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: firstname.lastname@example.org. Editorial assistance in the preparation of this manuscript was provided by Genevieve Belfiglio and Stephen Collins.
1. Dement WC. Normal sleep, disturbed sleep, transient and persistent insomnia. Acta Psychiatr Scand Suppl. 1986;332:41-46.
2. Kripke DF, Simons RN, Garfinkel L, Hammond EC. Short and long sleep and sleeping pills. Is increased mortality associated? Arch Gen Psychiatry. 1979;36:103-116.
3. Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med. 1998;158:1099-1107.
4. Taylor DJ, Lichstein KL, Durrence HH. Insomnia as a health risk factor. Behav Sleep Med. 2003;1:227-247.
5. 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.
6. American Psychiatric Association. Sleep disorders. In: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic Criteria for Primary Insomnia, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:597-661.
7. American Academy of Sleep Medicine. The International Classification of Sleep Disorders, Revised. Westchester, Ill: American Academy of Sleep Medicine;1997.
8. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva, Switzerland: World Health Organization; 1992.
9. Quera-Salva MA, Orluc A, Goldenberg F, Guilleminault C. Insomnia and use of hypnotics: study of a French population. Sleep. 1991;14:386-391.
10. Leger D, Guilleminault C, Dreyfus JP, Delahaye C, Paillard M. Prevalence of insomnia in a survey of 12,778 adults in France. J Sleep Res. 2000;9:35-42.
11. Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res. 1997;31:333-346.
12. American Academy of Sleep Medicine. The International Classification of Sleep Disorders. Westchester, Ill: American Academy of Sleep Medicine; 1990.
13. World Health Organization. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). 4th ed. Salt Lake City, Utah:Medicode; 1994.
14. Buysse DJ, Reynolds CF III, Kupfer DJ, et al. Clinical diagnoses in 216 insomnia patients using the International Classification of Sleep Disorders (ICSD), DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV Field Trial. Sleep. 1994;17:630-637.
15. Ohayon MM, Roberts RE. Comparability of sleep disorders diagnoses using DSM-IV and ICSD classifications with adolescents. Sleep. 2001;24:920-925.
16. Harvey AG. Insomnia: symptom or diagnosis? Clin Psychol Rev. 2001;21:1037-1059.
17. Primary insomnia. In: Medline Plus Medical Encyclopedia. Bethesda, Md: National Library of Medicine/National Institutes of Health. 2004. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000805.htm. Accessed June 8, 2005.
18. Richardson GS, Roth T. Future directions in the management of insomnia. J Clin Psychiatry. 2001;62(suppl 10):39-45.
19. Drake CL, Roehrs T, Roth T. Insomnia causes, consequences, and therapeutics: an overview. Depress Anxiety. 2003;18:163-176.
20. Niemcewicz S, Szelenberger W, Skalski M, et al. Psychophysiological correlates of primary insomnia [in Polish]. Psychiatr Pol. 2001;35:583-591.
21. Roth T, Roehrs T. Insomnia: epidemiology, characteristics, and consequences. Clin Cornerstone. 2003;5:5-15.
22. Ancoli-Israel S. Insomnia in the elderly: a review for the primary care practitioner. Sleep. 2000;23(suppl 1):S23-S30; discussion S36-S38.
23. Young TB. Natural history of chronic insomnia. NIH Insomnia abstract. J Clin Sleep Med. 2005;1(suppl):e466-e467.
24. Roth T. New developments for treating sleep disorders. J Clin Psychiatry. 2001;62(suppl 10):3-4.
25. National Heart, Lung, and Blood Institute Working Group on Insomnia. Insomnia: assessment and management in primary care. Am Fam Physician. 1999;59:3029-3038.
26. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep. 1995;18:425-432.
27. Newman AB, Enright PL, Manolio TA, Haponik EF, Wahl PW. Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study. J Am Geriatr Soc.1997;45:1-7.
28. Gislason T, Reynisdottir H, Kristbjarnarson H, Benediktsdottir B. Sleep habits and sleep disturbances among the elderly—an epidemiological survey. J Intern Med. 1993;234:31-39.
29. Habte-Gabr E, Wallace RB, Colsher PL, Hulbert JR, White LR, Smith IM. Sleep patterns in rural elders: demographic, health, and psychobehavioral correlates. J Clin Epidemiol. 1991;44:5-13.
30. Sukying C, Bhokakul V, Udomsubpayakul U. An epidemiological study on insomnia in an elderly Thai population. J Med Assoc Thai. 2003;86:316-324.
