Taylor DJ; Mallory LJ; Lichstein KL et al. Comorbidity of chronic insomnia with medical problems. SLEEP 2007;30(2):213-218.
NEED TO GET THIS PAPER--WHY ARE THE RED BARS DIFFERENT, IF THIS IS THE NO HEALTH PROBLEM GROUP? WOULD IT BE BETTER TO DEPICT THIS DIFFERENTLY IF THE COMPARATOR GROUP IS ALWAYS THE SAME, LIKE WITH A LINE AND THEN ONLY ONE BAR PER DISORDER?
ARE THERE ANY STATISTICS FOR THESE DATA, TO SHOW WHETHER THESE BARS SHOW SIGNIFICANT DIFFERENCES? Sleep Problems and Multiple Medical Conditions The objective of the study undertaken by Foley and colleagues was to assess the association between sleep problems and chronic disease in older adults. A majority of the participants (83%) reported 1 or more of 11 medical conditions and nearly 1 in 4 elderly respondents (age 65–84 years) had major comorbidity (ie, 4 conditions). As shown on the slide, there was a correlation between reports of insomnia and the number of medical conditions reported. Depression, heart disease, bodily pain, and memory problems were associated with more prevalent symptoms of insomnia (not shown). The authors concluded that the sleep complaints common in older adults are often secondary to their comorbidities and not to the aging process itself. Furthermore, the authors suggest that these types of studies may be useful in promoting sleep awareness among health professionals and among older adults, especially those with heart disease, depression, chronic bodily pain, or major comorbidity. Foley D, et al. J Psychosomatic Res . 2004;56:497-502.
WHAT ABOUT GROUPING THE MEDICAL VS PSYCHIATRIC COMORBIDITES VS. NO COMORBITIES, SINCE THIS TALK IS ABOUT COMORBIDITIES IN GEN? How’s this, Ruth? Rerendered deemphasizing all but psych comorbidities
AS LONG AS THE NUMBERS REPRESENT THE SAME THING, IT IS PROBABLY OK. HOWEVER, I’D INDICATE ON THE SLIDE THAT THE BRESLAU STUDY REPRESENTS LIFETIME RISK IN YOUNG ADULTS, WHEREAS THE FORD AND KAMEROW IS PREVALENCE DATA OVER A 6 MOS PERIOD IN ADULTS (VERIFY FOR BOTH, PLS). Ruth, part of me thinks I’m possibly violating some kind of thermodynamic statistical laws by doing this, but I thought it would be a good way to condense the data from both papers and provide a snapshot. Calling it “relative risk” sort of crosses over the causation-correlation line, though, doesn’t it? Unless there’s something else you can call a RR graph that isn’t “relative risk.” I made standard RR calculations to make this graph, but I’m not sure it’s “legal.” Considering that this graph contains data from two papers, I think it’d be a good idea to include the full references at the bottom of the slide, too?
What about creating a single, new slide regarding the predictive value of insomnia for psychiatric disorders and put data from several studies on there? Could then list a bunch of the key studies, with the points that insomnia most highly predictive of new or recurrent mood episode, but also predictive of onset of other psych disorders (could specify and reference) Ruth: do you mean include the Breslau paper (1996) and the relapse stuff from this same (Ohayon and Roth) paper? Not quite sure what you want here; if you want a lot of information like this, you’re talking about a table or bullets, right? Not a graph?
