previous research suggests that self-defined insomniacs are distinguished from normals by high levels of anxiety and physiological arousal , which might be mitigated by muscle relaxation . This study assessed the relative effects of frontal EMG biofeedback , progressive relaxation , and a placebo set of “ relaxation ” exercises on the sleep of 18 onset insomniacs . Each subject was trained in one of these three methods for six half-hour sessions and slept in the laboratory for two consecutive nights before and after training . The experimental groups demonstrated significant decreases in physiological activity during training while changes in the control group were minimal . Reductions in sleep-onset time were : biofeedback group , 29.66 minutes ; progressive relaxation group , 22.92 minutes ; control group , 2.79 minutes . The experimental groups improved significantly(p<.05 ) more than the control group , but did not differ from each other . No significant relationships between physiological levels and sleep-onset time were found , which suggests that muscle relaxation alone was not responsible for subjects ' improvements . Since 20 minutes of daily practice were required to achieve an approximate 30-minute decrease in sleep-onset time , the practical utility of the methods is question ed Older adults with comorbid insomnia and medical illness have been excluded from behavioral treatment research , but recent evidence suggested that such treatments would be effective with this population . In this study , 38 older adults with comorbid insomnia were r and omized to 1 of 3 conditions : classroom cognitive-behavioral treatment ( CBT ) , home-based audio relaxation treatment ( HART ) , or delayed-treatment control . Compared to the control group , the CBT group had significant changes in 5 of 7 self-report measures of sleep at the 4-month follow-up . The HART group obtained significant outcomes on 3 of 7 measures . Wrist actigraphy measures and secondary - outcome measures did not yield significant findings for either treatment . Clinical ly significant changes at follow-up were obtained for 54 % of patients in CBT , 35 % in HART , and 6 % in the control group when treatment dropouts were included . Although not as effective as in-person CBT , home interventions may have utility as a first-line , low-cost treatment To assess the effect of progressive relaxation training on  insomnia in institutionalised chronic alcoholic men , 22 subjects between the ages of 20 and 60 years , were r and omly allocated to treatment and control groups . The treatment group received 10 sessions of progressive relaxation training over a 2-wk . period after which both groups completed a postexperimental question naire . Analysis showed a significant improvement in the sleeping patterns of the treated group , but no changes in the sleeping patterns of the control group . In addition , a distribution-free two- sample permutation test to compare mean differences of the groups confirmed that a significantly greater change occurred in the quality of the sleeping patterns of the treated group This investigation compared progressive muscle relaxation plus cognitive distraction ( PMR/CD ) , hypothesized to better improve sleep onset , versus sleep restriction and stimulus control ( SR/SC ) , hypothesized to better improve sleep maintenance , versus a flurazepam ( Dalmane ) positive contrast condition ( MED ) and a sleep hygiene education minimal treatment control condition ( SHE ) . Participants with chronic insomnia ( N = 53 ) , completed 2 baseline weeks of sleep diaries , and were r and omly assigned to a treatment group for 2 more weeks . In the second phase ,  PMR/CD participants were assigned to 2 weeks of PMR/CD + SR/SC + SHE while SHE participants continued SHE . Results indicated that PMR/CD had greater effect upon sleep onset than SR/SC and SHE , SR/SC had greater effect on sleep maintenance than PMR/CD , and MED was better than the other treatments . In the second phase , the treatment package produced modest additional improvements and SHE performed superior to expectations OBJECTIVE The question addressed here is : Can a discrete sleep disordered breathing ( SDB ) play a role in the insomnia complaint of postmenopausal chronic insomniacs ? To respond to the query , two groups of individuals derived from a cohort of postmenopausal chronic insomniacs recruited mostly from the community were enlisted in a treatment protocol . These subjects were all individuals identified with normal breathing ( n=68 ) and all those recognized with Upper Airway Resistance Syndrome ( UARS ) ( n=62 ) pooled from a cohort of 349 postmenopausal insomniacs . TREATMENT PROTOCOL The 62 UARS were allocated to either treatment of chronic insomnia by behavioral approaches or treatment of SDB . Based on ENT evaluation , health professionals in charge of patients selected either treatment with nasal CPAP or treatment of nasal turbinates .  