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PubMed2001

[Insomnia. Prevalence and treatment of patients in general practice].

OBJECTIVE: To evaluate the prevalence of insomnia and the treatments used by patients attending general practice clinics. DESIGN: Survey of outpatients. SETTING: Quebec city, Que. metropolitan area. PARTICIPANTS: Two hundred eighteen patients recruited in waiting rooms of general practice clinics. MAIN OUTCOME MEASURES: Participants completed a survey on sleep and use of substances for insomnia, a questionnaire documenting their medical history and use of health care services, and three indices measuring presence of worry and symptoms of anxiety and depression. RESULT: Close to 38% of respondents suffered from insomnia: 26.2% had chronic insomnia and 11.4% had short-term insomnia. Prevalence was higher among women and people 35 to 54 years old. Among respondents who used substances to help them sleep, those 55 years and older consumed more prescription and medications (benzodiazepines); those 35 to 54 years old used mainly natural products; and those 16 to 34 years old consumed mainly over-the-counter medications. Respondents suffering from insomnia made heavier use of health care services and reported more worry and symptoms of anxiety and depression than those who slept well. CONCLUSION: Patients attending general practice clinics have a high prevalence of insomnia. Physicians must be on the lookout for these sleep disturbances so they can offer appropriate treatment.

Adolescent↗
PubMed2001

A psychiatric perspective on insomnia.

Insomnia is a cardinal symptom for many psychiatric disorders, especially depressive disorders. Treatment of the underlying psychiatric disorder may be sufficient to relieve the accompanying insomnia. If the insomnia fails to respond, then consideration should be given to the possibility of inadequate treatment of the primary psychiatric disorder, iatrogenic insomnia, insomnia related to a medical disorder, or learned/habit insomnia. Persistent insomnia should be aggressively pursued, since it has been associated with a variety of adverse outcomes in samples of depressed patients. The physician should always inquire about and encourage healthy sleeping behaviors, even if hypnotic medication is contemplated. Benzodiazepines and nonbenzodiazepine benzodiazepine receptor agonists (BzRAs) have the best evidence for efficacy as hypnotics, although sedating antidepressants are popularly prescribed. Although all benzodiazepine hypnotics and nonbenzodiazepine BzRAs are comparably efficacious in inducing sleep, they vary markedly in their potential for residual side effects.

Acetamides↗
PubMed2001

Future directions in the management of insomnia.

Research on insomnia has provided a number of important new insights, but fundamental deficits in our understanding remain. In considering priorities for future research, 3 areas warrant immediate attention. First, a causal relationship between insomnia and the adverse outcomes seen in insomnia patients needs to be established. Second, currently available symptomatic therapies need to be optimized. Recent data suggest that some benzodiazepine receptor agonists produce their hypnotic effect without side effects that were presumed to be inherent to sedation. Understanding the neuropharmacology underlying this differential effect would allow substantial improvements in the risk-benefit ratio for these drugs. Finally, the mechanisms of insomnia need to be better understood. Several lines of evidence suggest that physiologic arousal is important to the clinical presentation of primary insomnia. It remains unclear, however, whether this activation is primary or secondary to the insomnia itself. If physiologic hyperarousal causes primary insomnia, it would provide new approaches to the management of this disorder.

Comorbidity↗
PubMed2001

[NISAS-2000: The "Nationwide Insomnia Screening and Awareness Study". Prevalence and interventions in primary care].

AIM: To estimate the point prevalence of insomnia, recognition and prescription behavior in primary care. METHODS: Nationwide sample of 539 primary care settings along with their characterization (stage 1). Standardized assessment of all attenders (N = 19.155 patients) on the NISAS target day using a sleep questionnaire (PSQI) and additional questions to cover psychosocial and additional clinical variables. All patients were evaluated by the primary care doctors using a standardized clinical appraisal questionnaire, including a CGI-rating. RESULTS: Prevalence insomnia according to DSM-IV was 26.5%. Recognition of presence of any clinically significant sleep disorder was 72%, recognition of insomnia was poor 54.3%. 85.6% of insomnia patients were rated as chronic. Close to 50% of all insomnia cases did not receive a specific insomnia therapy. Herbals, followed by hypnotics and sedatives and antidepressants were the three most frequent treatments applied, psychotherapy was only seldomly indicated. DISCUSSION: NISAS provides for the first time nationally representative estimates of interventions for insomnia in primary care. The relatively low treatment rates and the high proportion of chronic patients receiving longterm prescription of benzodiazepines seem to be critical. Priorities for future agenda to improve this situation are discussed.

