Doi:10.1016/j.pop.2007.05.009

Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Eau Claire Family Medicine Residency Program, 617 West Clairemont Avenue, Eau Claire WI 54701, USA ‘‘The worst things: to be in bed and sleep not, to want for one who comesnot, to try to please and please not.’’ Insomnia is a common problem affecting persons in all stages of life. Ac- cording to the National Sleep Foundation 2005 ‘‘Sleep in America’’ Poll, oneout of every three respondents reported insomnia symptoms almost everynight of the week. Prevalence varies between 20% and 40% of adults in theUS having insomnia, and 10% to 15% of adults having chronic insomniaSleep problems are more prevalent in the elderly; more than 60% of pa-tients over 60 years report sleep difficulties Children and adolescents arenot immune from sleep problems; one out of four children receiving medicalcare for both acute or chronic medical conditions reported sleep disturbances. Some studies find more than 10% of teenagers struggle with insomnia In spite of the high prevalence of insomnia, most people who have sleep problems are not diagnosed. Almost 70% of persons who have insomnianever discuss sleep with their doctor, 26% discuss sleep issues during officevisits for other problems, and only 5% of persons who have sleep issuesschedule appointments with their doctor to discuss their insomnia. Evenfewer receive adequate treatment .
Insomnia is defined as difficulty falling asleep or staying asleep, or non- refreshing sleep, for a patient who has the opportunity to acquire a normalnight’s sleep of 7 to 8 hours. Insomnia has been classified either based on itsspecific symptoms (ie, sleep onset or sleep maintenance) or the duration ofthe disorder. Acute insomnia generally occurs for less than 4 weeks, whereaschronic insomnia occurs for greater than 4 weeks. Some make a distinction 0095-4543/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.pop.2007.05.009 of clinically relevant insomnia occurring in conjunction with daytime dys-function or distress of fatigue, poor concentration, or irritability Beyondthe loss of sleep for the insomniac, insomnia affects the parents of childrenand infants and caregivers of elderly. Employers of those who have insom-nia suffer when the insomniac’s work performance is affected and daytimedrowsiness leads to dangerous work behaviors or driving Transient or acute insomnia is most often caused by a change of sleeping environments; for example, sleeping in a hotel, sharing your bed with a sickchild, or sleeping in the summer heat without air conditioning. Jet lag,changes in work shift, excessive noise, unpleasant room temperature, stress-ful life events, acute medical or surgical illness (including intensive care unitsyndrome), and stimulants can also produce short-term sleep disruption. Jetlag occurs after traveling across several time zones. Some of the sleep prob-lems are related to ‘‘jet factor,’’ including long periods of time with limitedmobility, dry eyes, headache, fatigue and nasal congestion; whereas ‘‘lag fac-tor’’ results in dyssynchrony between the body’s internal clock and the sleepschedule of the new environment. Symptoms are more severe when travelingfrom west to east, and are more severe in the elderly. Readjustment and re-synchronization occur about 1 hour per day when traveling eastward and1.5 hours per day while traveling westward, because it is easier to lengthenrather than shorten the natural circadian cycle .
Insomnia occurs alone, or with another medical or psychiatric condition, or when the patient develops a conditioned state of hyper arousal or height-ened concern that she won’t be able to fall asleep, called ‘‘conditional insom-nia’’ . Primary insomnia or sleep disorder occurs without a coexistingdisorder. Examples of primary sleep disorders are obstructive sleep apnea,restless legs syndrome, or periodic limp movement disorder.
Comorbid insomnia, previously called secondary insomnia, occurs with an underlying medical psychiatric or psychological process. Previously theunderlying condition was thought to cause the insomnia, but newer studiesof the relationships between insomnia and associated medical andpsychiatric conditions undermine this notion. Although identifying andtreating the underlying condition is important, it may not be sufficient to al-leviate the insomnia . When insomnia continues, treatment targetedspecifically to the insomnia should be considered. Moreover, untreated in-somnia may adversely affect the course of the associated disorder.
Conditioned insomnia, also known as psychophysiologic insomnia, is a disorder in which the patient typically suffers acute insomnia caused bystress (loss of a loved one, work or marital stress). After several nights ofpoor sleep and tiredness during the day, the patient becomes anxious abouthis ability to sleep and perform when tired. This anxiety becomes an exac-erbating factor interfering with sleep, and begins a vicious cycle that con-tinues even after the initial stress has resolved. Although affectedindividuals are overconcerned and overfocused on the problem of sleep,they do not suffer from generalized anxiety, phobic, or other psychiatric disorders The characteristic feature of psychophysiologic insomnia isthe development of conditioned responses that are incompatible with sleep.
