追加：第 3 节第 26 条，长期失眠先做失眠的认知行为治疗，别一上来就长期吃安眠药

2026-10-14 追加。四问：长期失眠很常见（规范写患病率 10%～20%）；多数人以为失眠只能靠安眠药或者「放松心态」，不知道有一线的非药物治疗；全书原有的睡眠条目只管睡多久、作息规律、午睡、补觉、咖啡因、屏幕（第 2 节第 13、37、38 条，第 3 节第 2、3、4、8、9、11 条），没有一条管「已经失眠了怎么办」，第 34 节只在布洛芬那条提到含助眠成分的非处方药；来源有国家卫健委诊疗规范、两份美国指南和多篇荟萃分析。

放第 3 节：口径按时间（少躺着睡不着的时间），挂进节首导览「睡觉和熬夜」块。

1. 国家卫健委《精神障碍诊疗规范（2020 年版）》

  • 通知页：https://www.nhc.gov.cn/yzygj/c100068/202012/b4305ace9e14440792eb76d29602c88a.shtml（curl 只拿到反爬壳页，无头 Chrome 不带代理取到正文）。原文：「国卫办医函〔 2020 〕 945 号」「我委组织制定了《精神障碍诊疗 规范 （ 2020 年版 ）》。现印发给你们，请 参 照执行。」落款「国家卫生健康委办公厅 2020年 11 月 23 日」，发布时间 2020-12-07。
  • 附件 PDF：https://www.nhc.gov.cn/yzygj/c100068/202012/b4305ace9e14440792eb76d29602c88a/files/1733998716447_88723.pdf（curl 带浏览器 UA 可下，有文本层，pdftotext 逐字抽出）。目录：「第十二章 睡眠障碍 …… 第二节 失眠障碍 ……325」。
  • 患病率：「失眠障碍的患病率为 10%～20%」。
  • 诊断要点：「根据 ICSD-3，失眠障碍的诊断要点包括：①存在入睡困难、睡 眠维持困难或早醒症状；②日间疲劳、嗜睡，社会功能受损；③上述 症状每周至少出现 3 次，持续至少 3 个月。如果病程小于 3 个月可称 为短期失眠障碍。」
  • 要先排除呼吸障碍：「在做出失眠 障碍的诊断前，须注意与焦虑、抑郁等精神障碍的鉴别以及排除其他 常见睡眠障碍，如睡眠相关呼吸障碍、不宁腿综合征、睡眠-觉醒昼 夜节律障碍、睡眠不足综合征等。」
  • 一线治疗与五个部分：「失眠的认知行为治疗 …… 是失眠障碍的一线治疗方案。失眠认知行为治疗主要包括睡眠 限制、刺激控制、认知治疗、放松训练治疗和睡眠卫生 5 个部分。失 眠的认知行为治疗一般以 6～8 周为一个周期，疗效可延续 6～12 个 月。研究显示，对于慢性失眠患者，失眠的认知行为治疗与药物疗法 的短期疗效相当，但长期来看失眠的认知行为治疗疗效优于药物治 疗。」
  • 用药：「连续 给药一般不超过 4 周，如需继续给药，需每个月定期评估。」苯二氮䓬类「长期或高 剂量服用可能会产生戒断现象、反跳性失眠、耐受、依赖等不良反应」。
  • 中华医学会神经病学分会 2017 版、中国睡眠研究会 2023 版指南原文没取（期刊全文不开放），改用这份卫健委规范，是官方文件且能逐字核。

2. 美国医师协会 2016 指南

  • Qaseem A 等 (2016). Ann Intern Med 165(2):125-133. https://doi.org/10.7326/M15-2175，PMID 27136449，摘要经 Europe PMC 取得，卷期页经同一接口核对。
  • 原文：「ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence).」
  • 原文：「ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful.」

3. Trauer 2015 荟萃分析

  • Trauer JM 等 (2015). Ann Intern Med 163(3):191-204. https://doi.org/10.7326/M14-2841，PMID 26054060，摘要经 Europe PMC 取得。
  • 原文：「20 studies (1162 participants [64% female; mean age, 56 years]) were included.」
  • 原文：「At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, -0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%). Changes seemed to be sustained at later time points. No adverse outcomes were reported.」
  • 限制：「Studies of insomnia comorbid with medical, sleep, or psychiatric disorders were excluded.」备注据此写「排除了同时有别的病的失眠者」。

4. 长期效果（van der Zweerde / van Straten 2019）

  • van der Zweerde T, Bisdounis L, Kyle SD, Lancee J, van Straten A (2019). Sleep Med Rev 48:101208. https://doi.org/10.1016/j.smrv.2019.08.002，PMID 31491656。任务里写的「van Straten 2018」实际查到的长期效果荟萃是这一篇（van Straten 为末位作者）。
  • 原文：「we investigate long-term effects in 30 randomized controlled trials (RCTs) comparing CBT-I to non-active control groups.」「Hedges g for Insomnia severity index: 0.64 (3 m), 0.40 (6 m) and 0.25 (12 m)」「although effects decline over time, CBT-I produces clinically significant effects that last up to a year after therapy.」