Adolescent↗
PubMed2002

Assessment and diagnosis of insomnia in non-pharmacological intervention studies.

A number of non-pharmacologic interventions have been developed and studied for the treatment of primary insomnia in adults. Fifty-four non-pharmacological intervention studies published over the last 20 years were reviewed to determine how primary insomnia was assessed and to characterize patients participating in the studies. The main objectives were to inform clinicians who look to the literature for information on the treatment of insomnia about selection and diagnosis of participants, and to examine differences between clinic-based and research-based studies. Mean age for all patients was 47 years; 65% were women. Studies typically used interview procedures to assess participants. The most common exclusion criteria overall was insomnia secondary to medical illness or psychiatric disorder. Methods for assessing these criteria varied widely across studies. Inclusion most commonly required a 6-month duration of insomnia, and sleep difficulty at least 3 nights per week. There were significant differences between clinic- and research-based studies in the screening assessments, exclusion criteria, and participant drop-out rate. The heterogeneity in assessment and diagnosis complicates comparison across studies. Some studies were more likely to include severe insomnia sufferers and/or individuals with secondary insomnia. Comprehensive assessment and complete reporting of research methods is essential to determining the relative efficacy and clinical utility of interventions. Clinicians should be aware of the differences across studies from research vs. clinical settings. To enhance the generalizability of research-based studies to clinical practice, careful screening and description of study participants is essential. When participants are well-described, research-based studies can be useful and informative to clinicians.

Adult↗
PubMed2003

Hospitalized patients' preference in the treatment of insomnia: pharmacological versus non-pharmacological.

BACKGROUND: Insomnia is common in hospitalized patients, who become significantly vulnerable to the adverse effects of the benzodiazepines (BZDs) used to treat this condition. Consequently, there has been a logical search for non-drug alternatives (NDAs) for the treatment of insomnia. METHOD: Inpatient insomnia cases were surveyed over the Summer of 1999. Our hypotheses were that an attitudinal difference exists between acute and chronic users of BZDs towards NDAs; and that inpatients who were prescribed BZDs have also received proper information about alternative therapies. RESULTS: One hundred insomnia cases met the inclusion criteria. Fifty-one per cent were younger than age 65. Short acting BZDs were used in 88% of the cases. Fourty per cent of patients had started experiencing insomnia while in the hospital. Only 11% of patients received information about NDA therapy for insomnia. Eighty-two patients felt that NDAs were healthier, and the majority (n=67) responded that if an NDA were offered in the hospital, they would be willing to accept it. Female participants were more willing to consider NDAs (P<0.01). First time users of BZDs were by far more receptive to NDA remedies than were chronic users of BZDs (P<0.002). A significant number of participants who were receiving short-acting BZDs were willing to try an NDA (P<0.001). Participants interested in NDA therapies expressed preferences for for massage therapy, sleep hygiene, music and relaxation techniques (P<0.001). CONCLUSION: Significant attitudinal differences are seen in several domains of patient characteristics. First time female users of BZDs and those taking short acting BZD were more willing to try an NDA. Educational programs are needed for appropriate evidence-based management protocols for insomnia.

Aged↗
PubMed1992

Diagnosis and treatment of insomnia and risks associated with lack of treatment.

Despite the fact that the prevalence rate for insomnia in the United States is high (35.2%), the number of patients with this condition do not represent a large percentage of patients evaluated and treated in sleep disorders clinics. On the other hand, the great majority of patients with insomnia do not seek treatment for their condition from their physicians. Several hypotheses have been created to explain this phenomenon: (1) lack of training for physicians in the area of sleep disorders, (2) pessimism in relation to treatment outcome shared by patients and physicians, and (3) time constraints and other reasons on the part of the physicians. Insomniacs, however, deserve accurate diagnosis and effective treatments for their condition. Insomnia is often the result of multiple factors converging rather than one single cause. For academic purposes, however, different disorders in difficulties with initiation and maintenance of sleep are discussed. Among them, adjustment sleep disorder, obstructive sleep apnea, periodic limb movements in sleep, circadian abnormalities, and psychiatric disturbances. Emphasis is placed on the treatment of each, along with the treatment of the other factors that are commonly found in patients with insomnia: poor sleep hygiene, use of medications that disrupt sleep, performance anxiety, deficient exposure to entrainers of circadian rhythms, diet, and exercise. A comprehensive treatment that includes a multifactorial approach is the ideal way to treat patients with insomnia. Research that will enhance our knowledge of the biological substrate of insomnia will provide clinicians with additional tools to improve the outcome of their treatments of patients with insomnia.