Sufferers make up 15% of all insomniacs attending sleep disorder centers Little is known about the duration of chronic insomnia. The limited pro- spective data suggest that for the majority of insomniacs, symptoms are oflong duration, and for some, they are lifelong Very little is also knownabout the incidence, or the number of new cases arising each year.
Although risk factors have been identified, the causal relationships are not fully understood. Known associations for insomnia include older age, female gender present or past psychiatric illness and psycho-logical problems multiple medical conditions poor generalhealth increased health care use lower quality of life and so-cial relationships socioeconomic status (marital separation, unemploy-ment, poorer working conditions, and lower social status) , and memoryand cognitive deficits .
Although sleep patterns change with age, the ability to sleep is not af- fected by age alone. The higher rate of insomnia in the older populationis probably caused by multiple medical problems, polypharmacy, and envi-ronmental factors such as institutionalization and the absence of time andschedule cues, because healthy, active older adults with good social life sat-isfaction do not seem to have higher rates of insomnia .
The increased rate for females begins with menarche. Insomnia rates are the same for boys and girls until a girl’s menses, when her insomnia risk in-creases 2.75 times and continues throughout adult life . Hormones pregnancy , menopause, stress, medical conditions, and complex homelife may explain the higher prevalence of insomnia in women. The prev-alence of chronic insomnia increases with severity of hot flashes; 80% ofwoman suffering with severe hot flashes report insomnia .
There is a strong association between insomnia and psychiatric and psy- chological disorders: mood disorders (major depression and bipolar), anxi-ety disorders (generalized anxiety disorder, panic disorder, post-traumaticstress disorder, adjustment disorders), psychotic disorders, and substanceabuse Schizophrenia-associated sleep disturbances are related to the in-tensity of psychotic symptoms, with extremely prolonged sleep onset latencyduring acute illness and decrease in total sleep time Multiple medical conditions have increased rates of insomnia, including pulmonary and gastrointestinal disorders , heart disease , allergies,arthritis , malignancy, neurological diseases (Parkinson’s and stroke) , hypertension , diabetes mellitus and HIV infection Med-ical conditions disrupt sleep through a variety of mechanisms: joint or backpain requiring change of position, heartburn in supine position, need to voidbecause of enlarged prostate or polyuria associated with poorly controlleddiabetes mellitus, mobilization of fluids with volume overload conditionssuch as heart failure or venous stasis changes with sleep, shortness of breathwhen lying flat in congestive heart failure or lung disease, or drugs such asantidepressants and diuretics that interfere with sleep. Insomnia rates in-crease with the number of medical conditions. In patients who have fouror more medical conditions, the insomnia rate reaches 70% . Treatingthe underlying diseases may not improve the insomnia .
Poor sleep can also aggravate medical conditions . There is increas- ing evidence that chronic insomnia may predispose individuals to the devel-opment of psychiatric and medical disorders. One large study foundthat individuals who had insomnia at baseline were 34 times more likelyto develop a new psychiatric disorder (usually major depression) within 1year compared with those who had no insomnia. The bidirectional relation-ship between insomnia and mood disorder is complicated and poorly under-stood. Depression may lead to insomnia, and insomnia increases the risk ofdepression Self-reported symptoms of insomnia independently in-crease risk of cognitive decline in older men Heart disease patientswho sleep less than 5 hours a night have a threefold increase in myocardialinfarction Blood sugar control worsens with insomnia. Similarly,chronic pain can lead to insomnia, and insomnia increases pain ratings. A recent study demonstrated that worsening sleep apnea scores cor-related with the development of depression Stimulants, including nicotine and coffee, cause insomnia and sleep dis- turbances. Decaffeinated coffee was developed to encourage coffee con-sumption while limiting sleep disturbance, and thus improve sales;however, the amount of caffeine varies by the product Alcoholand a number of other drugs disrupt sleep. Alcohol disrupts sleep throughseveral mechanisms. Although alcohol taken before sleep may promotesleep onset, it tends to shorten total sleep time, and can exacerbate otherconditions, such as gastroesophageal reflux and sleep apnea, if taken in largequantities. Alcohol also is a diuretic, which may cause awakening for void-ing. Alcohol withdrawal in a heavy drinker may be associated with restless-ness or tremor.
