Overcoming Barriers to the Diagnosis and Treatment of Insomnia Thomas Roth, PhD Disclosure Note: This CME activity includes discussion about medications not approved by the US Food and Drug Administration and uses of medications outside of their approved labeling. CONTINUING MEDICAL EDUCATION LEARNING OBJECTIVES entity producing, marketing, re-selling enduring material for a maximum of 1.0 • Apply evidence-based diagnostic or distributing health care goods or ser- AMA PRA Category 1 credit(s)™. Physi- guidelines for patients who have clini- vices consumed by, or used on, patients. cians should claim only the credit com- cal features consistent with insomnia Mechanisms are in place to identify and mensurate with the extent of their par- resolve any potential conflict of interest ticipation in the activity. CME is available • Use evidence-based guidelines to prior to the start of the activity. In addi- September 1, 2020 to August 31, 2021. develop comprehensive treatment tion, any discussion of off-label, experi- plans that include cognitive-behav- mental, or investigational use of drugs or METHOD OF PARTICIPATION ioral therapy, pharmacologic treat- devices will be disclosed by the faculty. PHYSICIANS: To receive CME credit, ment, and combination therapies please read the journal article and, on to achieve optimal outcomes Dr. Roth discloses that he is on the advi- sory boards for Merck, Eisai, Jazz, Idorsia completion, go to www.pceconsortium. • Identify basic elements of cognitive- and Janssen. org/insomnia2 to complete the online behavioral therapy for insomnia post-test and receive your certificate of Gregory Scott, PharmD, RPh, editorial completion. • Differentiate among medications support, discloses he has no real or ap- FDA-approved for treating insomnia parent conflicts of interests to report. Ad- PHYSICIAN ASSISTANTS AND NURSE by discussing mechanism of action, ditional PCEC staff report no conflicts of PRACTITIONERS: AANP, ANCC, and AAPA safety, efficacy, and use interest. accept certificates of participation of edu- cational activities certified for AMA PRA TARGET AUDIENCE SPONSORSHIP Category 1 Credit™ from organizations ac- credited by ACCME. Family physicians and clinicians who This activity is sponsored by Primary Care Education Consortium, in collabo- wish to gain increased knowledge and SUPPORTER greater competency regarding primary ration with the Primary Care Metabolic care management of insomnia. Group. This article is supported by an education- al grant from Eisai. DISCLOSURES ACCREDITATION FACULTY As a continuing medical education pro- The Primary Care Education Consortium vider accredited by the Accreditation is accredited by the Accreditation Coun- Thomas Roth, PhD, Director, Sleep Dis- Council for Continuing Medical Educa- cil for Continuing Medical Education (AC- orders and Research Center, Henry Ford tion (ACCME), Primary Care Education CME) to provide continuing medical edu- Health System Detroit, MI. Consortium (PCEC) requires any individ- cation for physicians. ual in a position to influence educational ACKNOWLEDGMENT content to disclose any financial interest CREDIT DESIGNATION Editorial support was provided by Greg- or other personal relationship with any AMA PRA Category 1 – Primary Care ory Scott, PharmD, RPh, at the Primary commercial interest. This includes any Education Consortium designates this Care Education Consortium (PCEC). CASE SCENARIO EPIDEMIOLOGY A 72-year-old woman describes difficulty staying asleep and Insomnia, defined as difficulty initiating or maintaining sleep daytime fatigue for the past 8 months. Initially, she only had with associated daytime consequence, is 1 of 7 sleep-wake difficulty staying asleep 2 to 3 nights per week, but over the disorders according to the International Classification of past 5 months, these symptoms have increased in sever- Sleep Disorders, 3rd edition (ICSD-3).1 Insomnia is common, ity and frequency. She notes increased irritability and lack particularly among older adults.2 The estimated prevalence of motivation during the day associated with her disturbed varies based on the criteria, ranging from 22% using DSM-IV- sleep. TR, 15% using Research Diagnostic Criteria/ICSD-2, and 4% using ICD-10 criteria.3 Supplement to The Journal of Family Practice | Vol 69, No 7 | SEPTEMBER 2020 S45 DIAGNOSIS AND TREATMENT OF INSOMNIA TABLE 1. Assessment of sleep history16-18 Sleep Problem Sleep Times Consequences of Disturbed Sleep Symptom Duration Number of awakenings Bedtime Fatigue or malaise <3 months or ≥3 Duration of awakenings Duration until sleep onset Poor attention or concentration months Duration of the sleep problem Final awakening time Social/vocational/educational dysfunction Nap time(s) Motor disturbance or irritability Nap