General
Nonpharmacological treatment
Pharmacological Treatment

General

Insomnia in the elderly: A review for the primary care practitioner.
Ancoli-Israel, S.

[MEDLINE record in process]

Sleep,(2000) 23 Suppl 1: S23-30.

New epidemiologic findings about insomnia and its treatment.
Balter, M.B., Uhlenhuth E.H. .

Journal of Clinical Psychiatry, (1992)53 Suppl 12:34-39.

Practice parameters for the evaluation of chronic insomnia.
Chesson, A. Jr., Hartse K., Anderson, M.W., Davila D., Johnson S., Littner, M., Wise M., Rafecas J.

Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No systematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommendations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing this care can benefit from their use. Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia. Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily functioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evidence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments have not been shown to differentiate subtypes of insomnia complaints.

Sleep (2000)23(2), 237-241.

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Epidemiologic study of sleep disturbances and psychiatric disorders: An opportunity for prevention?
Ford, D. E., & Kamerow, D. B. .

Journal of the American Medical Association,(1989) 262, 1479-1484.

Perspectives on the management of insomnia in patients with chronic respiratory disorders.
George, C.F.P..

[MEDLINE record in process]

Sleep, (2000) 23 Suppl 1: S31-35.

Recognition and diagnosis of insomnia.
Kryger M., Lavie P., Rosen R. .

Sleep,(1999) 22 Suppl 3: S421-426.

Insomnia: Psychological assessment and management.
Morin, C. M. (1993). New York: The Guilford Press.

Managing insomnia in the primary care setting: Raising the issues.
Richardson, G.S.

[MEDLINE record in process]

Sleep,(2000) 23 Suppl 1: S9-12.

Public Health and Insomnia: Consensus statement regarding its status and needs for future actions.
Roth T., Roehrs T., Costa e Silva J. A., & Chase MH.

Sleep(1999)., 22 Suppl 3: S417-420.

Evaluation of chronic insomnia.
Sateia, M.J., Doghramji, K., Hauri, P.J., Morin, C.M. .

[No Abstract Available]

Sleep,(2000) 23(2), 243-263.

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Managing insomnia in the primary care setting: Raising the issues.
Richardson, G.S. (2000).

[MEDLINE record in process]

Sleep, 23 Suppl 1: S9-12.

Effects of sleep deprivation on daytime sleepiness in primary insomnia.
Stepanski, E., Zorick, F., Roehrs, T., & Roth, T.

[No Abstract Available]

Sleep, (2000)23(2), 215-219.

Presleep cognition and attributions in sleep-onset insomnia.
Van Egeren, L., Haynes, S. N., Franzen, M., & Hamilton, J.

This research examined the role of cognitive factors (attributions about the causes of sleep difficulties and presleep cognitive activity) in sleep-onset insomnia. Thirty-four subjects, including 13 mild to extreme insomniacs, were interviewed and then spent 5 consecutive nights in a sleep laboratory. In a multiple regression paradigm predictor measures included attribution ratings of sleep difficulty, perceived control of presleep cognitive content, and affect associated with presleep cognitions. Criterion measures included laboratory measured objectives and subjective sleep-onset latency, a score presenting the difference between objective and subjective laboratory measures of sleep-onset latency, interview- measured subjective sleep-onset latency, and degree of overall concern and presleep concern about initiating sleep. The results of multiple regression analyses suggested that the content of presleep cognitions and the attributions of sleep difficulties were significantly associated with several subjective measures of sleep- onset latency or concern with initiating sleep. None of the predictor measures was significantly associated with objectively measured sleep- onset latency. Implications for cognitive theories of sleep-onset insomnia and for the psychophysiologic-subjective dimension of insomnia are discussed.

Journal of Behavioral Medicine(1983), 6, 217-232.

Prevalence and health consequences of insomnia.
Walsh J., Ustin T.B..

Sleep (1999), 22 Suppl 3: S427-436.

Nonpharmacological treatment

Stimulus control treatment for insomnia.
Bootzin, R. R.

Proceedings of the American Psychological Association, 7, 395-396.(1972)

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Practice parameters for the non-pharmacologic treatment of chronic insomnia.
Chesson, A.L. Jr., McDowell A.W., Littner M., Davila D., Hartse K., Johnson S., Wise M., Rafecas J..