FINE TO INCLUDE THE SUICIDE DATA FOR THE TWO GROUPS, PERHAPS IN THE LEGEND, IN A COLUMN AFTER “CASES” Ruth: if you mention the 13 suicides in here, maybe we can ditch slide 17 (suicidal ideation) Key point: Insomnia is a risk factor for long-term psychiatric distress. Notes : The Johns Hopkins Precursors Study, a long-term prospective study, was used to study the relation between self-reported sleep disturbances and subsequent clinical depression and psychiatric distress. 1,053 men provided information on sleep habits during medical school at The Johns Hopkins University (classes of 1948-1964) and have been followed since graduation. During a median follow-up period of 34 years (range 1-45), 101 men developed clinical depression (cumulative incidence at 40 years, 12.2%), including 13 suicides. After adjusting for multiple variables, relative risk (RR) of clinical depression was greater in those who reported insomnia in medical school (RR 2.0, 95% CI 1.2-3.3) compared with those who did not and greater in those with difficulty sleeping under stress in medical school (RR 1.8, 95% CI 1.2-2.7) compared with those who did not report difficulty. Similar associations were observed between reports of sleep disturbances in medical school and psychiatric distress assessed in 1988 by the General Health Questionnaire. These findings suggest that insomnia in young men is indicative of a greater risk for subsequent clinical depression and psychiatric distress that persists for at least 30 years. [Chang, p. 105, abstract; graph from p. 110, Figure 1 a, top of page] Reference : Chang PP, Ford DE, Mead LA, Cooper-Patrick L, Klag MJ. Am J Epidemiol . 1997 Jul 15;146(2):105-114.
Ruth: this is kind of like the preceding slide; going for your “leitmotif request”
MAKE SURE THIS IS REFORMATTED SIGNIFICANTLY FROM WHAT I SENT--SOMEONE GAVE IT TO ME.
PERHAPS FORMAT THIS ONE AND THE PREVIOUS SLIDE SIMILARLY
Something doesn’t look right here. All of the graphs are identical. Perhaps something could be done combining this with the data from the prev slide. Ruth: Your comment alarmed me, since this was a slide I had taken from a program I made for Tom! I went back and checked, though; these are the correct data (Ohayon 2005); data are extremely close to each other. Ohayon MM. Relationship between chronic painful physical condition and insomnia. J Psychiatr Res . 2005 Mar;39(2):151-159
FIRST BULLET--BUT ARE THESE RATES HIGHER THAN OTHER MEDICAL DISORDERS? WHAT IS THE EVIDENCE FOR A SPECIAL ASSOCIATION BETWEEN CANCER AND INSOMNIA?
v1 I AGREE, WHERE DOES THE ABSENCE OF REG ETOH USE COME FROM? DO YOU HAVE THIS ARTICLE? Ruth: Desaturation Index. Also, is “absence of regular alcohol use” correct? It seems counterintuitive to me?
v1 SHOULD INDICATE WHICH PAPER GOES WITH WHICH DATA
PLS USE A BLACK LINE WITH END BARS TO SHOW THE CI’S Ruth: redone to your specs Key point: Insomnia has been demonstrated to be associated with an increased risk of hypertension. Notes : A recent study has shown insomnia to be significantly associated with a risk for the development of hypertension in Japanese men. 9237 male Japanese workers were assessed for insomnia (difficulty initiating sleep and difficulty maintaining sleep) and followed up for four years or until the development of hypertension. Subjects with persistent difficulty initiating sleep (n=192) were significantly more likely to develop hypertension than subjects with no difficulty initiating sleep (n=4602). Incidence of hypertension in the subjects with persistent difficulty initiating sleep was 40.1% (130.7/1000 person-years) as compared with subjects with no difficulty initiating sleep (30.6%, 89.9/1000 person years). Subjects with persistent difficulty maintaining sleep (n=286) were significantly more likely to develop hypertension than subjects with no difficulty initiating sleep (n=4157). Incidence of hypertension in the subjects with persistent difficulty initiating sleep was 42.3% (136.7/1000 person-years) as compared with subjects with no difficulty initiating sleep (30.7%, 90.8/1000 person years). After adjusting for BMI, tobacco and alcohol use, and job stress, persistent complaints of both persistent difficulty in initiating and maintaining sleep were significantly associated with an increased risk of hypertension (OR=1.96 and 1.88, respectively). [Suka p 344 c1 abstract] Reference : Suka M, Yoshida K, Sugimori H. Persistent insomnia is a predictor of hypertension in Japanese male workers. J Occup Health . 2003 Nov;45(6):344-350.