Insomnia has significant direct and indirect costs on the individual, family or caregiver, and society. Insomnia causes or is associated with im-paired cognitive functioning negative quality of life measures ,increased incidence of pain , poorer general health, increased futurerisk of psychiatric disorders increased drug use , decreased Table 1Common products and caffeine dose Hershey’s Special Dark Chocolate Bar (1.5 oz) job performance, increased absenteeism , increased risk of accidents increased incidence of a number of medical problems, and worsening of ex-isting medical problems . Patients who have insomnia use health caremore The economic costs of insomnia and associated morbidityare high; direct costs are estimated to be nearly $14 billion, and indirectcosts such as missed work and decreased productivity are estimated to benearly $28 billion The diagnosis of insomnia begins with suspicion and a good sleep history from the patient or family or caregivers. The accuracy of patient self-reportand sleep studies have shown both over- and under-reporting problems withsleep Because insomnia is very prevalent, sleep quality questions shouldbe included in all routine evaluation histories. In the 2000 National SleepFoundation Survey of Primary Care Physicians, almost all respondersagreed that a sleep history should be part of the routine visit; however,only 52% physicians conducted regular sleep assessments .
If a patient presents with complaints of fatigue, excessive daytime sleep- iness, depressed or anxious mood, memory or concentration problems, orpain, a sleep history should be taken, because sleep problems are commonwith these complaints. A sleep history should include onset, frequency, du-ration, and severity of sleep complaints, and their fluctuations over time.
Any precipitating event should be sought. Noise levels, activities, naps, eat-ing, medications, stimulants, alcohol, or drugs taken throughout the 24-hour period should be investigated. Determine if sleep difficulties involveinitiation or maintenance of sleep. Inquire about any bedtime rituals ortime in bed not sleeping, which may reveal sleep hygiene issues or condi-tioned insomnia.
Inquire if specific symptoms occur around sleep onset, such as paresthe- sias, unpleasant sensation, and uncontrollable limb movements. Restlesslegs syndrome presents with a delay in sleep because the patient feels an un-comfortable sensation of the legs at rest. Iron deficiency, renal failure, preg-nancy, and selective serotonin reuptake inhibitor (SSRI) antidepressants areassociated with restless legs syndrome Periodic leg movement disorderis noted in at least 80% of cases with restless legs syndrome Patientswho have recurring periodic limb movements in sleep (PLMS) most com-monly dorsiflex the ankles or flex the knees and hips, and occasionally theupper limbs, every 20 to 40 seconds. PLMS are more common in personsover age of 65; they may occur alone or in association with end-stage renaldisease, tricyclic antidepressants, or monoamine oxidase inhibitors .
Sleeping partners may suggest the diagnosis, but a polysomnographic studyconfirms the diagnosis.
Inquire about symptoms during sleep (repeated awakenings or early morning awakening, loud snoring, choking or gasping, cessation of breath-ing) or symptoms during the day (excessive fatigue, irritability, or difficultyconcentrating). Previous treatments should also be noted. A sleep log, pref-erably over 2 weeks, may yield important information.
Both current and past alcohol and drug history should be obtained. Ten to 15% of insomniacs are substance abusers . Objective alterations insleep architecture have been observed in alcoholics for 12 months of absti-nence Patients who have drug abuse problems can have insomnia even1 year after abstinence begins . Furthermore, patients who have a previ-ous history of alcohol or drug abuse who continue to have insomnia havehigher relapse rates Although caffeine is a well-known drug that causessleep disturbance, other drugs include nicotine, antidepressants (SSRIs,serotonin-norepinephrine reuptake inhibitors [SNRIs], bupropion, mono-amine oxidase inhibitors [MAOIs]), opiates, corticosteroids, central nervoussystem stimulants (dextroamphetamine, methylphenidate), bronchodilators,pseudoephedrine, methyldopa, beta blockers, alpha blockers, and cholines-terase inhibitors .
A family history may suggest certain primary sleep disorders. About one third of patients who have idiopathic restless legs syndrome have a positivefamily history .
