Supplements New Approaches to the Management and Treatment of Insomnia
The Epidemiology and Diagnosis of Insomnia
With regard to temporal patterns, a previous history of insomnia at baseline was strongly associated with the incidence of new psychiatric disorders, including MDD, anxiety disorders, substance abuse disorder, and nicotine dependence. The association with subsequent MDD was attenuated when the presence of other depressive symptoms at baseline was taken into account.36 However, a potential causative role for insomnia in the development of MDD has been postulated by several researchers.40,41 Whether insomnia is a precursor to MDD, an early clinical hallmark of MDD, or the result of etiological factors common to MDD remains to be clarified.
Hohagen et al reported that severe and moderate insomnia, but not mild insomnia, were associated with (unspecified) chronic somatic disorders. In addition, when asked to rate their overall health status, patients with severe insomnia rated their health as "moderate" (60%) or "bad" (25%) far more frequently than those with no insomnia (41% and 4%, respectively).38
The same study also showed a strong correlation between insomnia severity and psychiatric comorbidities. Among those with severe insomnia, the prevalence of any psychiatric disorder was 37.4% and the prevalence of depression was 21.7%, compared with prevalence rates of 9.9% and 3.7%, respectively, for those reporting no sleep problems.38
In addition to the strong correlations between insomnia and psychiatric comorbidities, the prevalence of insomnia is increased relative to healthy controls in the context of several chronic medical conditions, including osteoarthritis42; rheumatoid arthritis43; coronary artery disease44,45; end-stage renal disease46; type 1 and type 2 diabetes mellitus47,48; and neurologic disorders, such as restless legs syndrome,49 Parkinson's disease,50 and Alzheimer's disease.51 These associations and others are addressed in detail in the following article by Dr Ancoli-Israel ("The Impact and Prevalence of Chronic Insomnia and Other Sleep Disturbances Associated With Chronic Illness").
Although more studies are necessary, evidence indicates that (1) insomnia may coexist with both psychological conditions and physical illness, and (2) left untreated, it may become a long-term, chronic condition, particularly in women. Early intervention and management, therefore, could be beneficial. However, the proportion of insomnia patients who report insomnia to their physicians is quite small, and physicians may not adequately assess it.36,52 Both patients and physicians may not recognize the impact of poor sleep on daily functioning and the risk of serious accidents and psychological sequelae.5 Practice guidelines developed by the Standards of Practice Committee of the American Academy of Sleep Medicine strongly recommend routine clinical screening for symptoms of insomnia during health examinations so that treatment can be integrated into the patient's overall care.53
As with every illness, the cornerstone of assessment for insomnia begins with a comprehensive history and screening for comorbidities, such as depressive and anxiety disorders, respiratory problems, and substance use, among others.54 An in-depth sleep history is essential in identifying the cause of insomnia5 and should include results of previous treatments.54 Many of the tools that are useful in the assessment of insomnia are subjective questionnaires. Others include sleep logs, symptom checklists, psychological screening tests, and bed partner interviews.5 The Pittsburgh Sleep Quality Index is a sleep questionnaire that may provide useful information about sleep quality, timing, and duration.55 The Insomnia Severity Index (Figure) is a reliable and valid instrument to quantify perceived insomnia severity, including next-day consequences.56 Nocturnal polysomnography and daytime multiple sleep latency testing are not recommended for the routine evaluation of insomnia unless other sleep disorders are suspected, such as sleep-related respiratory disturbances or periodic limb movement disorder.
Many questions remain unanswered in our understanding of insomnia. Future research must clarify existing evidence surrounding the exact nature of the relationship between insomnia and psychological and physiologic comorbidities. In the absence of comprehensive knowledge about the active intricacies of the "resting"brain, what is known about the high prevalence and socioeconomic burden of insomnia should encourage increased awareness of the prevalence of sleep disturbances and promote effective treatment strategies.
Corresponding author: Karl Doghramji, MD, Director, Sleep Disorders Center, Thomas Jefferson University, 1015 Walnut Street, Suite 319, Philadelphia, PA 19107. E-mail: email@example.com. Editorial assistance in the preparation of this manuscript was provided by Genevieve Belfiglio and Stephen Collins.
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