NHANES information; ALL of the confounders are listed below. Hazard Ratio. Sleep duration and increased risk of HTN in subjects 32-59y; adjusted for daytime sleepiness, depression, physical activity, alcohol and salt consumption, smoking, pulse rate, gender, education, age, ethnicity overweight/obesity, and diabetes. Gangwisch 2006 Hypertension 2006;47;833-839; originally published online Apr 3, 2006; Dolores Malaspina Buijs, Felix Kreier, Thomas G. Pickering, Andrew G. Rundle, Gary K. Zammit and James E. Gangwisch, Steven B. Heymsfield, Bernadette Boden-Albala, Ruud M. National Health and Nutrition Examination Survey Short Sleep Duration as a Risk Factor for Hypertension: Analyses of the First Sleep durations of 5 hours per night were associated with a significantly increased risk of hypertension (hazard ratio, 2.10; 95% CI, 1.58 to 2.79) in subjects between the ages of 32 and 59 years, and controlling for the potential confounding variables only partially attenuated this relationship. The increased risk continued to be significant after controlling for obesity and diabetes, which was consistent with the hypothesis that these variables would act as partial mediators. Short sleep duration could, therefore, be a significant risk factor for hypertension. ] Gottlieb DJ; Redline S; Nieto FJ et al. Association of usual sleep duration with hypertension: the sleep heart health study. SLEEP 2006;29(8):1009-1014 Sleep duration above or below the median of 7 to < 8 hours/night is associated with an increased prevalence of hypertension,
IS THIS REALLY SLEEP DISORDERS OR REDUCED SLEEP TIME, AS MAY OCCUR IN INSOMNIA? ALSO, SHOULD THE CIRCLE IN THE MIDDLE BE REDUCED SLEEP WITH ARROWS POINTING OUT TO THE INDIVIDUAL BOXES, WHICH ARE THE EFFECTS? Ruth, this is new; sort of an obesity-insomnia lit review References: The association between sleep duration, body mass index and metabolic measures in the Hordaland Health Study. Bjorvatn B, Sagen IM, Oyane N, Waage S, Fetveit A, Pallesen S, Ursin R. J Sleep Res . 2007 Mar;16(1):66-76. Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway. email@example.com Several studies show that short self-reported sleep duration is associated with elevated body mass index (BMI). Short sleep duration may change appetite hormones, but whether this also influences metabolic measures like cholesterol and triglycerides is less clear. Furthermore, obesity is linked to increases in blood pressure, and recently, short sleep duration has been shown to be an independent risk factor for hypertension. This is a population-based cross-sectional study (The Hordaland Health Study). A subgroup of 8860 subjects, aged 40-45 years, answered a sleep questionnaire. Body weight, height and blood pressure were measured, and non-fasting blood samples were collected and analyzed for total cholesterol, HDL-cholesterol and triglycerides. Sleep duration was divided into the following subgroups: < 5, 5-5.99, 6-6.99, 7-7.99, 8-8.99 and > or = 9 h. The results show that short sleep duration was associated with elevated BMI and increased prevalence of obesity. Similar to BMI, levels of cholesterol, triglycerides, systolic and diastolic blood pressure were higher in subjects with short sleep duration. This co-variation seemed to be attributed to variables like gender, smoking and BMI. In conclusion, our study confirms a clear association between short sleep duration and elevated BMI and obesity. Furthermore, levels of total cholesterol, HDL-cholesterol, triglycerides and blood pressure were associated with sleep duration. Flint J, Kothare SV, Zihlif M, Suarez E, Adams R, Legido A, De Luca F. Association between inadequate sleep and insulin resistance in obese children. J Pediatr . 2007 Apr;150(4):364-9. Chaput JP, Despres JP, Bouchard C, Tremblay A. Short sleep duration is associated with reduced leptin levels and increased adiposity: Results from the Quebec family study. Obesity (Silver Spring) . 2007 Jan;15(1):253-61. Gottlieb et al. Arch Intern Med . 2005;165:863-868 Association of sleep time with diabetes mellitus and impaired glucose tolerance. Gottlieb DJ, Punjabi NM, Newman AB, Resnick HE, Redline S, Baldwin CM, Nieto FJ. Arch Intern Med . 2005 Apr 25;165(8):863-7.