Insomnia is the most common sleep complaint reported to physicians. Treatment has traditionally involved medication. Behavioral approaches have been available for decades, but lack of physician awareness and training, difficulty in obtaining reimbursements, and questions about efficacy have limited their use. These practice parameters review the current evidence with regards to a variety of nonpharmacologic treatments for insomnia. Using a companion paper which provides a background review, the available literature was analyzed. The evidence was graded by previously reported criteria of the American Academy of Sleep Medicine with references to American Psychological Association criteria. Treatments considered include: stimulus control, progressive muscle relaxation, paradoxical intention, biofeedback, sleep restriction, multicomponent cognitive behavioral therapy, sleep hygiene education, imagery training, and cognitive therapy. Improved experimental design has significantly advanced the process of evaluation of nonpharmacologic treatments for insomnia using guidelines outlined by the American Psychological Association (APA). Recommendations for individual therapies using the American Academy of Sleep Medicine recommendation levels for each are: Stimulus Control (Standard); Progressive Muscle Relaxation, Paradoxical Intention, and Biofeedback (Guidelines); Sleep Restriction, and Multicomponent Cognitive Behavioral Therapy (Options); Sleep Hygiene Education, Imagery Training, and Cognitive Therapy had insufficient evidence to be recommended as a single therapy. Optimal duration of therapy, who should perform the treatments, long term outcomes and safety concerns, and the effect of treatment on quality of life are questions in need of future research.

Sleep (1999) 22(8), 1128-1133.

A controlled comparative investigation of psychological treatments for chronic sleep-onset insomnia.
Espie, C. A., Lindsay, W. R., Brooks, D. M., Hood, E. M., & Turvey, T. .

A sample of physician-referred chronic insomniacs was randomly allocated to either progressive relaxation, stimulus control, paradoxical intention, placebo or no treatment conditions. Treatment process and outcome were investigated in terms of mean and standard deviation (night to night variability) measures of sleep pattern and sleep quality. Only active treatments were associated with significant improvement, but the nature of treatment gains varied. In particular, stimulus control improved sleep pattern, whereas relaxation affected perception of sleep quality. All improvements were maintained at 17 month follow-up. Results are discussed with reference to previous research and guidelines are given for clinical practice.

Behavior Research and Therapy, (1989)27, 79-88.

Nonpharmacologic treatment of chronic insomnia.
Morin C.M., Hauri P., Espie C., Spielman A., Buysse D.J., & Bootzin R.R. .

This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.

Sleep,(1999) 22(8), 1134-1155.

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Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. American Journal of Psychiatry,
Morin, C. M., Culbert, J. P., Schwartz S. M.

OBJECTIVE: Because of the role of psychological factors in insomnia, the shortcomings of hypnotic medications, and patients' greater acceptance of nonpharmacological treatments for insomnia, the authors conducted a meta-analysis to examine the efficacy and durability of psychological treatments for the clinical management of chronic insomnia. METHOD: A total of 59 treatment outcome studies, involving 2,102 patients, were selected for review on the basis of the following criteria: 1) the primary target problem was sleep-onset, maintenance, or mixed insomnia, 2) the treatment was nonpharmacological, 3) the study used a group design, and 4) the outcome measures included sleep-onset latency, time awake after sleep onset, number of nighttime awakenings, or total sleep time. RESULTS: Psychological interventions, averaging 5.0 hours of therapy time, produced reliable changes in two of the four sleep measures examined. The average effect sizes (i.e., z scores) were 0.88 for sleep latency and 0.65 for time awake after sleep onset. These results indicate that patients with insomnia were better off after treatment than 81% and 74% of untreated control subjects in terms of sleep induction and sleep maintenance, respectively. Stimulus control and sleep restriction were the most effective single therapy procedures, whereas sleep hygiene education was not effective when used alone. Clinical improvements seen at treatment completion were well maintained at follow-ups averaging 6 months in duration. CONCLUSIONS: The findings indicate that nonpharmacological interventions produce reliable and durable changes in the sleep patterns of patients with chronic insomnia.

American Journal of Psychiatry (1994) 151(8), 1172-80.

