Strategies for Treating Chronic Insomnia
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REPORTS Strategies for Treating Chronic Insomnia Anna K. Morin, PharmD Abstract 85%.2,3 Insomnia is often further classified in Insomnia is a prevalent condition that remains clinical practice, based on the duration of underdiagnosed and undertreated. Recognizing and symptoms, as follows: transient insomnia, treating insomnia are important in decreasing mor- lasting 1 to 3 nights; short-term insomnia, bidity and restoring quality of life for those who lasting 3 nights to 1 month; and chronic experience sleep disturbances. Appropriate treatment insomnia, lasting more than 1 month.1,2,4,5 of insomnia should involve multiple interventions The severity and treatment of insomnia take designed to address not only the symptoms of insom- into account the frequency, intensity, dura- nia itself, but also any coexisting factors that may be contributing to the sleep disturbances. A combination tion, and consequences associated with the 1,4 of pharmacologic and nonpharmacologic therapies sleep disturbances. may be particularly efficacious in those with chronic Chronic insomnia may exist in isolation and debilitating insomnia. Pharmacotherapy is the (primary insomnia) or coexist with other most frequently used intervention for insomnia in medical and psychiatric illnesses, medica- cases where the goal of therapy is immediate relief of tion and substance misuse, behavioral or symptoms, insomnia is accompanied by significant environmental factors, or other primary distress or impairment, nonpharmacologic approach- sleep disorders, such as obstructive sleep es alone are ineffective, or the patient prefers med- apnea.6 Although the direct consequences of ication. The ideal hypnotic has the following insomnia have not been fully identified, characteristics: rapid absorption, rapid sleep induc- chronic insomnia has been associated with tion, optimal duration of action, preservation of sleep architecture, and a favorable safety profile. This a higher risk for the development of depres- review will discuss currently available treatment sion, cardiovascular disorders, chronic options for insomnia, the benefits of each, and appro- obstructive pulmonary disease, back and priate treatment regimens. hip problems, osteoarthritis, rheumatoid (Am J Manag Care. 2006;12:S230-S245) arthritis, and peptic ulcer disease.6-8 Al- though prevalence estimates of insomnia vary depending on the definitions and crite- haracterized by disorders of initiating ria used, epidemiologic studies indicate that or maintaining sleep, or nonrestora- approximately 30% to 35% of the general Ctive sleep, insomnia is a prevalent population experience at least occasional condition that can coexist with psychiatric or intermittent sleep disturbances.6,7,9,10 and medical illness and cause significant Twenty-five percent of these individuals, or impairment of social and occupational func- 10% of the population, report chronic insom- tioning.1 Patients may experience several nia symptoms accompanied by daytime con- symptoms of insomnia at one time, and the sequences of fatigue, irritability, and pattern of symptoms may change over time.1 impaired concentration, which can lead to In studies evaluating the outcomes of treat- negative effects on overall health, mood, and ments of sleep disturbances, insomnia is functioning.6,7,10 Costs associated with in- often defined by a sleep latency (SL) and/or somnia can include related medical expens- wake after sleep onset (WASO) time period greater than 30 min, with a corresponding sleep efficiency (total amount of sleep time Corresponding author: Anna K. Morin, PharmD, Assistant Professor, divided by the total amount of time spent in Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, 19 Foster Street, Worcester, MA 01608. E-mail: bed with the intent to sleep) of less than [email protected]. S230 THE AMERICAN JOURNAL OF MANAGED CARE MAY 2006 Strategies for Treating Chronic Insomnia es, more frequent use of healthcare re- focus on modifying factors that precipitate sources, a higher rate of absenteeism, and perpetuate sleep disturbances. Several reduced subjective productivity, and an behavioral techniques (ie, sleep hygiene [SH] increased risk of accidents relative to those education, relaxation therapies, stimulus without insomnia.6,11 As a result, the overall control, sleep restriction) and cognitive ther- economic burden of insomnia is estimated apy have been shown to be effective in the to exceed $100 billion annually.6,10,12 Popu- treatment of insomnia.2-4,14,16-19 Clinical data lations at particular risk for insomnia may demonstrate that behavioral techniques, include women, elderly persons, people with particularly stimulus control and sleep medical and