Transcript 9-14 Wichita_Martinez insomnia_9-11

Insomnia
Maria D. Martinez, M.D., M.P.H.
St. Joseph’s Hospital and Medical
Center, Phoenix, Ariz.
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Learning objectives
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At the end of the session, the participant should
be able to:
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Discuss the etiologies of insomnia
Explain the importance and details of behavioral
therapy for insomnia
Help patients understand the respective roles of
behavioral and pharmacologic therapies for insomnia
Understand the limitations and adverse effects of
pharmacologic therapy
Prescribe appropriate interventions, both behavioral
and pharmacologic
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Audience Response Question
According to the National Sleep Foundation
what percentage of respondents suffered
frequent insomnia?
A.
B.
C.
D.
E.
1%
10%
25%
50%
90%
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Insomnia Prevalence
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40-70 million intermittent or chronic
20% population
Sleep in America poll (National Sleep
Foundation)
50% had frequent insomnia
 6% were formally diagnosed
 30-35% complained of nightly insomnia
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Agency for Health Care Research and Quality, NIH. Manifestations and
management of chronic insomnia in adults. June 2005.
http://www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf
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Costs of Insomnia
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Is the most common reported sleep
problem in the U.S. and industrialized
nations worldwide (Evaluation of chronic insomnia. Sleep
2000;23:1-66.)
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In1995, $13.9 billion were spent on
insomnia (Walsh JK, Engelhart CL. Sleep 1999;22:S386-93.)
Direct vs indirect
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Insomnia Costs (contd.)
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Leger D, et al., 2002
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Direct costs
SI vs GS (53% vs 4%) visited a doctor
 SI averaged 1.17 visits vs 0.2 visits to an MD
 Medications 28% vs 4%
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Indirect costs
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Health care costs
More medications for CV, CNS, urogenital, and
gastrointestinal
 More blood work and radiologic studies
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Insomnia Costs (contd.)
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Indirect costs
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Work related costs
Greater absenteeism due to illness
 Errors 15% SI vs 6% GS which could have
resulted in serious consequences
 Late to work 12% vs 6%
 Poor efficiency 13% vs 9%
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Accidents
Industrial more common
 Car accidents – annual incidence not statistically
different
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Insomnia Costs (contd.)
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Indirect costs
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Decreased sleep time and sleeping pills increased mortality (Kripke D, et al. Arch Gen Psychiatry
2002;59(2):131.)
Reports of “insomnia” not associated with
excess mortality
 Causality is unproven
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Risk Factors
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Aging
Female sex
Psychiatric disorders
Medical comorbidities
Ramakrishnan K, Scheid DC. Treatment options for
insomnia. Am Fam Physician 2007;76:517-26, 527-8.
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Risk Factors
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Impaired social relationships
Lower socioeconomic status
Unemployment
Separation from spouse or partner
Ramakrishnan K, Scheid DC. Treatment options for
insomnia. Am Fam Physician 2007;76:517-26, 527-8.
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What Exactly Is Insomnia?
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Insomnia Definition
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Complaint of difficulty initiating sleep,
difficulty maintaining sleep, waking up too
early, or sleep that is chronically
nonrestorative or poor in quality.
(International classification of sleep disorders: diagnostic and coding
manual, 2nd ed. Westchester, Ill.: AASM, 2005.)
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Types of Insomnia
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Three main types
Sleep onset
 Sleep maintenance
 Early awakenings
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Axis I
Type: Insomnia, Dyssomnia, or Parasomnia
Axis II Primary or Secondary
IIa Acute vs Chronic
Axis III Associated disorders
IIIa Psychiatric or psychological vs medical
Axis IV Onset: Wake-after-sleep-onset, or early
awakening
Axis V Dysfunction: Day, Night, or Both
Candaras MM. Sleep Review 2006;7:38.
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Research Diagnostic Criteria for
Insomnia Disorder
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One or more of the following:
Difficulty initiating
 Difficulty maintaining
 Early awakenings
 Sleep that is chronically nonrestorative
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Research Diagnostic Criteria for
Insomnia Disorder
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At least one of the following forms of
daytime impairment related to the
nighttime sleep difficulty is reported by the
individual:
1. Fatigue/malaise
 2. Attention, concentration, or memory
impairment
 3. Social/vocational dysfunction or poor
school performance
 4. Mood disturbance/irritability
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Research Diagnostic Criteria for
Insomnia Disorder
5. Daytime sleepiness
 6. Motivation/energy/initiative reduction
 7. Prone to errors/accidents at work or while
driving
 8. Tension headaches and/or GI symptoms in
response to sleep loss; and
 9. Concerns or worries about sleep.
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Primary vs Secondary
Acute vs Chronic
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Primary acute insomnia is very rare
15-20% of chronic insomnia is primary
(Med Clin North Am 2004;88:567.)
Drugs
 Medical illnesses
 Psych illnesses
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Causes of Chronic Insomnia
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Medical disorders
Medications
Primary sleep disorders
Psychiatric disorders
Sleep-wake cycle disorders
Substance abuse
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Causes of Chronic Insomnia
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Medical disorders
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Pain
Chronic pain
 Cancer
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GERD
 Nocturia due to benign prostatic hypertrophy
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Audience Response Question
The most common cause of insomnia is
which one of the following?
A.
B.
C.
D.
E.
Gastroesophageal disorder
Pain
Mental disorders
Prostatic hypertrophy
Obstructive sleep apnea
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Causes of Chronic Insomnia
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Mental disorders
The most common diagnosis (Sleep 17;(7):630.)