Age Factors↗
PubMed2004

Women and insomnia.

The occurrence of insomnia in women is influenced in great part by the complex hormonal cycles they undergo. Patterns of insomnia in younger women may be physiologically different on a hormonal basis from those found in older women. Although significant objective sleep disturbances have been difficult to demonstrate across the menstrual cycle in normal women, the International Classification of Sleep Disorders (ICSD) includes premenstrual insomnia and premenstrual hypersomnia as sleep disorders within the category of menstrual-associated sleep disorder. On the other hand, during pregnancy and after childbirth, profound fluctuations in steroid and hypothalamic-pituitary-adrenal axis-related hormones produce significant physiological changes, including sleep disruption. During the menopausal transition, significant sleep disruptions are provoked by sleep-disordered breathing, vasomotor disturbance, and mood disorders. Regardless of age, women with chronic insomnia are at higher risk for developing or sustaining depression. Thoughtful management approaches must consider known relationships between menstrual or menopausal status and various sleep disorders, and should rely on pharmacologic, nonpharmacologic, or a combination of treatments to achieve successful relief from insomnia. The off-label, first-line use of antidepressants for treating insomnia in the absence of depression is now considered debatable. The long-term efficacy and safety of the newer benzodiazepine receptor agonists (BZRAs) for insomnia, whether taken nightly or episodically, are supported by existing clinical experience. US Food and Drug Administration guidelines limiting the use of hypnotics to only a few weeks predate the newer generation BZRAs, and, as such, the guidelines may no longer be truly appropriate for these new agents.

Adult↗
PubMed2004

Daytime sleepiness and insomnia as correlates of depression.

Insomnia and daytime sleepiness are often associated with depression. The possible relationships between sleep difficulties and depression are numerous. Insomnia and other sleep disturbances can be precursors to the onset of major depressive disorder, so they may act as risk factors for or predictors of depression. The symptomatology of depression also prominently includes insomnia, and sleep disturbances may be residual symptoms after response to antidepressant treatment. Insomnia and the resultant daytime sleepiness may be short-term or long-term side effects of antidepressant treatment as well. Whether insomnia is a precursor, symptom, residual symptom, or side effect of depression or its treatment, clinicians must give serious attention to and attempt to resolve sleep disturbances because of the risk of depression onset, worsening of depressive symptoms, and relapse of depression after response to antidepressant treatment. Remission of depression cannot be fully achieved until the associated insomnia and daytime sleepiness are resolved. This article describes the relationships between insomnia and depression and discusses the effects of various antidepressants on sleep. Finally, several different treatment options, including antidepressant monotherapy and augmentation of antidepressants with other medications, are explored.

Antidepressive Agents↗
PubMed2006

Actigraphy validation with insomnia.

STUDY OBJECTIVE: Actigraphy, a method of inferring sleep from the presence or absence of wrist movement, has been well validated against polysomnography in trials with people without insomnia. However, the small amount of literature on validation with insomniacs has revealed an actigraphy bias toward overscoring sleep. The current validation trial with insomniacs used the largest number of subjects to date in such research and attracted participants with diverse demographic characteristics. DESIGN: People with insomnia slept 1 night in the laboratory while simultaneously being monitored by polysomnography, actigraphy (high-sensitivity algorithm of the Mini Mitter AW64 Actiwatch), and morning sleep diary. SETTING: Sleep disorders center. PARTICIPANTS: Participants were 57 volunteers from the community, 26 men and 31 women, ranging in age from 21 to 87 years. All participants satisfied conservative criteria for insomnia. The sample included subjects with primary insomnia, subjects with comorbid insomnia, and hypnotic users with current insomnia complaints. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Actigraphy was successfully validated on 4 measures of sleep pattern--number of awakenings, wake time after sleep onset, total sleep time, and sleep efficiency percentage--based on nonsignificant mean differences and significant correlation between actigraphy and polysomnography. Sleep-onset latency with actigraphy was not significantly different from polysomnography but was weakly correlated with polysomnography. Hypnotic use contributed to actigraphic overscoring of sleep. CONCLUSIONS: Actigraphy proved to be a satisfactory objective measure of sleep on 4 of 5 sleep parameters, but these results are specific to this particular instrument using this particular algorithm and should not be construed as a blanket endorsement of actigraphy for measuring insomnia.

Adult↗
PubMed1988

The prevalence of insomnia: the importance of operationally defined criteria.

