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JAMA Feb 2013Insomnia is one of the most prevalent health concerns in the population and in clinical practice. Clinicians may be reluctant to address insomnia because of its many... (Review)
Review
IMPORTANCE
Insomnia is one of the most prevalent health concerns in the population and in clinical practice. Clinicians may be reluctant to address insomnia because of its many potential causes, unfamiliarity with behavioral treatments, and concerns about pharmacologic treatments.
OBJECTIVE
To review the assessment, diagnosis, and treatment of insomnia in adults.
EVIDENCE REVIEW
Systematic review to identify and summarize previously published quantitative reviews (meta-analyses) of behavioral and pharmacologic treatments for insomnia.
FINDINGS
Insomnia is a common clinical condition characterized by difficulty initiating or maintaining sleep, accompanied by symptoms such as irritability or fatigue during wakefulness. The prevalence of insomnia disorder is approximately 10% to 20%, with approximately 50% having a chronic course. Insomnia is a risk factor for impaired function, development of other medical and mental disorders, and increased health care costs. The etiology and pathophysiology of insomnia involve genetic, environmental, behavioral, and physiological factors culminating in hyperarousal. The diagnosis of insomnia is established by a thorough history of sleep behaviors, medical and psychiatric problems, and medications, supplemented by a prospective record of sleep patterns (sleep diary). Quantitative literature reviews (meta-analyses) support the efficacy of behavioral, cognitive, and pharmacologic interventions for insomnia. Brief behavioral interventions and Internet-based cognitive-behavioral therapy both show promise for use in primary care settings. Among pharmacologic interventions, the most evidence exists for benzodiazepine receptor agonist drugs, although persistent concerns focus on their safety relative to modest efficacy. Behavioral treatments should be used whenever possible, and medications should be limited to the lowest necessary dose and shortest necessary duration.
CONCLUSIONS AND RELEVANCE
Clinicians should recognize insomnia because of its effects on function and health. A thorough clinical history is often sufficient to identify factors that contribute to insomnia. Behavioral treatments should be used when possible. Hypnotic medications are also efficacious but must be carefully monitored for adverse effects.
Topics: Cognitive Behavioral Therapy; Female; Humans; Middle Aged; Risk Factors; Sleep Initiation and Maintenance Disorders
PubMed: 23423416
DOI: 10.1001/jama.2013.193 -
Climacteric : the Journal of the... Dec 2020The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women.... (Review)
Review
The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women. According to its pathogenetic model (3-P Model), different predisposing factors (i.e. a persistent condition of past insomnia and aging per se) increase the risk of insomnia during menopause. Moreover, multiple precipitating and perpetuating factors should favor its occurrence across menopause, including hormonal changes, menopausal transition stage symptoms (i.e. hot flashes, night sweats), mood disorders, poor health and pain, other sleep disorders and circadian modifications. Thus, insomnia management implies a careful evaluation of the psychological and somatic symptoms of the individual menopausal woman by a multidisciplinary team. Therapeutic strategies encompass different drugs but also behavioral interventions. Indeed, cognitive behavioral therapy represents the first-line treatment of insomnia in the general population, regardless of the presence of mood disorders and/or vasomotor symptoms (VMS). Different antidepressants seem to improve sleep disturbances. However, when VMS are present, menopausal hormone therapy should be considered in the treatment of related insomnia taking into account the risk-benefit profile. Finally, given its good tolerability, safety, and efficacy on multiple sleep and daytime parameters, prolonged-released melatonin should represent a first-line drug in women aged ≥ 55 years.