I added your sleep hygiene slide since you listed it in the previous “Management of insomnia” slide
SMEI 10/18/10 12:45 Optional Slides
Put the first bullet last, as a caveat
Ruth: This OK? I LIKE THE IDEA. PERHAPS MORE COLORFUL SOMEHOW, AND HAVE THE TEETER-TOTTER MORE ANGLED UP TO THE RIGHT? Have a slide that introduces next group, which is that Rx of insomnia seems to improve comorbid conditions.
Discuss up-state/down-state EEG vs. LFP issue?
Discuss up-state/down-state EEG vs. LFP issue?
Ruth Benca, MD PhD Wisconsin Sleep Insomnia and Primary Care
sleep that is chronically nonrestorative or poor in quality
Sleep difficulty occurs despite adequate opportunity and circumstances for sleep.
Insomnia is not sleep deprivation, but the two may coexist.
Insomnia defined American Academy of Sleep Medicine. International classification of sleep disorders, 2nd ed.: Diagnostic and coding manual. Westchester, Illinois: American Academy of Sleep Medicine, 2005.
At least one daytime impairment related to the nighttime sleep difficulty must be present:
Attention, concentration, or memory impairment
Social/vocational dysfunction or poor school performance
Proneness for errors/accident at work or while driving
Tension headaches, and/or GI symptoms in response to sleep loss
Concerns or worries about sleep
Insomnia must be associated with daytime impairment American Academy of Sleep Medicine. International classification of sleep disorders, 2nd ed.: Diagnostic and coding manual. Westchester, Illinois: American Academy of Sleep Medicine, 2005.
Impacts quality of life and worsens clinical outcomes 1,2
Predisposes patients to recurrence 3
May continue despite treatment of the primary condition 4
“ Comorbid insomnia” more appropriate than “secondary insomnia,” because limited understanding of mechanistic pathways in chronic insomnia precludes drawing firm conclusions about the nature of these associations or direction of causality. Considering insomnia to be “secondary” may also result in undertreatment. 5
1 Roth T, Ancoli-Israel S. Sleep . 1999;22:S354-S358. 2 Katz DA, McHorney CA. J Fam Pract . 2002;51:229-235. 3 Chang PP, et al. Am J Epidemiol . 1997;146:105-114. 4 Ohayon MM, Roth T. Psychiatr Res . 2003;37:9-15. 5 National Institutes of Health State of the Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. National Institutes of Health. Sleep . 2005 Sep 1;28(9):1049-1057.
Increased prevalence of medical disorders in those with insomnia Taylor DJ., et al. Sleep. 2007;30(2):213-218 . p values are for Odds Ratios adjusted for depression, anxiety, and sleep disorder symptoms. From a community-based population of 772 men and women, aged 20 to 98 years old. Heart Disease Cancer HTN Neuro-logic Breath-ing Urinary Diabetes Chronic Pain GI Any medical problem % N=137 N=401 p <.05 p <.05 p <.01 p <.01 p <.001 p <.001 p <.001 p <.001
Increased prevalence of insomnia in those with medical disorders Prevalence, % Survey Of Adults (N=2101) Living In Tucson, Arizona, Assessed Via Self-administered Questionnaires * * ** * * Klink ME et al. Arch Intern Med . 1992;152:1634-1637. * P ≤ .001, ** P ≤ .005 vs. no health problem ASVD, arteriosclerotic vascular disease; OAD, obstructive airway disease.
Insomnia prevalence increases with greater medical comorbidity Foley D, et al. J Psychosom Res . 2004;56:497-502. Self-reported questionnaire data from 1506 community-dwelling subjects aged 55 to 84 years 80 Number of Medical Conditions 0 10 20 30 40 50 60 70 Percent of Respondents Reporting any Insomnia 0 1 2 or 3 4
Psychiatric disorder is the most common condition comorbid with insomnia Adjustment disorder (2%) Anxiety disorder (24%) Bipolar disorder (2%) Depressive disorder (8%) Psychiatric Disorders (36%) Other DSM-IV Distribution of Insomnia(64%) No DSM-IV diagnosis (24%) Other sleep disorders (5%) Insomnia due to a general medical condition (7%) Substance-induced insomnia (2%) Insomnia related to another mental disorder (10%) Primary insomnia (16%) Ohayon MM. Sleep Med Rev . 2002;6:97-111. N=20,536. European meta-analysis
Relative risk for psychiatric disorders associated with insomnia 1 Breslau N, et al. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry . 1996;39:411-418. 2 Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA . 1989;262(11):1479-1484. 1 Breslau, 1996. N=1007 2 Ford and Kamerow, 1989. N=811 1 1 1 2 2 1,2 1,2 1,2 1,2
Timing of insomnia related to onset of psychiatric illness Ohayon MM , Roth T. J Psychosom Res . 2003;37:9-15. N=14,915
Insomnia is a risk factor for later-life depression * Number of men included at each time point. Chang P et al. Am J Epidemiol . 1997;146:105-114. Insomnia* Yes 137 135 133 127 117 106 99 27 9 No 887 877 859 838 799 740 616 382 216 Cumulative Incidence (%) Yes No Total Cases 137 23 887 76 Insomnia P =.0005 Follow-up Time (Years) 0 5 10 15 20 25 30 35 40 0 5 10 15 20 25 30 35 40
Objective sleep abnormalities are seen in psychiatric patients Comparison of sleep EEG in groups of patients with psychiatric disorders or insomnia to age-matched normal controls. Benca RM et al. Arch Gen Psych . 1992;49:651-668 TST SE SL SWS REM L Mood Alcoholism Anxiety Disorders Schizophrenia Insomnia
Bidirectional relationship between psychiatric disorders and insomnia ACTH, adrenocorticotropic hormone TST, total sleep time SOL, sleep onset latency SWS, slow wave sleep
Peri- and postmenopausal women have more sleep complaints 1
41% of early perimenopausal women report sleep difficulties 2
Frequent awakenings suggest insomnia is secondary to vasomotor symptoms 3
However, waking episodes may occur in absence of hot flashes 4
1 Young T, et al. Sleep . 2003;26:667-672. 2 Gold E, et al. Am J Epidemiol . 2000;152:463-473. 3 Woodward S, Freedman RR. Sleep .1994;17:497-501. 4 Polo-Kantola P, et al. Obstet Gynecol . 1999;94:219-224.
Complaints of sleep problems with age Age Group, y 50 40 30 20 10 0 Percent 10-19 20-29 30-39 40-49 50-59 60-69 70+ “ Trouble With Sleeping” Assessed in a comprehensive survey of 1645 individuals in Alachua County, Florida Karacan I et al. Soc Sci Med . 1976;10:239-244.
Prevalence of insomnia by age group % Age Group, years Large-scale community survey of non-institutionalized American adults, aged 18 to 79 years Mellenger GD, et al. Arch Gen Psychiatry . 1985;42:225-232.
McCracken LM, Iverson GL. Pain Res Manag . 2002;7:75-79.
Insomnia comorbid with pain N=18,980; p <.001. Based on survey data. *Pain categories included limb pain, backaches, joint pain, GI pain, and headaches. Ohayon MM. J Psychiatr Res . 2005 Mar;39(2):151-159. Control Any pain* %
Bidirectional relationship between pain and insomnia DIS, difficulty initiating sleep DMS, difficulty maintaining sleep
Bidirectional relationship between insomnia and cancer SDB, sleep-disordered breathing Fiorentino L, Ancoli-Israel, S. Sleep dysfunction in patients with cancer. Curr Treat Opt Neurol. 2007;9:337–346.