Previous studies on the prevalence of sleep disturbances have shown that insomnia occurs in 3.2-42% of different populations. The wide reported variation in prevalence prompted a rigorous definition of insomnia to be introduced in this study. Randomly selected members of the population aged 30 to 65 years from two geographically different rural parts of central Sweden answered a sleep questionnaire. The response rates were 69.2% and 70.2%, respectively. Females significantly more often reported difficulty in falling asleep (7.1% of the women and 5.1% of the men). Among women 8.9 and among men 7.7% of individuals reported trouble with nocturnal awakenings. Using a stringently defined concept of insomnia as a disorder of initiating sleep (DIS), the prevalence rate of insomnia among women was 1.1% and among men 0.5%. Defining insomnia as a disorder of maintaining sleep (DMS), the prevalence among both women and men was 1.1%. Defining insomnia as a disorder of initiating and maintaining sleep (DIMS), the prevalence rate was 1.7% among women and 1.4% among men. This prevalence, which is lower than previously reported, demonstrate the importance of an operational definition of insomnia.

Adult↗
PubMed1982

[Where do we place insomnia within the framework of psychiatric nosography].

According to sleep specialists, 30 to 80% of insomnia cases have a psychiatric cause. The author distinguishes between acute insomnia induced by acute psychiatric disorders and chronic insomnia associated with more or less permanent personality disturbances. This article reviews neurotic, depressive and maniac insomnia, insomnia of the alcoholic and of the toxicomaniac, insomnia during schizophrenia and chronic delusion. Insomnia may be the first symptom reported by the patient, hiding a subjacent psychiatric disorder. At the contrary, a short and insufficient sleep can only be discovered through a thorough investigation of the patient and questioning of his familiars.

Alcoholism↗
PubMed1995

Management of insomnia.

Insomnia is a common problem and studies in Singapore and abroad have shown that up to a third of any population studied has experienced insomnia. There is also increasing awareness of insomnia as a health risk. Current views of the problem not only focus on the disturbed sleep pattern but also on the daytime consequences. Younger adults tend to experience sleep latency problems and older adults, sleep maintenance problems. Sleep varies from person to person and according to age. There are no normative values to help in the diagnosis of insomnia but some features typical of insomnia have been noted. The aetiologies of insomnia are diverse and must be determined in the assessment of patients. Treatment of insomnia is non-pharmacologic and/or pharmacologic therapy. There are an increasing number of studies on the various treatments and at present a combination of both types appears best in the long-term management of the problem.

Behavior Therapy↗
PubMed1995

[Insomnia in general practice: the opinion of the patient and the professional].

OBJECTIVES: Although insomnia is a common complaint in Primary Care, the patient's perception of the problem and the variables which affect his/her visit to the doctor have been little studied. In this study the Subjective Complaint of Insomnia (SCI) was evaluated. These data were then compared with those found in the clinical records and those contributed by the doctors at a Health Centre. DESIGN: An observational crossover study, using a structured personal interview based on Goldberg's Clinical Interview Schedule, was carried out. The clinical records of those interviewed were reviewed and a questionnaire aimed at the doctors was designed to determine their perception of insomnia from their consultations. RESULTS: The prevalence of SCI in the preceding week was 45.45%. 45.7% of patients with SCI attended for this reason. Those patients who did not declare SCI to their doctor often lacked psychiatric antecedents, attended because of acute (rather than chronic) pathology and scored lower on the subjective evaluation scale of the intensity of the insomnia. Quality of sleep was recorded in 58.7% of the clinical records, with 20.6% prevalence of insomnia. All the doctors interviewed thought that the prevalence of insomnia among their patients was below 40%. CONCLUSIONS: The prevalence of insomnia in Primary Care is greater than doctors believe and than that recorded in the clinical notes. Patients who do not mention their problems are those who are less seriously ill.

Adolescent↗
PubMedDate not supplied

[Insomnia in asthmatic patients].

In this paper, in order to assess the prevalence and features of insomnia as a subjective complaint in a sample of asthmatic outpatients. (n = 43; mean age = 36.39 +/- 12.85), items 44, 64 and 66 (that deal with insomnia complaints) of Derogatis' SCL-90-R (Symptom Check List 90 REvised), that was applied to the patients of the sample, are studied. A high prevalence of insomnia complaints is observed in our patients; over 70% of the sample manifests complaints of some type of insomnia. Insomnia complaints were higher (p < 0.0001) than in general population. No significant differences were evidenced according to sex and no correlation with age was observed in any of the items taken into account for insomnia complaints. A high positive intercorrelation was evidenced among the three items that we considered. Various factors associated with insomnia in asthma are discussed.