Topics: Antidepressive Agents; Cognitive Behavioral Therapy; Female; Hormone Replacement Therapy; Humans; Melatonin; Menopause; Middle Aged; Mood Disorders; Sleep Initiation and Maintenance Disorders
PubMed: 32880197
DOI: 10.1080/13697137.2020.1799973 -
American Family Physician Dec 2015Insomnia affects 10% to 30% of the population with a total cost of $92.5 to $107.5 billion annually. Short-term, chronic, and other types of insomnia are the three major... (Review)
Review
Insomnia affects 10% to 30% of the population with a total cost of $92.5 to $107.5 billion annually. Short-term, chronic, and other types of insomnia are the three major categories according to the International Classification of Sleep Disorders, 3rd ed. The criteria for diagnosis are difficulty falling asleep, difficulty staying asleep, or early awakening despite the opportunity for sleep; symptoms must be associated with impaired daytime functioning and occur at least three times per week for at least one month. Factors associated with the onset of insomnia include a personal or family history of insomnia, easy arousability, poor self-reported health, and chronic pain. Insomnia is more common in women, especially following menopause and during late pregnancy, and in older adults. A comprehensive sleep history can confirm the diagnosis. Psychiatric and medical problems, medication use, and substance abuse should be ruled out as contributing factors. Treatment of comorbid conditions alone may not resolve insomnia. Patients with movement disorders (e.g., restless legs syndrome, periodic limb movement disorder), circadian rhythm disorders, or breathing disorders (e.g., obstructive sleep apnea) must be identified and treated appropriately. Chronic insomnia is associated with cognitive difficulties, anxiety and depression, poor work performance, decreased quality of life, and increased risk of cardiovascular disease and all-cause mortality. Insomnia can be treated with nonpharmacologic and pharmacologic therapies. Nonpharmacologic therapies include sleep hygiene, cognitive behavior therapy, relaxation therapy, multicomponent therapy, and paradoxical intention. Referral to a sleep specialist may be considered for refractory cases.
Topics: Adult; Aged; Aged, 80 and over; Chronic Disease; Cognitive Behavioral Therapy; Education, Medical, Continuing; Female; Humans; Middle Aged; Practice Guidelines as Topic; Pregnancy; Relaxation Therapy; Sleep Initiation and Maintenance Disorders; United States
PubMed: 26760592
DOI: No ID Found -
Sleep Medicine Reviews Apr 2002Epidemiologists have published more than 50 studies of insomnia based on data collected in various representative community-dwelling samples or populations. These...
Epidemiologists have published more than 50 studies of insomnia based on data collected in various representative community-dwelling samples or populations. These surveys provide estimates of the prevalence of insomnia according to four definitions: insomnia symptoms, insomnia symptoms with daytime consequences, sleep dissatisfaction and insomnia diagnoses. The first definition, based on insomnia criteria as defined by the DSM-IV, recognizes that about one-third of a general population presents at least one of them. The second definition shows that, when daytime consequences of insomnia are taken into account, the prevalence is between 9% and 15%. The third definition represents 8-18% of the general population. The last definition, more precise and corresponding to a decision-making diagnosis, sets the prevalence at 6% of insomnia diagnoses according to the DSM-IV classification. These four definitions of insomnia have higher prevalence rates in women than in men. The prevalence of insomnia symptoms generally increases with age, while the rates of sleep dissatisfaction and diagnoses have little variation with age. Numerous factors can initiate or maintain insomnia. Mental disorders and organic diseases are the factors that have been the most frequently studied. The association between insomnia and major depressive episodes has been constantly reported: individuals with insomnia are more likely to have a major depressive illness. Longitudinal studies have shown that the persistence of insomnia is associated with the appearance of a new depressive episode. Future epidemiological studies should focus on the natural evolution of insomnia. Epidemiological genetic links of insomnia are yet to be studied.
Topics: Adolescent; Adult; Aged; Child; Female; Humans; Male; Mental Disorders; Middle Aged; Prevalence; Psychiatric Status Rating Scales; Severity of Illness Index; Sleep Initiation and Maintenance Disorders
PubMed: 12531146
DOI: 10.1053/smrv.2002.0186 -
Health Reports Nov 2005This article estimates the prevalence of insomnia among Canadians aged 15 or older, and factors related to it. Associations between insomnia and coping ability, work...
OBJECTIVES
This article estimates the prevalence of insomnia among Canadians aged 15 or older, and factors related to it. Associations between insomnia and coping ability, work status, two-week disability days and life dissatisfaction are analyzed.
DATA SOURCES
The data are from the 2002 Canadian Community Health Survey: Mental Health and Well-being.
