-
The American Journal of Managed Care Mar 2020Insomnia, whether short-term or chronic, is a common condition. It has a negative impact on vulnerable patient groups, including active military personnel and veterans,... (Review)
Review
Insomnia, whether short-term or chronic, is a common condition. It has a negative impact on vulnerable patient groups, including active military personnel and veterans, patients with coexisting psychiatric and medical disorders, those in life transitions such as menopause, and elderly persons. Although cognitive behavioral therapy for insomnia (CBTI) is first-line treatment for insomnia, its high cost and a lack of trained providers has prevented widespread uptake. Now, digital CBTI (dCBTI) is emerging as a scalable option with the potential to overcome these barriers in managed care. The first part of this article reviews the epidemiology and pathophysiology of insomnia with a focus on vulnerable patient groups. The second part explores the rapidly evolving landscape of nondrug therapy for insomnia. The underlying concepts and supporting evidence for CBTI and dCBTI are presented, including their utility in vulnerable patient groups.
Topics: Aged; Cognitive Behavioral Therapy; Female; Humans; Menopause; Military Personnel; Sleep Initiation and Maintenance Disorders; Treatment Outcome; Veterans; Vulnerable Populations
PubMed: 32282177
DOI: 10.37765/ajmc.2020.42769 -
Journal of Clinical Sleep Medicine :... Jun 2018Insomnia remains one of the most common sleep disorders encountered in the geriatric clinic population, frequently characterized by the subjective complaint of... (Review)
Review
BACKGROUND
Insomnia remains one of the most common sleep disorders encountered in the geriatric clinic population, frequently characterized by the subjective complaint of difficulty falling or maintaining sleep, or nonrestorative sleep, producing significant daytime symptoms including difficulty concentrating and mood disturbances.
METHODS
A search of the literature was conducted to review the epidemiology, definition, and age-related changes in sleep, as well as factors contributing to late-life insomnia and scales utilized for the assessment of insomnia in older people. The aim is to summarize recent diagnostic guidelines and both nonpharmacological and pharmacological strategies for the management of insomnia in the older population.
RESULTS
Insomnia remains a clinical diagnosis. There are several demographic, psychosocial, biologic, and behavioral factors that can contribute to late-life insomnia. Older adults are at higher risk for the medical and psychiatric effects of insomnia.
CONCLUSIONS
The most important aspect in evaluation of insomnia is detailed history taking and thorough physical examination. Nonpharmacological treatment options have favorable and enduring benefits compared to pharmacological therapy.
Topics: Aged; Female; Humans; Male; Sleep Initiation and Maintenance Disorders
PubMed: 29852897
DOI: 10.5664/jcsm.7172 -
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 -
The Journal of Family Practice Jul 2023Insomnia is a distinct disorder that is common, yet underrecognized and undertreated in primary care. Treating insomnia has been shown to improve outcomes, including... (Review)
Review
Insomnia is a distinct disorder that is common, yet underrecognized and undertreated in primary care. Treating insomnia has been shown to improve outcomes, including reduced risk of developing cardiovascular and mental health disorders. Insomnia is influenced by the brain's regulation of sleep and wake, which are mutually exclusive events. Insomnia should be treated as a distinct condition, even when occurring with a comorbid diagnosis such as depression or anxiety. Clinicians should implement a multimodal approach to insomnia management, including nonpharmacologic interventions and pharmacologic therapy (when indicated). Pharmacologic agents that are approved by the US Food and Drug Administration for insomnia include benzodiazepine receptor agonists (zolpidem, eszopiclone, and zaleplon), low-dose doxepin (tricyclic antidepressant), ramelteon (melatonin receptor agonist), and dual orexin receptor agonists (DORAs, daridorexant, lemborexant, and suvorexant). Unlike other pharmacologic agents, DORAs inhibit wakefulness rather than induce sedation. Additionally, these medications have no evidence of rebound insomnia or withdrawal, and little to no abuse potential. Daridorexant is the newest DORA, has an ideal half-life of 8 hours, and has demonstrated continued efficacy over a 12-month period. Selection of pharmacologic agent should be based on the patient's comorbid conditions, treatment goals and preferences, and other clinical characteristics.
Topics: Humans; Sleep Initiation and Maintenance Disorders; Sleep; Zolpidem; Doxepin
PubMed: 37549414
DOI: 10.12788/jfp.0620 -
Missouri Medicine 2019Insomnia disorder is an economic burden and public health concern affecting up to one-third of the population of the United States. It is mostly seen in older age... (Review)
Review
Insomnia disorder is an economic burden and public health concern affecting up to one-third of the population of the United States. It is mostly seen in older age groups, and often considered a normal aging phenomenon. The diagnosis and treatment of insomnia rely mainly on a thorough sleep history to address the precipitating factors as well as maladaptive behaviors resulting in poor sleep. It is important for clinicians to recognize and manage the symptoms of insomnia to prevent the morbidity associated with it. This review aims to highlight the pathophysiology, associated comorbidities, clinical evaluation and effective management strategies for insomnia disorder.
