The American Journal of Managed Care August 2010
Insomnia Risks and Costs: Health, Safety, and Quality of Life
This review article discusses the issues surrounding the risks and costs of sleep disturbance as they relate to society and the individual.
The effect of insomnia on next-day functioning, health, safety, and quality of life results in a substantial societal burden and economic cost. The annual direct cost of insomnia has been estimated in the billions of US dollars and is attributed to the association of insomnia with the increased risk of certain psychiatric and medical comorbidities that result in increased healthcare service utilization. It is well known that psychiatric conditions, anxiety and depression in particular, are comorbid with insomnia. However, emerging data have shown links with several common and costly medical conditions such as heart disease and diabetes. Furthermore, studies show that patients who have insomnia have more emergency department and physician visits, laboratory tests, and prescription drug use than those who do not have insomnia, increasing direct and indirect consumption of healthcare resources. Insomnia also has been shown to negatively affect daytime functioning, including workplace productivity, as well as workplace and public safety. These daytime effects of insomnia are translated into indirect costs that are reportedly higher than the direct costs of this disorder. These observations have significant implications for managed care organizations and healthcare providers. Improvements in diagnosing and treating insomnia can significantly reduce the healthcare cost of insomnia and its comorbid disorders, while providing additional economic benefits from improved daytime functioning and from increased productivity.
(Am J Manag Care. 2010;16(8):617-626)
This review describes the evidence associated with the direct and indirect economic costs of insomnia, as well as available and emerging therapeutic strategies.
- The direct and indirect costs of insomnia are highlighted to impress on the reader a need for improvements in the management of insomnia.
- Links between common costly medical conditions and insomnia are made, demonstrating the importance of improving the diagnosis and treatment of not only insomnia but also its comorbidities.
- The benefits and drawbacks of current and future treatments are discussed to help healthcare providers make informed treatment decisions for their patients.
Insomnia is a disorder of inadequate sleep (poor quantity or quality) that can result in impairment of daytime function or in emotional distress.1,2 There are several types of insomnia, which are not mutually exclusive and include difficulty initiating sleep (sleep-onset insomnia), frequent or long nighttime awakenings (sleep-maintenance insomnia), and waking up too early without being able to return to sleep (also sleep-maintenance insomnia).1 The type of insomnia can vary over time in any individual and is classified based on its duration.3 Acute insomnia lasts 1 to 3 nights, short-term insomnia lasts 3 nights to 1 month, and chronic insomnia lasts longer than 1 month.4 Acute insomnia is often caused by emotional or physical discomfort and, if left untreated, may develop into chronic insomnia.5
Insomnia can exist as a primary disorder or as comorbid with another condition.6 Primary insomnia is commonly caused by life changes, including extended periods of stress or emotional upset.5 Comorbid insomnia (sometimes referred to as secondary insomnia) is the most common type of insomnia, afflicting more than 8 of 10 people with insomnia.5,7 The identification and diagnosis of insomnia are challenged by difficulty and ambiguity because of the variation in the ways insomnia can manifest in an individual, the potential overlap and changes in insomnia symptoms, and the possible disruption of sleep due to lifestyle or environmental factors unassociated with insomnia. Also, there is a discrepancy between subjective reporting and objective measuring of sleep, further complicating insomnia diagnosis and assessment. Generally, insomniacs tend to underestimate their ability to sleep.8
Determining the true prevalence of insomnia is further complicated due to patient underreporting and differences in operational definitions.1,9-11 In the United States, general population surveys consistently find that approximately one-third of adults report having sleep problems.12-15 Within this group, sleep-maintenance insomnia is reported more commonly than sleep-onset insomnia, as demonstrated by an international survey in which 73% of patients with insomnia reported problems with sleep maintenance, 61% reported difficulties falling asleep, and 48% reported poor sleep quality.16 In the 2009 Sleep in America Poll conducted by the National Sleep Foundation, 64% of individuals surveyed had complaints of frequent insomnia, with only 15% being formally diagnosed.15 In this poll, insomnia with nighttime awakenings and with waking up feeling unrefreshed characterized the most prevalent symptoms (46% and 45%, respectively).15
Certain populations have a higher likelihood for developing insomnia.7 Risk factors include female sex,17 increasing age,18,19 employment status,20,21 shift work,21 and a family history of insomnia.22,23 Among women, insomnia seems to be more prevalent in the perimenopausal years, and a gradual increase in insomnia is seen in early-to-late perimenopause transition.24,25 Although older age is associated with an increased risk of insomnia, reports of insomnia or trouble sleeping have been found to peak in middle age (range, 45-54 years), to decrease slightly during older age (range, 65-84 years), and to increase again at very old age (>85 years), suggesting that the relationship between insomnia or trouble sleeping and age may not be linear.26 Greater risk of chronic insomnia exists in shift workers, another group at high risk of insomnia, possibly due to the misalignment of their circadian sleep–wake patterns and sleep–wake schedules.21
This review will focus on the health and societal effects of insomnia as they relate to its economic cost burden. This issue is relevant to managed care organizations and healthcare providers because insomnia contributes to increased direct and indirect consumption of healthcare resources. Improvements in diagnosing and treating insomnia can relieve its cost burden by significantly reducing the associated direct and indirect healthcare costs.