ANALYTICAL TECHNIQUES
Cross-tabulations were used to estimate the prevalence of insomnia by selected characteristics. Associations between these characteristics and insomnia, and between insomnia and selected negative situations, were examined in multivariate logistic regression models.
MAIN RESULTS
In 2002, an estimated 3.3 million Canadians (13.4% of the household population aged 15 or older) had insomnia. Factors independently associated with insomnia included painful chronic conditions, activity limitations, mood and anxiety disorders, life stress, frequent use of alcohol or cannabis, obesity, and low education. Compared with those who did not have insomnia, people with insomnia were more likely to report negataive situations such as difficulty coping and not having a job.
Topics: Adaptation, Psychological; Adolescent; Adult; Aged; Canada; Comorbidity; Female; Health Surveys; Humans; Male; Middle Aged; Prevalence; Risk Factors; Sleep Initiation and Maintenance Disorders
PubMed: 16335690
DOI: No ID Found -
Journal of Consulting and Clinical... Jun 2015To determine if a treatment for interepisode bipolar disorder I patients with insomnia improves mood state, sleep, and functioning. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To determine if a treatment for interepisode bipolar disorder I patients with insomnia improves mood state, sleep, and functioning.
METHOD
Alongside psychiatric care, interepisode bipolar disorder I participants with insomnia were randomly allocated to a bipolar disorder-specific modification of cognitive behavior therapy for insomnia (CBTI-BP; n = 30) or psychoeducation (PE; n = 28) as a comparison condition. Outcomes were assessed at baseline, the end of 8 sessions of treatment, and 6 months later. This pilot was conducted to determine initial feasibility and generate effect size estimates.
RESULTS
During the 6-month follow-up, the CBTI-BP group had fewer days in a bipolar episode relative to the PE group (3.3 days vs. 25.5 days). The CBTI-BP group also experienced a significantly lower hypomania/mania relapse rate (4.6% vs. 31.6%) and a marginally lower overall mood episode relapse rate (13.6% vs. 42.1%) compared with the PE group. Relative to PE, CBTI-BP reduced insomnia severity and led to higher rates of insomnia remission at posttreatment and marginally higher rates at 6 months. Both CBTI-BP and PE showed statistically significant improvement on selected sleep and functional impairment measures. The effects of treatment were well sustained through follow-up for most outcomes, although some decline on secondary sleep benefits was observed.
CONCLUSIONS
CBTI-BP was associated with reduced risk of mood episode relapse and improved sleep and functioning on certain outcomes in bipolar disorder. Hence, sleep disturbance appears to be an important pathway contributing to bipolar disorder. The need to develop bipolar disorder-specific sleep diary scoring standards is highlighted.
Topics: Adult; Affect; Bipolar Disorder; Cognitive Behavioral Therapy; Female; Humans; Male; Middle Aged; Pilot Projects; Sleep; Sleep Initiation and Maintenance Disorders; Treatment Outcome
PubMed: 25622197
DOI: 10.1037/a0038655 -
Journal of Psychosomatic Research Sep 2002Psychometric evaluation of the Pittsburgh Sleep Quality Index (PSQI) for primary insomnia.
OBJECTIVE
Psychometric evaluation of the Pittsburgh Sleep Quality Index (PSQI) for primary insomnia.
METHODS
The study sample consisted of 80 patients with primary insomnia (DSM-IV). The length of the test-retest interval was either 2 days or several weeks. Validity analyses were calculated for PSQI data and data from sleep diaries, as well as polysomnography. To evaluate the specificity of the PSQI, insomnia patients were compared with a control group of 45 healthy subjects.
RESULTS
In primary insomnia patients, the overall PSQI global score correlation coefficient for test-retest reliability was .87. Validity analyses showed high correlations between PSQI and sleep log data and lower correlations with polysomnography data. A PSQI global score > 5 resulted in a sensitivity of 98.7 and specificity of 84.4 as a marker for sleep disturbances in insomnia patients versus controls.
CONCLUSION
The PSQI has a high test-retest reliability and a good validity for patients with primary insomnia.