Topics: Central Nervous System Depressants; Comorbidity; GABA-A Receptor Agonists; Histamine Agonists; Humans; Hypnotics and Sedatives; Life Style; Muscle Relaxants, Central; Orexin Receptor Antagonists; Risk Factors; Sleep Aids, Pharmaceutical; Sleep Initiation and Maintenance Disorders
PubMed: 30862990
DOI: No ID Found -
Physiological Reviews Jul 2021While insomnia is the second most common mental disorder, progress in our understanding of underlying neurobiological mechanisms has been limited. The present review... (Review)
Review
While insomnia is the second most common mental disorder, progress in our understanding of underlying neurobiological mechanisms has been limited. The present review addresses the definition and prevalence of insomnia and explores its subjective and objective characteristics across the 24-hour day. Subsequently, the review extensively addresses how the vulnerability to develop insomnia is affected by genetic variants, early life stress, major life events, and brain structure and function. Further supported by the clear mental health risks conveyed by insomnia, the integrated findings suggest that the vulnerability to develop insomnia could rather be found in brain circuits regulating emotion and arousal than in circuits involved in circadian and homeostatic sleep regulation. Finally, a testable model is presented. The model proposes that in people with a vulnerability to develop insomnia, the locus coeruleus is more sensitive to-or receives more input from-the salience network and related circuits, even during rapid eye movement sleep, when it should normally be sound asleep. This vulnerability may ignite a downward spiral of insufficient overnight adaptation to distress, resulting in accumulating hyperarousal, which, in turn, impedes restful sleep and moreover increases the risk of other mental health adversity. Sensitized brain circuits are likely to be subjectively experienced as "sleeping with one eye open". The proposed model opens up the possibility for novel intervention studies and animal studies, thus accelerating the ignition of a neuroscience of insomnia, which is direly needed for better treatment.
Topics: Animals; Arousal; Brain; Humans; Sleep; Sleep Initiation and Maintenance Disorders
PubMed: 32790576
DOI: 10.1152/physrev.00046.2019 -
Sleep Medicine Reviews Jun 2018Insomnia disorder is very common in adolescents; it is particularly manifest in older adolescents and girls, with a prevalence comparable to that of other major... (Review)
Review
Insomnia disorder is very common in adolescents; it is particularly manifest in older adolescents and girls, with a prevalence comparable to that of other major psychiatric disorders (e.g., depressive disorders). However, insomnia disorder in adolescence is poorly characterized, under-recognized, under-diagnosed, and under-treated, and the reason for the female preponderance for insomnia that emerges after puberty is largely unknown. Insomnia disorder goes beyond an individual complaint of poor sleep or a sleep state misperception, and there is emerging evidence supporting the association of insomnia symptoms in adolescents with alterations in several bio-systems including functional cortical alterations and systemic inflammation. Insomnia disorder is associated with depression and other psychiatric disorders, and is an independent risk factor for suicidality and substance use in adolescents, raising the possibility that treating insomnia symptoms in early adolescence may reduce risk for these adverse outcomes. Cognitive behavioral treatments have proven efficacy for adolescent insomnia and online methods seem to offer promising cost-effective options. Current evidence indicates that insomnia in adolescence is an independent entity that warrants attention as a public health concern in its own right.
Topics: Adolescent; Cognitive Behavioral Therapy; Depression; Humans; Risk Factors; Sex Factors; Sleep; Sleep Initiation and Maintenance Disorders
PubMed: 28974427
DOI: 10.1016/j.smrv.2017.06.009 -
Neurotherapeutics : the Journal of the... Jan 2021Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs... (Review)
Review
Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.
Topics: Cognitive Behavioral Therapy; Disease Management; Humans; Sleep Initiation and Maintenance Disorders; Treatment Outcome
PubMed: 33821446
DOI: 10.1007/s13311-021-01029-2 -
The Permanente Journal Mar 2023Sleep disorders in older adults increase with aging, likely due to increased sleep latency, decreased sleep efficiency, and total sleep time. Common sleep issues include... (Review)
Review
Sleep disorders in older adults increase with aging, likely due to increased sleep latency, decreased sleep efficiency, and total sleep time. Common sleep issues include chronic insomnia, circadian rhythm sleep-wake disorders, sleep-related movement disorders, and sleep-disordered breathing. Diagnostic tools, such as a comprehensive sleep history and questionnaires, or a sleep log for more specific complaints, are commonly used. Polysomnography is not recommended as a routine test; however, it can be used for abnormal behaviors during sleep or if treatment fails. Sleep disorder management is based on the etiology and may include nonpharmacological and pharmacological alternative treatments. For example, nonpharmacological management for chronic insomnia and some sleep disorders may consist of cognitive behavioral therapy, sleep hygiene education, relaxation therapy, sleep restriction, light therapy, and stimulus control therapy. Because the quality of evidence for pharmacological treatment is poor, the medication choice should be based on shared decision-making between the practitioner and the patient, with limited prescription.
Topics: Humans; Aged; Sleep Initiation and Maintenance Disorders; Sleep; Cognitive Behavioral Therapy; Polysomnography; Sleep Wake Disorders
PubMed: 36503403
DOI: 10.7812/TPP/22.114 -
Sleep Medicine Clinics Jun 2019This article reviews the literature on cognitive-behavioral therapy for insomnia in adults and adolescents with depression. Recent research has expanded on previous... (Review)
Review
This article reviews the literature on cognitive-behavioral therapy for insomnia in adults and adolescents with depression. Recent research has expanded on previous research, which established that sleep problems are an important predictor of depression and that sleep problems are associated with more severe depression, more suicidality, and worse outcomes for treatment of depression. The relationship between sleep problems and depression is complex, likely bidirectional, and impactful. To further improve the lives of patients with depression who experience insomnia, it will be important to investigate which patients will do better in a sequential versus concomitant approach.
Topics: Cognitive Behavioral Therapy; Comorbidity; Depressive Disorder; Humans; Sleep Initiation and Maintenance Disorders
PubMed: 31029185
DOI: 10.1016/j.jsmc.2019.01.009