The medical, including psychiatric, history and physical examination are useful in identifying comorbid conditions. The most common comorbidity isa psychiatric diagnosis. Forty percent of chronic insomniacs have a coexist-ing psychiatric diagnosis . More than half of persons who have depres-sion, anxiety disorders, psychosomatic disorders, neuroses, dementia, andschizophrenia have insomnia complaints For most patients who haveinsomnia, the diagnosis is made with only a good history and a physical ex-amination. Sleep diaries or sleep questionnaires may be helpful, but nonehave been standardized. The Epworth Sleepiness Scale may be used to de-termine the level of daytime sleepiness and if further evaluation is necessary.
Although multichannel polysomnography is the most sensitive tool to differ-entiate wakefulness and sleep, it is not necessary for most cases of insomnia.
Because it is expensive and can disrupt sleep, its use should be limited tocases in which sleep-related breathing problems such as sleep apnea are sus-pected. Patients who have daytime sleepiness, snoring, witnessed apneicspells, and a body mass index over 35 have a greater than 70% probabilityof having sleep apnea . Patients who have these symptoms, narcolepsy,or sleepwalking should be referred for polysomnography. Additionally, pa-tients who have daytime sleepiness, especially those with occupations suchas pilot or truck driver, should have sleep studies done.
A good history may uncover an important perceived insomnia caused by the variations in the periodicity of the biologic clocks that create the phe-nomenon of the ‘‘owl,’’ or type B, and the ‘‘lark,’’ or type A persons. Thesetendencies appear to be genetically predetermined, but may change over thelife cycle. Adolescents tend to have a natural sleep phase delay, and are owls,up late and wanting to wake later, and the elderly tend to have a naturalphase advance, and are larks who go to bed early and arise early. These var-iations are not true insomnia.
Insufficient sleep syndrome probably represents the most common cause of excessive sleepiness in the general population. One third of normal adultsappear to get inadequate sleep because of lifestyle choices or stimuli People who ‘‘choose’’ to sleep fewer than 7 hours a night because of workingtwo jobs, staying up late watching television, studying, or carrying for a sickchild, suffer from insufficient sleep, not insomnia.
Four out of ten insomniacs self-medicate with an over-the-counter medi- cine or alcohol . The most common treatments used by persons who havechronic insomnia are over-the-counter antihistamines, alcohol, and prescrip-tions medicines . Over 11% of Americans report using either prescription(6%) or over-the-counter medicines (6%) at least a few nights each month tohelp them sleep, according to a 2002 Sleep in America Poll .
Treatments for insomnia are considered effective if they decrease sleep onset latency or increase total sleep time by 30 minutes. Most treatmentstudies use patient-reported sleep diaries to measure outcome. Criteriaused include total sleep time, sleep-onset latency, and number of nocturnalawakenings. Recognized insomnia treatments include: (1) non pharmaco-logic (cognitive and behavioral therapy), and (2) pharmacologic, with threetypes of prescription medicines (benzodiazepines, nonbenzodiazepines, andantidepressants).
Cognitive-behavioral therapies (CBTs) comprise several components: (1) cognitive understanding of sleep, (2) sleep hygiene, (3) relaxation training, (4) stimulus control, and (5) sleep restrictions. Cognitive therapy involves re-structuring how a person views sleep; it dispels anxiety-producing beliefsand erroneous beliefs about sleep and sleep lost, such as the negativethoughts, ‘‘I will never get to sleep,’’ ‘‘I have a chemical imbalance that re-quires a pill to sleep,’’ or ‘‘If I don’t get to sleep now, I will have a terribleday tomorrow.’’ Many insomniacs feel powerless in their sleep struggles, and have poor understanding about their role in their insomnia. Improving sleep hygieneencourages behaviors that enhance sleep and avoids behaviors that interferewith sleep initiation or maintenance (a list of do’s and don’ts) .
The third component of CBT is relaxation training, which can reduce the physiological and cognitive arousal at bedtime that often interferes withsleep initiation. Techniques include progressive muscle relaxation, medita-tion, and yoga. These techniques have been shown to be effective comparedwith the age-old ‘‘counting sheep.’’ Stimulus control, the fourth component of CBT, involves re-establishing the bedroom for only sleep (and sex). One should not watch television, listento music or audio tapes, check e-mail, answer cell phones, solve family prob-lems, or read in bed. If one is not asleep within 20 minutes of lying down,one is to leave the bed and do quiet activities in another room. One returnsto bed only when tired. The process is repeated until sleep is initiated.
