Supplements New Approaches to the Management and Treatment of Insomnia
Managing Insomnia in an Evolving Marketplace
Insomnia is a condition that many people experience, periodically, throughout their lives. Whether it is based on stress, lifestyle changes, or environmental issues, transient insomnia can be a troublesome complaint. However, the impact of chronic insomnia is perhaps of even greater concern. Defined as insomnia that persists for at least 1 month, chronic insomnia can have a significant impact on many aspects of life. Inadequate quantity and quality of sleep can have repercussions on both physical and mental well-being, and can hamper a person's ability to function at an optimal level. Such deficits in functioning can lead to a number of challenges and obstacles for patients with insomnia and those who live and work with them.
A diagnosis of primary insomnia implies that no other cause of sleep disturbance has been identified,1 whereas insomnia that is comorbid with other conditions is known as secondary insomnia. However, a limited understanding of the mechanistic pathways in chronic insomnia precludes firm conclusions from being drawn about the nature of such associations or the direction of causality. Use of the term secondary insomnia can also promote undertreatment. We therefore propose the term comorbid insomnia as more appropriate. Common insomnia comorbidities include psychiatric disorders, particularly depression, anxiety, and substance use disorders; cardiopulmonary disorders; and conditions resulting in chronic somatic complaints that may result in sleep disruption. Other disorders that affect sleep, such as obstructive sleep apnea, restless legs syndrome, or periodic limb movement disorder, may also contribute to insomnia. Diagnosing insomnia may pose a challenge, but distinguishing whether insomnia is the cause or the result of associated problems is critical to identifying appropriate treatment strategies for individual patients.
Treatment options for insomnia include both pharmacologic and nonpharmacologic modalities. Until recently, there were no approved pharmacologic therapies for the treatment of chronic insomnia and no randomized, placebo-controlled trials studying the effects of long-term nightly use of these therapies. A number of issues, including tolerance with some of the older therapies, have proved to be problematic for physicians seeking long-term treatment for their patients' chronic insomnia. However, pharmacologic hypnotic therapies recently approved for long-term nightly use have demonstrated their effectiveness for the treatment of various insomnia symptoms, and can provide sustained efficacy without evidence of tolerance.
Managed care organizations (MCOs) are faced with the challenge of providing access to appropriate healthcare for patients with insomnia. Evidence suggests that healthcare resource utilization is increased and workplace productivity is reduced in patients who suffer from insomnia, whether primary or comorbid. The direct and indirect costs attributable to insomnia can also be high, suggesting that early treatment may be a more cost-effective approach in a managed care environment.
This supplement will discuss the epidemiology and diagnosis of chronic insomnia, the prevalence of chronic insomnia and other sleep disturbances associated with chronic illness, and strategies for treating chronic insomnia. It will also explore the impact of insomnia on MCOs, highlighting the pharmacoeconomic implications of insomnia on managed care networks and the need for MCOs to take a proactive role in providing their members with appropriate care and treatment for sleep deficits.
Corresponding author: Lawrence D. Goldberg, MD, MBA, Goldberg, MD + Associates, 2210 West Main Street, Suite 107-384, Battle Ground, WA 98604. E-mail: firstname.lastname@example.org.
1. National Institutes of Health. State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults; June 13-15, 2005. Sleep. 2005;28:1049-1057.