5. 网上做（Zachariae 2016、Espie 2019）

  • Zachariae R 等 (2016). Sleep Med Rev 30:1-10. https://doi.org/10.1016/j.smrv.2015.10.004，PMID 26615572。原文：「Eleven randomized controlled trials examining a total of 1460 participants were included.」「eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I」「longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes」。
  • Espie CA 等 (2019). JAMA Psychiatry 76(1):21-30. https://doi.org/10.1001/jamapsychiatry.2018.2745，PMID 30264137。原文：「This online, 2-arm, parallel-group randomized trial comparing dCBT for insomnia with sleep hygiene education (SHE) evaluated 1711 participants」「Use of dCBT was associated with a small improvement in functional health compared with SHE …… and psychological well-being …… and with a large improvement in sleep-related quality of life」。量表分值不好翻成日常话，条目只写「小幅」「大幅」，不写分值。

6. 安眠药对老人（Glass 2005）

  • Glass J 等 (2005). BMJ 331(7526):1169. https://doi.org/10.1136/bmj.38623.768588.47，PMID 16284208，PMC1285093。摘要经 Europe PMC，全文经 https://pmc.ncbi.nlm.nih.gov/articles/PMC1285093/（带代理取得）。
  • 摘要原文：「Randomised controlled trials of any pharmacological treatment for insomnia for at least five consecutive nights in people aged 60 or over」「24 studies (involving 2417 participants)」「total sleep time increased (mean 25.2 minutes, P < 0.001), and the number of night time awakenings decreased (0.63, P < 0.001)」「adverse cognitive events were 4.78 times more common (95% confidence interval 1.47 to 15.47, P < 0.01) …… reports of daytime fatigue were 3.82 times more common (1.88 to 7.80, P < 0.001)」
  • 全文原文：「the number needed to harm for sedative hypnotics compared with placebo is 6 (4.7 to 7.1)」「The number needed to treat for improved sleep quality was 13 and the number needed to harm for any adverse event was 6. This ratio indicates that an adverse event is more than twice as likely as enhanced quality of sleep.」说人话「出副作用的是睡好了的两倍多」按这句写。
  • 正文里 4.78 写成「odds ratio 4.78」，所以条目标 OR。
  • 没用的数：摘要写精神运动类副作用「2.61 times more common (1.12 to 6.09, P > 0.05)」，全文写「0.93 to 5.41, P = 0.07」，两处对不上，不写。

7. 刺激控制与睡眠限制的做法（AASM 2021）

  • Edinger JD 等 (2021). J Clin Sleep Med 17(2):255-262. https://doi.org/10.5664/jcsm.8986，PMC7853203，全文经 PMC 网页取得。
  • 刺激控制：「Stimulus control instructions are: (a) go to bed only when sleepy; (b) get out of bed when unable to sleep; (c) use the bed/bedroom for sleep and sex only (no reading, watching TV, etc. in bed); (d) wake up the same time every morning; (e) refrain from daytime napping.」
  • 睡眠限制：「A method designed to enhance sleep drive and consolidate sleep by limiting time in bed equal to the patient's sleep duration, typically estimated from daily diaries. Time in bed is initially limited to the average sleep duration, and subsequently increased or decreased based on sleep efficiency thresholds」
  • 慎用人群：「this treatment may be contraindicated in certain populations such as those working in high risk occupations (eg, heavy machinery operators or drivers) or those predisposed to mania/hypomania poorly controlled seizure disorders or excessive daytime sleepiness」；白天更困：「increased daytime sleepiness and difficulties with concentration, but these effects typically dissipate as treatment progresses」；「if the treatment rationale is adequately explained and the patient is monitored by a clinician during treatment」。
  • 单用睡眠卫生：「We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)」

定级与收益量级

  • 证据 A：核心结论来自随机对照试验的荟萃分析，有具体数字，国内外指南一致。未标争议：没找到反对「CBT-I 作一线」的指南或荟萃；短期疗效与药物相当这一点规范已写明，条目照写。
  • 收益「中」：按时间口径的阈值。入睡快 19.03 分钟加夜里醒着少 26.00 分钟，每晚约 45 分钟，一周约 5 小时，属「每周小时级」。总睡眠时间只多 7.61 分钟且不显著，所以不按「每天小时级」定大。
  • 成本标签：钱=少（医院几次治疗或网上课程，作者判断，未查到国内统一收费标准）；时间=中（6～8 周疗程加每天睡眠日记）；毅力=是（睡眠限制要连续几周压缩躺床时间、忍白天困）。不加人群标签：慢性失眠没有对应值。
  • 「国内去睡眠门诊、精神科、心理科」是作者经验，C 级，没有官方清单。

没写的

  • Z 药（唑吡坦等）的复杂睡眠行为警示、苯二氮䓬与跌倒髋骨骨折的队列数字：都没在本轮核原文，不写。
  • 国内数字化 CBT-I 的随机试验：没查，条目只说「网上的自助课程」，不点名任何产品。