The final component is sleep restrictions. The patient determines how much sleep is needed and then restricts time in bed with rigid bed and risetimes, even if sleep wasn’t successful the night before. Daytime naps are Box 1. Sleep hygiene: a list of do’s and don’ts Do’sRegular exercise in morning or afternoonRelaxing bedtime activitiesIncrease bright light during the dayComfortable sleep environment: dark, cool, quiet, safe, Don’tsNo strenuous exercise 3 hours before bedNo eating or drinking 3 hours before bedNo stimulants: caffeine or nicotineNo alcoholNo daytime nappingLimit bright light at nightNo clock in bedroom discouraged because they may aggravate the following nights’ sleep prob-lems. These times should also be followed on the weekends.
CBTs have been shown to be effective for the treatment of chronic insom- nia in randomized controlled trials Therapy is less expensive than med-ications, benefits last beyond the therapy, and there are no adverse sideeffects. Stimulus control therapy was found effective and superior to pro-gressive muscle relaxation, imagery training, and paradoxical intention (pro-hibiting sleep until a certain hour). Progressive muscle relaxation wassuperior to placebo. Although CBTs have demonstrated efficacy, few clini-cians are skilled in them, and therefore they are not in widespread use. Phy-sicians are more apt to write a prescription than counsel in CBTs or refer tosomeone who is trained in CBTs.
Other proposed insomnia treatments include tai chi, which may improve sleep quality (level 2 evidence) in inactive adults greater than 60 years oldA program of regular exercise may be useful in the treatment of pa-tients who have sleep disorders. Warm baths before bed, wearing socks tobed (proposed to improve sleep by improving vasodilatation), yoga, acu-puncture, and light therapy have not been adequately evaluated.
The Food and Drug Administration (FDA) has approved eight medica- tions for insomnia, and seven are approved for 35 days or less. Only the re-cently FDA-approved eszopiclone (Lunesta) has no restriction on durationof use . Yet an estimated 0.5% of the population takes sedative medica-tions nightly for insomnia for more than 1 year . Benzodiazepine recep-tor agonists fall into two broad groups of prescription hypnotics: (1)benzodiazepinesdestazolam (Prosam), flurazepam (Dalmane), quazepam(Doral), temazepam (Restoril), and triazolam (Halcion); and (2) the morerecent agents that act at benzodiazepine receptors, but have nonbenzodiaze-pine structuresdzaleplon (Sonata), zolpidem (Ambien), and eszopiclone(Lunesta). Several studies show that benzodiazepines and nonbenzo-diazepines are effective in the short-term management of insomnia; however,with the exception of eszopiclone, long-term use of either benzodiazepinesor nonbenzodiazepines has not been studied using randomized controlledtrials. Furthermore, all of these medications have adverse effects, includingdaytime sedation, cognitive impairment, motor incoordination, dependence,and rebound insomnia, and the problems are more pronounced in the el-derly . In a meta-analysis of hypnotics in the elderly , sedativeswere associated with a statistically significant improvement in sleep quality(number needed to treat 13). Although effective, adverse effects were signif-icant (number needed to harm was 6). The most common adverse reportswere fatigue, headache, nightmares, and nausea. Cognitive effects, includingmemory loss and confusion, daytime fatigue, and impairment of perfor-mance tasks, were significantly more common with sedative use (number needed to harm 22). Psychomotor problems were more common with seda-tive use, including seven serious falls and one motor vehicle collision, but thedifference did not reach statistical significance . Sedative hypnotics are as-sociated with a small improvement in some aspects of sleep in older patients,but this therapy also carries significant risk of adverse events. Sedative-hyp-notics are not recommended in the elderly because risks may outweigh benefits(Grade B recommendation). In 2007, the FDA requested that all manufac-turers of sedative-hypnotic drug products (Ambien/Ambien CR, ButisolSodium, Carbrital, Dalmane, Doral, Halcion, Lunesta, Placidyl, Prosom, Re-storil, Rozerem, Seconal, and Sonata), strengthen their product labeling to in-clude stronger language concerning potential risks. These risks include severeallergic reactions and complex sleep-related behaviors, which may includesleep driving. Sleep driving is defined as driving while not fully awake after in-gestion of a sedative-hypnotic product, with no memory of the event.
The use of short-acting agents does not appear safer than long-acting agents. Zolpidem (Ambien) or zaleplon has a shorter duration of actionthan benzodiazepines and proposed fewer adverse effects, but there are nodirect comparison trials. In one study zolpidem (Ambien) use was as-sociated with significant increased risk of hip facture (adjusted odd ratio,[AOR] 1.95) compared with benzodiazepines (AOR 1.46) and antipsychotics(AOR 1.61).