31. Barbar SI, Enright PL, Boyle P, et al. Sleep disturbances and their correlates in elderly Japanese American men residing in Hawaii. J Gerontol A Biol Sci Med Sci. 2000;55:M406-M411.
32. Foley DJ, Monjan A, Simonsick EM, Wallace RB, Blazer DG. Incidence and remission of insomnia among elderly adults: an epidemiologic study of 6,800 persons over three years. Sleep. 1999;22(suppl 2):S366-S372.
33. Ancoli-Israel S. Sleep disorders in older adults: a primary care guide to assessing 4 common sleep problems in geriatric patients. Geriatrics. 2004;59:37-40; quiz 41.
34. Morgan K, Dallosso H, Ebrahim S, Arie T, Fentem PH. Characteristics of subjective insomnia in the elderly living at home. Age Ageing. 1988;17:1-7.
35. Quan SF, Katz R, Olson J, et al. Factors associated with incidence and persistence of symptoms of disturbed sleep in an elderly cohort: the Cardiovascular Health Study. Am J Med Sci. 2005;329:163-172.
36. Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996;39:411-418.
37. Owens JF, Matthews KA. Sleep disturbances in healthy middle-aged women. Maturitas. 1998;30:41-50.
38. Hohagen F, Rink K, Kappler C, et al. Prevalence and treatment of insomnia in general practice. A longitudinal study. Eur Arch Psychiatry Clin Neurosci. 1993;242:329-336.
39. Hohagen F, Kappler C, Schramm E, Riemann D, Weyerer S, Berger M. Sleep onset insomnia, sleep maintaining insomnia and insomnia with early morning awakening—temporal stability of subtypes in a longitudinal study on general practice attenders. Sleep. 1994;17:551-554.
40. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA. 1989;262:1479-1484.
41. Riemann D, Voderholzer U. Primary insomnia: a risk factor to develop depression? J Affect Disord. 2003;76:255-259.
42. Wilcox S, Brenes GA, Levine D, Sevick MA, Shumaker SA, Craven T. Factors related to sleep disturbance in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis. J Am Geriatr Soc. 2000;48:1241-1251.
43. Drewes AM, Nielsen KD, Hansen B, Jørgensen Taagholt S, Bjerregård K, Svedsen L. A longitudinal study of clinical symptoms and sleep parameters in rheumatoid arthritis. Rheumatology (Oxford). 2000;39:1287-1289.
44. Mallon L, Broman JE, Hetta J. Sleep complaints predict coronary artery disease mortality in males: a 12-year follow-up study of a middle-aged Swedish population. J Intern Med. 2002;251:207-216.
45. Schwartz S, McDowell Anderson W, Cole SR, Cornoni-Huntley J, Hays JC, Blazer D. Insomnia and heart disease: a review of epidemiologic studies. J Psychosom Res. 1999;47:313-333.
46. Williams SW, Tell GS, Zheng B, Shumaker S, Rocco MN, Sevick MA. Correlates of sleep behavior among hemodialysis patients. The Kidney Outcomes Prediction and Evaluation (KOPE) study. Am J Nephrol. 2002;22:18-28.
47. Renko A, Hiltunen L, Laakso M, Rajala U, Keinanen-Kiukaanniemi S. The relationship of glucose tolerance to sleep disorders and daytime sleepiness. Diabetes Res Clin Pract. 2005;67:84-91.
48. Gislason T, Almqvist M. Somatic diseases and sleep complaints. An epidemiological study of 3,201 Swedish men. Acta Med Scand. 1987;221:475-481.
49. Phillips B, Hening W, Britz P, Mannino D. Prevalence and correlates of restless legs syndrome: results from the 2005 National Sleep Foundation Poll. Chest. 2006;129:76-80.
50. Thorpy MJ. Sleep disorders in Parkinson's disease. Clin Cornerstone. 2004;6(suppl 1A):S7-S15.
51. Bliwise DL. Sleep disorders in Alzheimer's disease and other dementias. Clin Cornerstone. 2004;6(suppl 1A):S16-S28.
52. The Gallup Organization for the National Sleep Foundation. Sleep in America: 1995. Princeton, NJ: The Gallup Organization;1995.
53. Chesson A Jr, Hartse K, Anderson WM, et al. Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2000;23:237-241.
54. Sateia MJ, Nowell PD. Insomnia. Lancet. 2004;364:1959-1973.
55. Buysse DJ, Reynolds CF III, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193-213.
56. Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297-307.
57. Morin CM. Insomnia: Psychological Assessment and Management. New York, NY: Guilford Press; 1993.