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