Because of these risks of hypnotics, physicians have changed their pre- scribing practices for insomnia in the past 20 years from benzodiazepinesto antidepressants Trazodone (Desyrel) is now the most commonly pre-scribed medication for insomnia in the United States . Trazodone is se-dating and improves several sleep parameters; however, there is no longterm use study of trazodone or other antidepressants for chronic insomnia.
Further, some antidepressants, such as the SSRIs, may cause insomnia.
Also, the tricyclics may worsen restless legs syndrome and periodic limbmovements . More sedating antidepressants have been prescribed inlow doses for insomnia. In the absence of clinical depression, the evidenceto support the use of antidepressants for chronic insomnia is less clear.
The FDA recently approved ramelteon (Rozerem), a melatoninin receptor agonist for persons having problems falling asleep. No published studies havecompared ramelteon with melatonin, which is over-the-counter and muchless expensive. The biological action of ramelteon is similar to melatoninand nonaddictive. The prescription ramelteon product is more likely to bepure. In a couple of randomized trials of short duration (5 weeks or less)with placebo, ramelteon demonstrated improved sleep latency (8 minutes av-erage) in patients 65 years and older who had chronic insomnia ; how-ever, in patients younger than 65 there was no difference in sleep parametersbetween ramelteon and placebo The expense of the drug (more than $90per month) may not be worth the small benefit, if any, in getting to sleep.
Although most medications are discouraged in pregnancy, especially in the first trimester, the FDA Pregnancy Category ratings B for zolpidem (Ambien), C for zaleplon, eszopiclone and ramelteon, and Category D or Xfor all benzodiazepines .
A recent meta-analysis found no difference in outcomes between pharmacotherapy and behavioral therapy, except that behavioral therapymore significantly decreased sleep latency, was less expensive, and had fewerside effects. In the only randomized controlled trial of CGT versuszopicolone, however, CBT was superior to zopicolone in most outcomes.
Zopiclone did not differ from placebo in either short-term or long-term(6 months) evaluations. Measured outcomes included both sleep diariesand polysomnographic data. Although CBT has more lasting effect, phar-macotherapy has a more rapid onset, and may be used if the patient willbenefit from the more rapid effect of drug therapies while pursuing behaviormodifications.
For peri/postmenopausal women who have insomnia, a randomized con- trolled trial found that eszopiclone provided significant improvementsin sleep, and positively impacted mood, quality of life, and menopause-related symptoms.
A number of unapproved medications have been used for the treatment of insomnia. Antihistamines such as diphenhydramine (Benadryl) are themost commonly used over-the-counter treatment for insomnia, althoughthere is no evidence for efficacy. The elderly especially have significant ad-verse effects from these medicines, including daytime sedation, diminishedcognitive function, and delirium, as well as dry mouth, blurred vision, uri-nary retention, constipation, and risk of increased intraocular pressure inpersons who have narrow angle glaucoma. Several herbal products suchas L-tryptophan, melatonin, and valerian have been touted to improvesleep. Melatonin may be helpful in a subset of insomnia patients. There isno known risk of harm, although long-term use has not been studied. Mel-atonin, a natural hormone produced by the pineal gland, plays a role in thecontrol of circadian rhythms. Because melatonin is not regulated by theFDA and concentrations vary in strength, studies are difficult. Melatoninwas shown to be effective over placebo in the treatment of circadian rhythmdisorders (jet lag) but its effectiveness for chronic insomnia or an effec-tive dose is undetermined. Valerian is derived from the root of the plant va-leriana, and also is not regulated by the FDA. Limited studies do not showany benefit when compared with placebo in chronic insomnia. Further, thecase reports of hepatotoxicity are troubling. There is not sufficient evidenceon the effectiveness or safety of L-tryptophan in the management of chronicinsomnia.
Consensus groups from Canada, England, and the United States have all proposed clinical guidelines for the management of chronic insomnia Treatment of insomnia should be individualized based on the natureand severity of symptoms. Causes and comorbidities should be soughtand treated. If insomnia persists, cognitive and behavioral therapies shouldbe started first; pharmacologic treatment should be considered an adjunct treatment for insomnia, and prescribed for short-term use only. Patientswho have insomnia need regular follow-up like those who have otherchronic conditions Sleep is a good indicator of health. Sufficient sleep, like nutrition and ex- ercise, is an essential component of a healthy lifestyle. