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Strategies for Treating Chronic Insomnia

Anna K. Morin, PharmD

Insomnia is a prevalent condition that remains underdiagnosed and undertreated. Recognizing and treating insomnia are important in decreasing morbidity and restoring quality of life for those who experience sleep disturbances. Appropriate treatment of insomnia should involve multiple interventions designed to address not only the symptoms of insomnia itself, but also any coexisting factors that may be contributing to the sleep disturbances. A combination of pharmacologic and nonpharmacologic therapies may be particularly efficacious in those with chronic and debilitating insomnia. Pharmacotherapy is the most frequently used intervention for insomnia in cases where the goal of therapy is immediate relief of symptoms, insomnia is accompanied by significant distress or impairment, nonpharmacologic approaches alone are ineffective, or the patient prefers medication. The ideal hypnotic has the following characteristics: rapid absorption, rapid sleep induction, optimal duration of action, preservation of sleep architecture, and a favorable safety profile. This review will discuss currently available treatment options for insomnia, the benefits of each, and appropriate treatment regimens.

(Am J Manag Care. 2006;12:S230-S245)


Characterized by disorders of initiating or maintaining sleep, or nonrestorative sleep, insomnia is a prevalent condition that can coexist with psychiatric and medical illness and cause significant impairment of social and occupational functioning. 1 Patients may experience several symptoms of insomnia at one time, and the pattern of symptoms may change over time.1 In studies evaluating the outcomes of treatments of sleep disturbances, insomnia is often defined by a sleep latency (SL) and/or wake after sleep onset (WASO) time period greater than 30 min, with a corresponding sleep efficiency (total amount of sleep time divided by the total amount of time spent in bed with the intent to sleep) of less than 85%.2,3 Insomnia is often further classified in clinical practice, based on the duration of symptoms, as follows: transient insomnia, lasting 1 to 3 nights; short-term insomnia, lasting 3 nights to 1 month; and chronic insomnia, lasting more than 1 month.1,2,4,5 The severity and treatment of insomnia take into account the frequency, intensity, duration, and consequences associated with the sleep disturbances.1,4

Chronic insomnia may exist in isolation (primary insomnia) or coexist with other medical and psychiatric illnesses, medication and substance misuse, behavioral or environmental factors, or other primary sleep disorders, such as obstructive sleep apnea.6 Although the direct consequences of insomnia have not been fully identified, chronic insomnia has been associated with a higher risk for the development of depression, cardiovascular disorders, chronic obstructive pulmonary disease, back and hip problems, osteoarthritis, rheumatoid arthritis, and peptic ulcer disease.6-8 Although prevalence estimates of insomnia vary depending on the definitions and criteria used, epidemiologic studies indicate that approximately 30% to 35% of the general population experience at least occasional or intermittent sleep disturbances.6,7,9,10 Twenty-five percent of these individuals, or 10% of the population, report chronic insomnia symptoms accompanied by daytime consequences of fatigue, irritability, and impaired concentration, which can lead to negative effects on overall health, mood, and functioning.6,7,10 Costs associated with insomnia can include related medical expenses, more frequent use of healthcare resources, a higher rate of absenteeism, reduced subjective productivity, and an increased risk of accidents relative to those without insomnia.6,11 As a result, the overall economic burden of insomnia is estimated to exceed $100 billion annually.6,10,12 Populations at particular risk for insomnia may include women, elderly persons, people with medical and psychiatric comorbidities, and shift workers.2,6,13-15

However, despite the fact that insomnia is a prevalent condition that can be associated with negative consequences, it remains underdiagnosed and undertreated. Recognizing and treating insomnia are important in decreasing morbidity and restoring quality of life for those who experience sleep disturbances. A comprehensive assessment of an individual's medical, psychiatric, and pharmacologic history, sleep and wakefulness patterns, and family history of sleep disorders is necessary before a diagnosis of insomnia can be made and a treatment plan implemented. Appropriate treatment of insomnia should involve multiple interventions designed to address not only the symptoms of insomnia itself but also any coexisting factors that may be contributing to the sleep disturbances.

Many people with insomnia complain about difficulties in falling asleep, and, as a result, sleep onset has long been the focus of both pharmacologic and nonpharmacologic treatment interventions. Sleep maintenance (staying asleep) can also be a significant problem, particularly in the elderly and in individuals with insomnia coexisting with psychiatric and medical disorders.6,14 Although many individuals may benefit from pharmacologic intervention, evidence also supports the use of nonpharmacologic treatments in the management of insomnia. A combination of pharmacologic and nonpharmacologic therapies may be particularly efficacious in those with chronic and debilitating insomnia.