SLEEP ARCHITECTURE AND CHANGES OCCURRING IN INSOMNIA
Normal sleep consists of 2 alternating states, non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.27 The NREM-REM cycle, beginning with NREM, generally occurs 3 to 7 times per night and normally lasts 90 to 120 minutes each time.28 The NREM sleep is composed of 4 stages (NREM1 through NREM4). Stage 1 is viewed as shallow or light sleep, having the lowest arousal threshold, and stage 2 is the transition from light sleep to deep sleep as the heart rate slows and body temperature decreases. Stages 3 and 4 are defined by high-voltage slow-wave activity, with stage 4 having a predominance of these wave-forms.29 Such high-voltage slow-wave activity is characteristic of slow-wave sleep (SWS) or deep sleep. These latter deep sleep stages have the highest arousal threshold and are believed to be required for physical restoration, while REM sleep is required for cognitive restoration.30,31
There are several determinants of a good night’s sleep, and these can be measured in different ways. Sleep efficiency is the ratio of time spent asleep (total sleep time) to the time spent in bed. A decrease in sleep efficiency typically reflects a decrease in total sleep time, which subsequently affects next-day alertness and performance.8 Sleep quality refers to the restorative and undisturbed quality of sleep. The depth of NREM sleep, the amount of REM sleep, and sleep continuity are major determinants of sleep quality.8 Refreshing sleep (ie, sleep that makes one feel refreshed the next day) requires sufficient total sleep time and sleep that is in synchrony with the sleep-wake circadian rhythm.32 Ultimately, good sleep manifests as an ability to function well the next day.
The sleep pattern of individuals with chronic insomnia demonstrates a marked deficiency in the SWS stage.33,34 Electroencephalographic data show that insomniacs have fewer waves that are characteristic of deep sleep and more higher-frequency lower-amplitude waves that are typical of wakefulness, REM sleep, and NREM1 and NREM2 light sleep.29,31,35
EFFECT OF INSOMNIA ON HEALTH, SAFETY, AND QUALITY OF LIFE
Insomnia has a negative association with health and quality of life (QoL) if left untreated. In a study36 that surveyed severe insomniacs, mild insomniacs, and good sleepers, insomniacs were reported to have a lower self-reported overall health status and higher bodily pain, both of which contribute to reduced QoL. Successful treatment of insomnia is expected to enhance QoL. However, treatment efficacy investigations in insomnia generally have a narrow range of outcome measures that tend to focus on short-term improvements and include mostly quantitative measurements of sleep improvements, with measures of QoL (if included) as secondary evaluations.37 A placebo-controlled study37 that included measurement of QoL demonstrated that long-term treatment of insomnia with eszopiclone enhanced QoL.
The potential negative effect that insomnia may have on health is further evidenced by its association with the increased risk of certain psychiatric and medical comorbidities, including anxiety and depression,1,38 obesity or weight gain,39 obstructive sleep apnea hypopnea syndrome,40 and alcoholism41 (Figure). In addition, certain medical conditions are associated with an increased risk of insomnia.42 These include chronic pain, high blood pressure, gastrointestinal problems, urinary problems, osteoarthritis, hip impairment, fibromyalgia, peptic ulcer disease, and breathing problems (Figure).43-46 For example, more than 50% of patients with chronic obstructive pulmonary disease complain of difficulties initiating or maintaining sleep,47 and 50% of adults with diabetes are reported to have insomnia.48 Shorter sleep time is associated with impaired glucose regulation and with increased risk of diabetes.49 However, the cause–effect relationship of insomnia with psychiatric and medical comorbidities is unclear.46,50-52 Some evidence suggests a reciprocal cause–effect relationship between insomnia and psychiatric disorders such as depression, anxiety, and alcohol or drug abuse.53 Moreover, combined treatment of insomnia and depression or anxiety can augment the efficacy of antidepressants or antianxiolytics.54,55
Insomnia can affect daytime functioning by impairing one’s ability to perform common tasks. In the 2009 Sleep in America Poll, 40% of adults reported that daytime sleepiness interfered significantly with their daily activities.15 These daytime impairments are due to the negative effects of insomnia on memory, the ability to concentrate and focus, psychomotor function, and alertness. Such functional impairments can result in decreased productivity at home and at work.56
Decreased safety in the workplace is another consequence of daytime functional impairments resulting from insomnia. Workers with sleep disorder symptoms have a higher occupational injury rate than those without sleep problems.57 In a Swedish study,58 trouble sleeping was significantly associated with increased risk of fatal occupational accidents. Impaired performance due to reduced or inefficient sleep creates public safety risks when individuals with excessive daytime sleepiness are involved in potentially dangerous daily activities such as driving.59
ECONOMIC COSTS OF INSOMNIA
It is difficult to determine exactly the direct cost of insomnia because there are varying degrees of overlapping expenditures with other medical conditions, and some cost attributed to insomnia may be due to other coexisting conditions.60 Nevertheless, patients with insomnia have been shown to have 60% higher mean total healthcare costs than those without insomnia.61 Patients with insomnia have more emergency department and physician visits, laboratory tests, and prescription drug use than those without insomnia, and patients with severe insomnia use more healthcare resources than their counterparts with less severe insomnia or those without insomnia.62 Other issues that contribute to the difficulty in assessing costs include differing definitions of insomnia and the fact that not all patients experiencing sleep problems may label or report themselves as insomniacs.
Direct Costs of Insomnia