Adolescent↗
PubMedDate not supplied

Economic effects of insomnia.

Insomnia affects up to 40% of the general population yearly and is a significant cause of morbidity and mortality. The direct and indirect costs of insomnia place a tremendous economic burden on society and employers. In addition to the cost of medical treatment and drugs, measurable costs of insomnia include reduced productivity, increased absenteeism, accidents, and hospitalization, as well as medical costs due to increased morbidity and mortality, depression due to insomnia, and increased alcohol consumption. This article reviews the literature on the economic costs and effects associated with insomnia. Based on the data reviewed, a conservative estimate of the total annual cost of insomnia was calculated at $92.5 to $107.5 billion. Early recognition and treatment of insomnia can reduce the costs associated with the condition, as well as possibly prevent other illnesses.

Absenteeism↗
PubMed1993

[Treatment of insomnia related to depressive disorders. Effects of zolpidem versus flunitrazepam administration and withdrawal evaluated in a double-blind study].

The effects of a 15 day treatment with zolpidem (10 mg) and with flunitrazepam (1 mg) on Insomnia Disorders Related to Depressive Disorders (DSM-III-R) have been evaluated on 30 depressive in-patients (mean age 42.3 +/- 9.8). The trial has been carried out on double blind condition after 5 days of single blind placebo administration. Withdrawal effects have been evaluated in single blind condition on a 10 day period after drugs discontinuation. Patient's diagnosis was Major Depression or Dysthymia according to DSM-III-R; inclusion criteria were insomnia (total sleep time < or = 6 h, sleep latency > or = 30 min, wake after sleep onset > or = 30 min, No of awakenings > or = 3) refractory to clomipramine administration at constant dose (75-150 mg/day among patients). Both drugs have been followed by a rapid, significant diminution of insomnia as demonstrated by significant changes at Stanford Sleepiness Scale and Saint Mary Hospital Sleep Questionnaire and by a significant reduction of HDRS total scores. No clinical phenomena of rebound insomnia were detected after zolpidem and flunitrazepam withdrawal. Drug discontinuation however was followed by the slow increase of the score on insomnia items, approximating basal values at the end of the 10 day period after zolpidem and flunitrazepam withdrawal. A parallel increase of HDRS total score was also detected; HDRS changes were mainly due to the increase of the items anxiety somatic, general somatic symptoms, gastrointestinal somatic symptoms, hypochondriasis. The study confirms the therapeutic efficacy of zolpidem and of flunitrazepam in the treatment of insomnia resistant to antidepressant drugs in depressed patients. They also suggest that early drug discontinuation is frequently associated with clinical relapse of insomnia and of several other symptoms correlated with the affective pathology.

Adult↗
PubMed1996

The empirical identification of insomnia subtypes: a cluster analytic approach.

Over the past 15 years, there has been considerable debate concerning the extent to which insomnia patients can be classified into diagnostic subtypes. Despite this debate, relatively little research has been conducted to empirically determine whether naturally occurring insomnia subtypes might be identified within populations of sleep clinic patients. In the current study we used a hierarchical cluster analysis to empirically identify subtypes among a mixed group of normal sleepers and the insomnia outpatients who presented to our sleep center over the past decade. Using factor-analytically derived composite variables that summarized data obtained from sleep history questionnaires and polysomnographic monitoring, this clustering procedure resulted in the identification of 14 subgroups that varied between four and 34 patients/subjects in size. Subsequently, subgroup mean scores for the composite variables used in the clustering procedure were used to construct profiles for each of the 14 clusters. A multivariate profile analysis, employed to elucidate subgroup differences, showed that these cluster profiles differed in terms of their configural shapes, average elevations, and degrees of interscale differences. Furthermore, both DSM-III-R (American Psychiatric Association) and International Classification of Sleep Disorders (ICSD) insomnia diagnoses, assigned independent of cluster findings, suggested that these subtypes differed significantly in regard to their diagnostic compositions. Nevertheless, a far-from-perfect concordance was observed between such clinically assigned diagnoses and cluster group membership. In fact, many of the empirically identified groups were composed of various DSM-III-R and/or ICSD diagnostic subtypes. These results provided only partial support for current DSM and ICSD insomnia categories. However, our results support the existence of multiple, clinically discrete insomnia subtypes and provide information that may be useful in future revisions of current insomnia nosologies.

Adult↗