 Major depressive disorder
 Anxiety
 Dysthymic disorder
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Causes of Chronic Insomnia
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Obstructive sleep apnea
Restless leg syndrome/periodic limb
movement disorder
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Causes of Chronic Insomnia
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Medications
Bronchodilators
 Steroids
 Stimulants
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Modafinil
 Dextroamphetamine
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Causes of Chronic Insomnia
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Medications
Beta blockers
 Antidepressants
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Bupropion
 Protriptyline
 Fluoxetine
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Causes of Chronic Insomnia
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Substance abuse
Caffeine
 Alcohol
 Drug withdrawal
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Management
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Pharmacologic
Nonpharmacologic
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Nonpharmacologic
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Stimulus-control therapy
Sleep-restriction therapy
Relaxation therapy
Cognitive therapy
Sleep-hygiene education
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Nonpharmacologic
Stimulus-Control Therapy
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Assumes maladaptive response
Get into bed only when sleepy
If not asleep within 15-20 minutes, get out
of bed
Get up at the same time every day
Avoid napping
J Clin Psychiatry 1992;53(Suppl 6):37.
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Nonpharmacologic
Sleep-Restriction Therapy
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People with insomnia can learn to increase
their sleep time by inducing temporary sleep
deprivation through voluntarily reducing time
in bed
Allows a light sleep debt
Increases ability to sleep
Time in bed is increased gradually
Sleep 1987;10:45.
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Nonpharmacologic
Relaxation Therapy
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Hypothesis that insomnia is associated
with hyperarousal
Encompasses many different approaches
to accomplish same goal
Physical component:
Progressive muscle relaxation
 Biofeedback
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Nonpharmacologic
Relaxation Therapy
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Progressive muscle relaxation
Used for many years
 Developed by Edmund Jacobsen in 1930s
 Taught to systematically relax each part of the
body until the entire body is relaxed
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Nonpharmacologic
Relaxation Therapy
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Mental component:
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Imagery training, meditation, hypnosis
Deep breathing – relaxed
 Specific scene visualized
 More useful for patients who have cognitive
arousal
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Nonpharmacologic
Cognitive Therapy
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Education to alter faulty beliefs about
sleep
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Audience Response Question
Which of the following modalities is not
sufficient, by itself, to treat insomnia?
A.
B.
C.
D.
E.
Stimulus control therapy
Sleep relaxation therapy
Cognitive therapy
Relaxation therapy
Sleep hygiene education
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Nonpharmacologic
Sleep-Hygiene Education
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Correct extrinsic factors affecting sleep
30% of patients have inadequate sleep
Should be evaluated in all insomnia patients
Presence of at least one of the following:
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Improper sleep scheduling
Routine use of alcohol, nicotine, or caffeine
Mentally stimulating activity
Use bed for activities other than sleep or sex
Unable to maintain comfortable sleeping environment
Chest 2006;130;276-286.
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Nonpharmacologic Treatment
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Morin CM, et al. Sleep 1999;22:1134
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Holbrook, et al. CMAJ 2000;152:216
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Smith MT, et al. AM J Psychiatry
2002;159:5
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Vincent N, et al. Sleep 2001;24:411
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Nonpharmacologic Treatment
AASM Practice Parameters
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Chronic primary insomnia: Psychological
and behavioral interventions are effective
and recommended
Secondary insomnia: Psychological and
behavioral interventions are effective and
recommended
Sleep 2006;29:1415.
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Nonpharmacologic Treatment
AASM Practice Parameters
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Individual therapies – chronic insomnia
Stimulus control
 Relaxation training
 Cognitive behavior therapy with or without
 Sleep restriction - guideline
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Sleep 2006;29:1415.
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Pharmacologic Treatment
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Herbal and dietary supplements
Insufficient evidence
 Melatonin
 Valerian
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Pharmacologic Treatment
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Melatonin
Produced by pineal gland
 Circadian schedule alterations (jet lag)
 Higher doses cause sleep disruption
 Exogenous melatonin has hypnotic properties
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(Sleep 2006;29(5):609.)
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Valerian root
Inhibits breakdown of gama-aminobutyric acid
 Not much evidence
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Audience Response Question
Which of the following medications is a
selective melatonin receptor agonist?
A.
B.
C.
D.
E.
Ramelteon
Temazepam
Clonazepam
Zolpidem
Eszopiclone
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Pharmacologic Treatment
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Ramelteon (Rozerem)
Selective melatonin receptor agonist - MT1
and MT2 receptors
 Low likelyhood of abuse
 Only non-scheduled drug for insomnia
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Audience Response Question
Which one of the following benzodiazepines
has a rapid onset and a short duration of
action?
A.
B.
C.
D.
E.
Diazepam
Estazolam
Flurazepam
Triazolam
Oxazepam
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Pharmacologic Treatment
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Benzodiazepines
Temazepam (Restoril)
 Flurazepam (Dalmane)
 Triazolam (Halcion)
 Estazolam
 Lorazepam (Ativan)
 Clonazepam (Klonopin)
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Audience Response Question
Patients taking benzodiazepines are at a
higher risk of which one of the following?
A.
B.
C.
D.
E.
Motor vehicle accidents
Falls and fractures
Cognitive impairments
None of the above
A, B, and C
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Pharmacologic Treatment
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Nonbenzodiazepines - interact with benzo
receptor
Zolpidem (Ambien)
 Zaleplon (Sonata)
 Eszopiclone (Lunesta)
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Approved for long-term treatment
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Pharmacologic Treatment
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Antidepressants
Amitriptyline
 Trazodone (Desyrel)
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Antihistamines
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Conclusions
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Insomnia is common and frequently goes
undiagnosed.
Although primary chronic insomnia is not
rare, underlying causes are more
common.
Behavioral therapies actually help patients
with insomnia and are recommended to
treat such individuals.
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