Topics: Adult; Female; Humans; Male; Middle Aged; Polysomnography; Psychometrics; Reproducibility of Results; Sleep; Sleep Initiation and Maintenance Disorders; Surveys and Questionnaires
PubMed: 12217446
DOI: 10.1016/s0022-3999(02)00330-6 -
Neurologic Clinics Aug 1996The series of cases presented here should illustrate that the complaint "I can't sleep" is deceptively simple. The clinician must be prepared to gather information from... (Review)
Review
The series of cases presented here should illustrate that the complaint "I can't sleep" is deceptively simple. The clinician must be prepared to gather information from many disparate aspects of the patient's history and present circumstances. Diagnostic considerations are complicated further by the significant night-to-night variation in the manifestations of the insomnia. Too often, the result of this hidden complexity is a tendency either to prescribe hypnotic drugs as a first intervention or to give signals to patients with insomnia that not much can be done and that difficulty sleeping is simply a fact of life. The sleep log can help to bring order to the jumble of insomniac experiences. It leads both the clinician and patient away from assigning too much weight to a specific instance, instead allowing more general patterns to be discerned. As order is created out of the factors contributing to the insomnia, a treatment plan can be designed that goes beyond mere symptomatic treatment.
Topics: Adult; Female; Humans; Male; Middle Aged; Sleep; Sleep Initiation and Maintenance Disorders
PubMed: 8871975
DOI: 10.1016/s0733-8619(05)70272-3 -
Nihon Rinsho. Japanese Journal of... Aug 2009Primary insomnia is relatively common. According to The International Classification of Sleep Disorders, primary insomnia is a syndrome mainly composed of...
Primary insomnia is relatively common. According to The International Classification of Sleep Disorders, primary insomnia is a syndrome mainly composed of psychophysiological insomnia, paradoxical insomnia and idiopathic insomnia. Primary insomnia is difficulty initiating sleep (sleep onset insomnia), difficulty maintaining sleep (mid-sleep awakening, early morning awakening) or chronic non restorative sleep, which persist longer than three weeks despite having adequate opportunity for sleep and result in impaired daytime functioning. Primary insomnia is not explained by currently known psychiatric disorders, medical conditions, substance use disorders. Primary insomnia is a non-organic, unknown etiology, middle-aged female predominant sleep disturbance. Recent findings suggest the hyperarousal hypothesis of primary insomnia. In the near future, non restorative sleep might be excluded from the definition of primary insomnia.
Topics: Female; Humans; Middle Aged; Sleep Initiation and Maintenance Disorders
PubMed: 19768930
DOI: No ID Found -
Journal of Psychosomatic Research Jun 2000To describe and validate the Athens Insomnia Scale (AIS). (Comparative Study)
Comparative Study
OBJECTIVES
To describe and validate the Athens Insomnia Scale (AIS).
METHODS
The AIS is a self-assessment psychometric instrument designed for quantifying sleep difficulty based on the ICD-10 criteria. It consists of eight items: the first five pertain to sleep induction, awakenings during the night, final awakening, total sleep duration, and sleep quality; while the last three refer to well-being, functioning capacity, and sleepiness during the day. Either the entire eight-item scale (AIS-8) or the brief five-item version (AIS-5), which contains only the first five items, can be utilized. The validation of the AIS was based on its administration to 299 subjects: 105 primary insomniacs, 144 psychiatric patients and 50 non-patient controls.
RESULTS
Regarding internal consistency, for both versions of the scale, the Cronbach's alpha was around 0. 90 and the mean item-total correlation coefficient was about 0.70. Moreover, in the factor analysis, the scale emerged as a sole component. The test-retest reliability correlation coefficient was found almost 0.90 at a 1-week interval. As far as external validity is concerned, the correlations of the AIS-8 and AIS-5 with the Sleep Problems Scale were 0.90 and 0.85, respectively.
CONCLUSION
The high measures of consistency, reliability, and validity of the AIS make it an invaluable tool in sleep research and clinical practice.
Topics: Adolescent; Adult; Aged; Comorbidity; Female; Humans; Male; Mental Disorders; Middle Aged; Personality Inventory; Psychiatric Status Rating Scales; Psychometrics; Reproducibility of Results; Sleep Initiation and Maintenance Disorders
PubMed: 11033374
DOI: 10.1016/s0022-3999(00)00095-7