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Diagnosing, treating chronic insomnia: What PCPs need to know

SAN DIEGO — When diagnosing and treating the sleep disturbed patient, primary care physicians should consider established criteria for chronic insomnia, as well as the patients’ individual underlying cause, according to a presentation at the ACP Internal Medicine Annual Meeting.

“Chronic insomnia is very prevalent,” H. Klar Yaggi, MD, MPH, associate professor of medicine and director of Yale Centers for Sleep Medicine, said during the presentation. “It is one of the most common sleep disorders that we see as clinicians. It affects about 6 to 10% of adults and yet this is underreported to clinicians. Oftentimes, patients don’t report their sleep symptoms, so it is very important for clinicians to ask questions about their sleep.”

Criteria for chronic insomnia

“As sleep clinicians, one of the things we do when we’re evaluating patients is try to determine whether disrupted sleep or sleep symptoms patients are describing fit into categories of insomnias, parasomnias or hypersomnias,” Yaggi said.

The International Classification of Sleep Disorders (ICSD) is a helpful tool in identifying patients with chronic insomnia, according to Yaggi. The classification system notes that patients reporting one or more of the following symptoms suffer from chronic insomnia: difficulty initiating or maintaining sleep, waking up earlier than desired, resistance to going to bed on appropriate schedule and difficulty sleeping without intervention of a caregiver. In relation to sleep difficulty, these patients may also exhibit fatigue and/or malaise; impaired attention, concentration, memory; impaired social, family, occupational and/or academic performance; mood disturbance; daytime sleepiness; hyperactivity, impulsivity and/or aggression; reduced motivation, energy, initiative and/or proneness for errors or accidents; and concerns about dissatisfaction with sleep, according to the ICSD. These systems occur three or more times a week, are present for three or four months and cannot be explained by another sleep disorder, Yaggi said.

Underlying causes of chronic insomnia

Clinicians should also consider “the three P’s” when caring for patients with chronic insomnia: predisposing factors (anxiety, depression, stress and decreased homeostatic sleep drive), precipitating factors (medical or psychiatric illness, use of drugs and stressful life events) and perpetuating factors (counterproductive efforts to solve problems, poor sleep hygiene and psychological conditioning).

In addition, clinicians should be mindful of secondary causes of insomnia that can be easily treatable, including depression, benign prostatic hypertrophy, pain, sleep-disordered breathing (e.g., sleep apnea), sleep-related movement disorders (e.g., restless leg syndrome) and Circadian rhythm disorders (e.g., advanced or delayed sleep phase syndrome), according to Yaggi. Treating these underlying causes of insomnia can significantly improve sleep quality and symptoms in patients, he said.

Recommendations for treating chronic insomnia

“The goals of insomnia treatment are to improve sleep quality and quantity and improve the insomnia-related daytime impairments,” Yaggi said. “This should be patient centered and targeted to each patient by focusing on their functional consequences of insomnia — their own underlying predisposing conditions, their medical and psychiatric history, as well as any comorbid conditions.”

The risks and benefits of various insomnia treatments should be discussed with each patient, he added.

Yaggi noted ACP’s clinical practice guideline for the management of chronic insomnia which includes two essential recommendations:

• All adult patients with chronic insomnia should receive cognitive behavioral therapy as the initial treatment.
• Clinicians should use a shared approach in deciding whether to incorporate pharmacological therapy in adults for whom cognitive behavioral therapy was not successful.

According to Yaggi, cognitive behavioral therapy typically involves a number of sessions that focuses on several components, including:

• Educating the patient on the underlying causes of sleep,
• restricting sleep by reducing the amount of time spent awake in bed and regularizing the patient’s sleep schedule in order to increase the sleep drive,
• eliminating the relationship between bedroom and arousal and strengthening the relationship between the bed and sleep,
• employing sleep hygiene techniques by correcting behavioral and lifestyle factors impacting sleep quality (reducing naps and using bright light therapy),
• implementing cognitive therapy to correct inaccurate or maladaptive beliefs about sleep, and
• relaxation therapy.

Studies assessing cognitive behavioral therapy have shown improvements in sleep outcomes, including the quality and patterns of sleep, as well as sleep satisfaction and efficiency, he said. In addition, distress associated with sleep difficulties, time to fall asleep and time awake during the night also improved, he said. Yaggi noted that these improvements tend to last six to 12 months, have minimal adverse effects and are oftentimes generalizable to other disorders, such as anxiety and depression. While there are a variety of delivery methods (individual, group, telephone, telemedicine, web-based, self-help books) that have shown benefit for sleep in patients with chronic insomnia, cognitive behavioral therapy can be difficult to obtain, he said. There is often a lag-time of approximately five to eight weeks between initiation and its effect to commence, he added.

In contrast, pharmacologic therapies act quite immediately, he said. FDA-approved insomnia medications include benzodiazepines, nonbenzodiazepines, ramelteon, doxepin and suvorexant, he noted. However, there are significant safety concerns for some of these medications, potentially causing daytime drowsiness, memory and psychomotor impairment and depression and suicidal thoughts, he said. Over-the-counter antihistamines and herbal and nutritional substances should be avoided, as there is a lack of efficacy and safety data and no FDA oversight, according to Yaggi.

“We should encourage our patients to have an open mind about [cognitive behavioral therapy] because it is truly quite effective,” he said. When cognitive behavioral therapy alone is not successful, clinicians should consider medication, he added.

“Areas in need of further study include examining cognitive behavioral therapy and pharmacologic agents in patients with more medical comorbidities who have insomnia and the efficacy novel ways to administer cognitive behavioral therapy,” Yaggi concluded. – by Alaina Tedesco

Reference:

Yaggi HK. MTP 099: I Didn’t Sleep at All Last Night: The Sleep-Disturbed Patient. Presented at: ACP Internal Medicine Annual Meeting; March 29-April 1, 2017; San Diego.

Disclosure: Yaggi reports no relevant financial disclosures.