Eg, depression, smoking, orthopnea, and nocturnal hypoxemia
Suggests multiple factors in pathogenesis of insomnia in COPD
Insomnia can impair pulmonary function
Spirometric decline is observed after one night of sleep deprivation
Despite importance of treating the underlying COPD, this may not lead to improvement of insomnia in clinical practice
Cormick W, et al. Thorax . 1986;41:846-854. Kutty K. Curr Opin Pulm Med. 2004;10:104-112. Maggia S, et al. J Am Geriatric Soc. 1998;46:161-168. Phillips BA, et al. Chest . 1987;91:29-32. Wetter DW, et al. Prev Med. 1994;23:328-334.
Insomnia may be a predictor of hypertension N=9237 male Japanese workers assessed for difficulty initiating and/or maintaining sleep and followed up for 4 years or until the development of HTN (initiation of anti-HTN therapy or a SBP of ≥140 mmHg or a DBP of ≥140 mmHg). Results adjusted for BMI, tobacco and alcohol use and job stress. Suka M, et al. J Occup Health . 2003;45:344-350. HTN Incidence (%) n=4602 n=192 n=4157 n=286 95% CI: 1.42-2.70 95% CI: 1.45-2.45
Short sleep duration and hypertension: NHANES I and the Sleep Heart Health Study Gangwisch et al. Hypertension. 2006;47:833-839. Gottlieb DJ, et al. Sleep . 2006;29(8):1009-1014. ≤ 5h 6h 7-8h ≥ 9h ≤ 6h 6-7h 7-8h 8-9h ≥ 9h (1.0; referent) (1.0; referent) Hazard Ratios. N=4180. Subjects 32-59y. Sleep duration and increased risk of HTN, adjusted for multiple confounders including physical activity, alcohol/salt consumption, smoking, age, overweight/obesity, and diabetes. Odds Ratios . N=5910. Subjects 40-100y. Sleep duration and increased risk of HTN adjusted for age, sex, race, apnea-hypopnea index and BMI.
Relationships between sleep disorders* and obesity * Insomnia or sleep deprivation. 1 Bjorvatn B, et al. J Sleep Res . 2007;16(1):66-76. 2 Flint J, et al. J Pediatr . 2007;150(4):364-369. 3 Chaput JP, et al. Obesity (Silver Spring) . 2007;15(1):253-261. 4 Gottlieb et al. Arch Intern Med . 2005;165:863-868. Factors associated with reduced sleep time* may contribute to obesity
use of stimulants, eg, caffeine, nicotine, particularly near bedtime 1,3
heavy meals or drinking alcohol within 3 hours of bed 1
exposure to bright light during the night 1,3
Enhance sleep environment: dark, quiet, cool temperature 1,3
Increase exposure to bright light during the day 2
Practice relaxing routine 1-3
Reduce time in bed; regular sleep/wake cycle 1-3
Time regular exercise for the morning and/or afternoon 1,3
1 NHLBI Working Group on Insomnia. 1998. NIH Publication . 98-4088. 2 Kupfer DJ, Reynolds CF. N Engl J Med . 1997;336:341-346. 3 Lippmann S et al. South Med J . 2001;94:866-873.
Behavioral techniques Technique Aim Stimulus control therapy Imprint bed and bedroom as sleep stimulus Sleep restriction Restrict actual time spent in bed to enhance sleep depth & consolidation Cognitive therapy Address dysfunctional beliefs and attitudes about sleep Relaxation training Decrease arousal and anxiety Circadian rhythm entrainment Reinforce or reset biological rhythm using light and/or chronotherapy Cognitive behavior therapy Combination of behavioral and cognitive approaches listed above
Patients with psychoactive substance use disorder history
Patients with insomnia related to depression, anxiety
Treatment failures with BzRA
Suspected sleep apnea
Primary insomnia (second-line agents)
Not FDA-approved for use as hypnotics
Antidepressant drug effects on sleep Sleep continuity Slow wave sleep REM sleep Other Tricyclic To To To PLMs Apnea SSRI To To To Eye movements in NREM PLM apnea Trazodone, Nefazodone To To Trazodone more sedating Bupropion To No increase in PLM Mirtazapine Low doses sedating