length(s) Daytime sleepiness Reduced motivation or energy Increased errors or accidents Behavioral problems Ongoing worry Insomnia can lead to complications, such as psychiatric and complementary and alternative medicines. Actigraphy disorders,4-8 falls,9-12 cardiovascular disorders,13,14 and meta- could be considered to characterize circadian rhythm pat- bolic syndrome.15 Psychiatric complications include depres- terns or sleep disturbances.16 Other laboratory testing, such sion and anxiety, and cardiovascular disorders include isch- as blood, radiography, or polysomnography, is needed only emic heart disease, ischemic (but not hemorrhagic) stroke, to investigate suspected comorbid disorders.16 hypertension, and heart failure.13,14 Recent evidence indi- Because insomnia is a component of many psychiat- cates severe insomnia is associated with increased risk of ric and medical conditions, an insomnia diagnosis should metabolic syndrome in women age ≥50, but not men.15 be considered only when the symptoms are prominent and require further evaluation and treatment. If an associated DIAGNOSIS comorbidity is identified, consider that it is sometimes dif- Insomnia is diagnosed clinically based on history and char- ficult to determine whether the insomnia or the comorbidity acterizing the nature and severity of the sleep problem (TABLE occurred first. Due to this uncertainty, insomnia is no longer 1).16-18 Asking the patient to talk through a typical 24-hour day classified as primary or secondary, and treatment targets can provide valuable insight. A sleep diary could be helpful both insomnia and the comorbid disorder.1,19 for patients with substantial variability in the sleep problem. An insomnia diagnosis requires that the patient experi- Well-rested adults fall asleep within 10 to 20 minutes of ences difficulty initiating or maintaining sleep despite ade- attempting to sleep and spend <30 minutes awake during the quate opportunity and circumstances for sleep that results in night. Adults with chronic insomnia, however, usually take daytime consequences.1 Insomnia differs from sleep depri- ≥30 minutes to fall asleep (for those with sleep initiation dif- vation in that insomnia occurs despite adequate opportunity ficulty), spend ≥30 minutes awake during the night (for those and circumstances for sleep, whereas sleep deprivation does with sleep maintenance difficulty), and/or terminate sleep ≥30 not. Those with chronic insomnia experience symptoms minutes prior to the desired wake-up time. It is not uncommon ≥3 times per week for ≥3 months. Daytime consequences for patients to report 1 or more nights of poor sleep followed include fatigue or malaise, poor attention or concentration, by a night of better sleep or to have minimal sleep over several social/vocational/educational dysfunction, increased errors consecutive nights. Patients often overestimate the amount of or accidents, motor disturbance or irritability, daytime sleep- time it takes to fall asleep and underestimate total sleep time. iness, reduced motivation or energy, or behavioral problems Asking patients why they are experiencing the sleep such as hyperactivity, impulsivity, or aggression. Patients problem often identifies contributing factors and comorbid with chronic insomnia might have ongoing worry that insuf- psychiatric or medical disorders, such as depression, anxiety, ficient sleep could lead to daytime dysfunction, thereby cre- pain, restless leg syndrome, and obstructive sleep apnea.16 ating a cycle that worsens insomnia. The Epworth Sleepiness Scale is useful to identify patients with daytime sleepiness. Question patients about the use of TREATMENT prescription and non-prescription medications, such as cen- Overview of clinical guidelines tral nervous system stimulants or depressants, antidepres- Several guidelines for managing patients with insomnia sants, beta-agonists, diuretics, opioids, and glucocorticoids. have been developed. Based on growing understanding of Ask patients about their consumption of caffeine, alcohol, the often bi-directional association between insomnia and S46 SEPTEMBER 2020 | Vol 69, No 7 | Supplement to The Journal of Family Practice DIAGNOSIS AND TREATMENT OF INSOMNIA comorbid disorders, these guidelines increasingly have insomnia, particularly because not all patients achieve ade- emphasized the importance of identifying and treating quate benefits with CBT-I and long-term adherence can be comorbid condition(s) as well as the insomnia itself.16,19,20 challenging.20,21 Approved medications include benzodiaz- Discussion regarding the treatment of comorbid disorders epines, nonbenzodiazepine hypnotics, melatonin agonist, associated with insomnia is beyond the scope of this review. doxepin, and orexin receptor antagonists.