psychiatric comorbidities, and restriction, are superior to placebo and as shift workers.2,6,13-15 effective as pharmacotherapy in the short- However, despite the fact that insomnia is term treatment of sleep initiation problems a prevalent condition that can be associated associated with insomnia.2,3,17,19 Most behav- with negative consequences, it remains ioral and cognitive interventions are com- underdiagnosed and undertreated. Recog- patible with one another and can be nizing and treating insomnia are important combined to optimize outcome. In general, in decreasing morbidity and restoring quali- advantages of these behavioral and cognitive ty of life for those who experience sleep dis- interventions are minimal adverse effects turbances. A comprehensive assessment of and documented improvement in sleep an individual’s medical, psychiatric, and sustained over 6 to 24 months.2,17,19,20 Limi- pharmacologic history, sleep and wakeful- tations to the implementation of these inter- ness patterns, and family history of sleep ventions include a shortage of personnel disorders is necessary before a diagnosis of trained in the provision of these techniques, insomnia can be made and a treatment plan high cost and limited or no insurance reim- implemented. Appropriate treatment of bursement, patient preferences for pharma- insomnia should involve multiple interven- cologic interventions, and the fact that these tions designed to address not only the symp- techniques are time intensive and require toms of insomnia itself but also any motivation on the part of the individual expe- coexisting factors that may be contributing riencing insomnia symptoms.3,4,16-18 Fur- to the sleep disturbances. thermore, some research has suggested that Many people with insomnia complain the efficacy of behavioral and cognitive inter- about difficulties in falling asleep, and, as a ventions decreases with increasing age.14,19 result, sleep onset has long been the focus of Behavioral and cognitive interventions are both pharmacologic and nonpharmacologic typically implemented when pharmacother- treatment interventions. Sleep maintenance apy is contraindicated as augmentation to (staying asleep) can also be a significant pharmacotherapeutic interventions or as a problem, particularly in the elderly and in result of patient preference. individuals with insomnia coexisting with First outlined in 1977 and based on clini- psychiatric and medical disorders.6,14 Al- cal observations of patients with sleep distur- though many individuals may benefit from bances, SH recommendations have evolved pharmacologic intervention, evidence also into a list of behaviors, environmental con- supports the use of nonpharmacologic treat- ditions, and other sleep-related factors that ments in the management of insomnia. A are believed to be instrumental in promoting combination of pharmacologic and non- improved quantity and quality of sleep.16 pharmacologic therapies may be particular- The assumption that accompanies SH edu- ly efficacious in those with chronic and cation in patients with insomnia is that sleep debilitating insomnia. disturbances arise, to some extent, when these patients deviate from SH behav- Nonpharmacologic Interventions for iors.16,18 Although commonly used as an Treating Insomnia approach to the treatment of insomnia, def- Nonpharmacologic interventions in the initions of SH in the scientific literature treatment of insomnia primarily include vary, depending on investigator and study behavioral and cognitive techniques that focus. However, common components of SH VOL. 12, NO. 8, SUP. THE AMERICAN JOURNAL OF MANAGED CARE S231 REPORTS recommendations include limiting the use of that regulates sleep and wakefulness.17,18 the bedroom only for sleep and intimacy; The allowable time spent in bed is increased keeping a regular bedtime and wake-up or decreased by 15 to 20 min each week schedule; avoiding alcohol, tobacco, caf- until a goal of 80% to 90% sleep efficiency is feine, large meals, and vigorous exercise met.2,18 Because gains in total sleep time are near bedtime; eliminating or minimizing not seen immediately, both stimulus control daytime napping; and modifying the sleep and sleep restriction require patient motiva- environment to eliminate or remove sleep- tion and encouragement. Both techniques disturbing elements, such as bright lights, have been shown to be highly efficacious as extremes in temperature and noise levels, single or combined therapies for sleep-onset and bedroom clocks.4,16,18 Evidence support- and sleep-maintenance insomnia.2,19 ing SH education as a stand-alone approach Cognitive approaches used in the treat- to the treatment of insomnia is limited.2,16,19 ment of insomnia involve restructuring tech- Although these factors are rarely the pri- niques