Insomnia: Psychological assessment and management.
Morin, C. M. . New York: The Guilford Press.(1993)

Treatment of chronic insomnia by restriction of time in bed.
Spielman, A. J., Saskin, P., & Thorpy, M. J.

A treatment of chronic insomnia is described that is based on the recognition that excessive time spent in bed is one of the important factors that perpetuates insomnia. Thirty-five patients, with a mean age of 46 years and a mean history of insomnia of 15.4 years, were treated initially by marked restriction of time available for sleep, followed by an extension of time in bed contingent upon improved sleep efficiency. At the end of the 8-week treatment program, patients reported an increase in total sleep time (p less than 0.05) as well as improvement in sleep latency, total wake time, sleep efficiency, and subjective assessment of their insomnia (all p less than 0.0001). Improvement remained significant for all sleep parameters at a mean of 36 weeks after treatment in 23 subjects participating in a follow-up assessment. Although compliance with the restricted schedule is difficult for some patients, sleep restriction therapy is an effective treatment for common forms of chronic insomnia.

Sleep(1987), 10, 45-56.

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Pharmacological treatment

The need for flexibility in dosing of hypnotic agents.
Doghramji, K..

[MEDLINE record in process]

Sleep (2000), 23 Suppl 1: S16-20.

Limitations on the use of benzodiazepines in anxiety and insomnia: are they justified?
Lader M.

The benzodiazepines are still extensively used in psychiatry, neurology and medicine in general. Anxiety disorder and severe insomnia are important syndromal indications, but these drugs are widely prescribed at the symptomatic level, resulting in potential overuse. The official data sheets recommend short durations of usage and conservative dosage. Although short-term efficacy is established, long-term efficacy remains controversial, as relevant data are scanty and relapse, rebound and dependence on withdrawal not clearly distinguished. The risks of the benzodiazepines are well-documented and comprise psychological and physical effects. Among the former are subjective sedation, paradoxical release of anxiety and/or hostility, psychomotor impairment, memory disruption, and risks of accidents. Physical effects include vertigo, dysarthria, ataxia with falls, especially in the elderly. Dependence can supervene on long-term use, occasionally with dose escalation. The benzodiazepines are now recognised as major drugs of abuse and addiction. Other drug and non- drug therapies are available and have a superior risk benefit ratio in long-term use. It is concluded that benzodiazepines should be reserved for short-term use--up to 4 weeks--and in conservative dosage.

European Neuropsychopharmacology,(1999) 9 Suppl 6:S399-405.

Symptomatic treatment of insomnia.Langer S., Mendelson W., & Richardson G.

[MEDLINE record in process]

Sleep(1999), 22 Suppl 3: S437-450.

Nonselective and selective benzodiazepine receptor agonists: Where are we today?
Mitler, M.M.

[MEDLINE record in process]

Sleep(2000), 23 Suppl 1: S39-47.

Ten-year trends in the pharmacological treatment of insomnia.
Walsh J.K., Schweizer P.K.

STUDY OBJECTIVE: To assess patterns of pharmacological treatment of insomnia during the period 1987-1996. DESIGN AND MEASUREMENTS: Data were obtained from the National Disease and Therapeutic Index (NDTI; IMS America, Ltd., Plymouth Meeting, PA) which samples office-based physicians in 24 specialties. Drug mentions, a measure of patient contacts in which drug therapy is recommended, with a physician- indicated desired action of "promote sleep" or "sedative night" were compiled for each year. Z-scores were calculated to determine statistical differences over time for total drug mentions, drug mentions by category (hypnotics, non-hypnotic benzodiazepines, antidepressants, or other), and for some individual drugs. RESULTS: Total drug mentions for the treatment of insomnia fell 24.4% from 1987 to 1996. From 1987 to 1996 hypnotic mentions decreased 53.7%, antidepressants increased 146%, "other" drugs decreased by 63.2%, and benzodiazepine non-hypnotics remained relatively unchanged. CONCLUSIONS: Since 1987, overall pharmacological treatment of insomnia has decreased substantially although surveys indicate a stable or increasing prevalence of sleep disturbance. There has also been a dramatic shift to use of antidepressants in lieu of hyponotics for the symptomatic treatment of insomnia despite a paucity of data regarding their efficacy and the potential for serious side effects.

Sleep(1999), 22(6), 371-5.

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