Nonpharmacologic Interventions for Treating Insomnia

Nonpharmacologic interventions in the treatment of insomnia primarily include behavioral and cognitive techniques that focus on modifying factors that precipitate and perpetuate sleep disturbances. Several behavioral techniques (ie, sleep hygiene [SH] education, relaxation therapies, stimulus control, sleep restriction) and cognitive therapy have been shown to be effective in the treatment of insomnia.2-4,14,16-19 Clinical data demonstrate that behavioral techniques, particularly stimulus control and sleep restriction, are superior to placebo and as effective as pharmacotherapy in the short-term treatment of sleep initiation problems associated with insomnia.2,3,17,19 Most behavioral and cognitive interventions are compatible with one another and can be combined to optimize outcome. In general, advantages of these behavioral and cognitive interventions are minimal adverse effects and documented improvement in sleep sustained over 6 to 24 months.2,17,19,20 Limitations to the implementation of these interventions include a shortage of personnel trained in the provision of these techniques, high cost and limited or no insurance reimbursement, patient preferences for pharmacologic interventions, and the fact that these techniques are time intensive and require motivation on the part of the individual experiencing insomnia symptoms.3,4,16-18 Furthermore, some research has suggested that the efficacy of behavioral and cognitive interventions decreases with increasing age.14,19 Behavioral and cognitive interventions are typically implemented when pharmacotherapy is contraindicated as augmentation to pharmacotherapeutic interventions or as a result of patient preference.

First outlined in 1977 and based on clinical observations of patients with sleep disturbances, SH recommendations have evolved into a list of behaviors, environmental conditions, and other sleep-related factors that are believed to be instrumental in promoting improved quantity and quality of sleep.16 The assumption that accompanies SH education in patients with insomnia is that sleep disturbances arise, to some extent, when these patients deviate from SH behaviors.16,18 Although commonly used as an approach to the treatment of insomnia, definitions of SH in the scientific literature vary, depending on investigator and study focus. However, common components of SH recommendations include limiting the use of the bedroom only for sleep and intimacy; keeping a regular bedtime and wake-up schedule; avoiding alcohol, tobacco, caffeine, large meals, and vigorous exercise near bedtime; eliminating or minimizing daytime napping; and modifying the sleep environment to eliminate or remove sleep-disturbing elements, such as bright lights, extremes in temperature and noise levels, and bedroom clocks.4,16,18 Evidence supporting SH education as a stand-alone approach to the treatment of insomnia is limited.2,16,19 Although these factors are rarely the primary cause of chronic insomnia, individuals should always be educated about good SH and proper sleep habits, regardless of the etiology of the sleep disturbance.

Relaxation therapies for insomnia specifically target the arousal system and focus on reducing factors, such as tension and stress, that may precipitate sleep disturbances.17,18 Many individuals, however, do not recognize the significance of stress reduction in the treatment of their insomnia and do not invest the time required to learn progressive muscle relaxation, meditation, simple breathing retraining, guided imagery, or other forms of relaxation. There is currently no evidence to support the use of relaxation techniques as the sole intervention in the management of insomnia.2,18

The basis for the use of stimulus control is to associate the bedroom and bedtime with sleep rather than wakefulness.2-4,18,19 To increase sleep efficiency and decrease frustration that occurs with extended time awake in bed, individuals are instructed to go to sleep only when drowsy, to keep a regular sleep-wake cycle, to use the bed only for sleep and sex, to avoid napping during the day, and to get out of bed if unable to fall asleep within 20 min.2,18 Equally important, individuals should be encouraged to engage in relaxing activities until they feel drowsy or sleepy again, and to repeat this last step as often as necessary. Often used in conjunction with stimulus control, sleep restriction limits the amount of time spent in bed to only the time actually spent sleeping.17,18 Maintenance of a consistent wake time, even after a poor night's sleep, is necessary to synchronize the endogenous circadian rhythm that regulates sleep and wakefulness.17,18 The allowable time spent in bed is increased or decreased by 15 to 20 min each week until a goal of 80% to 90% sleep efficiency is met.2,18 Because gains in total sleep time are not seen immediately, both stimulus control and sleep restriction require patient motivation and encouragement. Both techniques have been shown to be highly efficacious as single or combined therapies for sleep-onset and sleep-maintenance insomnia.2,19

Cognitive approaches used in the treatment of insomnia involve restructuring techniques that address maladaptive thought patterns and attitudes that exacerbate and amplify sleep disturbances.2,3,18 The goal is to recognize, challenge, and change patient-specific unrealistic sleep expectations, misconceptions about the causes of insomnia, and apprehension and anxiety about bedtime. Cognitive therapy has not been evaluated as a stand-alone treatment for chronic insomnia, but treatment approaches that incorporate cognitive restructuring techniques have shown positive outcomes.2,3

Pharmacologic Interventions for Treating Insomnia

Pharmacotherapy is the most frequently used intervention for primary and secondary insomnia when immediate symptom relief is needed, when the sleep disturbances produce significant distress or impairment, when behavioral and cognitive interventions alone are insufficient in treating the insomnia, or when a patient prefers the use of medication.2,18,21

Characteristics of a desirable hypnotic include rapid absorption, rapid sleep induction, optimal duration of action, preservation of sleep architecture, and being free from unwanted effects and drug interactions.21 The desired hypnotic agent should not cause residual daytime effects or memory loss, should not interact synergistically with ethanol to produce respiratory depression, and should not produce tolerance, dependence, or rebound insomnia.

 
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