A stratification correction was performed to obtain a near equal number of both treatment modalities in each of the two subgroups . The 68 individuals with normal breathing were r and omly allocated to immediate behavioral treatment of insomnia or delay treatment of insomnia . The delay treatment received a list of 10 sleep hygiene recommendations by mail . METHODOLOGY Question naires , visual analog scales ( VAS ) , Epworth Sleepiness Scale ( ESS ) , clinical interviews , clinical evaluation with oto-laryngologic clinical assessment of a presence/absence of narrow upper airway and location of narrowing . Actigraphy and polysomnography ( PSG ) with pressure transducer/ and nasal cannula system and esophageal manometry . DATA ANALYSES All recording data were scored blind to patient 's condition . RESULTS Two subjects in the SBD-CPAP treated group ( Group B ) and two subjects in the delayed treatment group ( Group D ) dropped out . Total sleep time was improved compared to baseline in all groups , including the delayed treatment group . One group was significantly better ( ANOVA , P=.05 ) with a more important delta score compared to baseline , and this was the behaviorally treated non-SDB . Sleep latency was significantly decreased in the behaviorally treated group ( with or without SBD ) , P=.05 , compared to SBD-treated and delayed treatment groups . Sleep latency was , however , improved in all groups . VAS for " quality of sleep " was higher at 6 months in all the groups when compared to " baseline " values . VAS for " daytime fatigue " showed significant differences among the four groups ( ANOVA , P=.01 ) ; the overall score at the end of treatment was significantly better in the SDB-treated group than the other three groups . SBD was treated either by radio frequency on nasal turbinate or by nasal CPAP . CPAP-treated patients had a lower VAS score than nasal turbinate treatment , but the difference was only a trend . The delta improvement ( 6-month baseline condition ) in " daytime fatigue " of each subgroup was calculated and compared within and between groups . Despite the small number of subjects , the turbinate-treated subgroup was significantly different from Groups B , C and D ( ANOVA , P=.05 ) . When a similar comparison was made with the nasal CPAP group , there was only a nonsignificant trend when compared to Groups B , C and D. CONCLUSION Abnormal breathing during sleep significantly enhanced complaints of daytime fatigue in postmenopausal chronic insomniacs and this complaint improved with SDB treatment . This improvement is significantly better compared to SDB insomniacs treated with a behavioral regimen . Behavioral treatment , however , gave the best response in the non-SDB chronic insomnia group and improved better long sleep latency even in the SDB group . These results suggest the need to find an appropriate treatment for SBD even if mild and to recognize the role of SDB in relation to symptoms seen with chronic insomnia OBJECTIVE To evaluate the clinical and cost impact of providing cognitive behaviour therapy ( CBT ) for insomnia ( comprising sleep hygiene , stimulus control , relaxation and cognitive therapy components ) to long-term hypnotic drug users in general practice . DESIGN A pragmatic r and omised controlled trial with two treatment arms ( a CBT treated ' sleep clinic ' group , and a ' no additional treatment ' control group ) , with post-treatment assessment s commencing at 3 and 6 months . SETTING Twenty-three general practice s in Sheffield , UK . PARTICIPANTS Two hundred and nine serially referred patients aged 31 - 92 years with chronic sleep problems who had been using hypnotic drugs for at least 1 month ( mean duration = 13.4 years ) . RESULTS At 3- and 6-month follow-ups patients treated with CBT reported significant reductions in sleep latency , significant improvements in sleep efficiency , and significant reductions in the frequency of hypnotic drug use ( all P<0.01 ) . Among CBT treated patients SF-36 scores showed significant improvements in vitality at 3 months ( P<0.01 ) . Older age presented no barrier to successful treatment outcomes . The total cost of service provision was 154.40 per patient , with a mean incremental cost per quality -adjusted life-year of 3416 ( at 6 months ) . However , there was evidence of longer term cost offsets owing to reductions in sleeping tablet use and reduced utilisation of primary care services . CONCLUSIONS In routine general practice setting s , psychological treatments for insomnia can improve sleep quality and reduce hypnotic consumption at a favourable cost among long-term hypnotic users with chronic sleep difficulties Psychological treatment of insomnia has focused on primary insomnia ( i.e. , having a psychological origin ) . Secondary insomnia , sleep disturbance caused by a psychiatric or medical disorder , although it is more common than primary insomnia , has received very little attention as a result of the belief that it would be refractory to treatment . The present study r and omly assigned older adults with secondary insomnia to a treatment group , 4 sessions composed of relaxation and stimulus control , or a no-treatment control group . Self-report assessment s conducted at pretreatment , posttreatment , and a 3-month follow-up revealed that treated participants showed significantly greater improvement on wake time during the night , sleep efficiency percentage , and sleep quality rating . The authors hypothesize that treatment success was probably due in part to difficulty in diagnostic discrimination between primary and secondary insomnia There is substantial experimental evidence that behavioral treatment of insomnia produces significant clinical improvement and that treatment gains tend to be maintained over time . Less clear is whether behavioral treatment is effective as it is plied in clinical setting s. In this clinical case series study , we evaluated 47 patients with primary insomnia . It was found that patients were , on average , 43 % improved . This average 
    Output:
    
RESULTS Psychological and behavioral therapies produced reliable changes in several sleep parameters of individuals with either primary insomnia or insomnia associated with medical and psychiatric disorders .
DISCUSSION These up date d findings provide additional evidence in support of the original review 's conclusions as to the efficacy and generalizability of psychological and behavioral therapies for persistent insomnia .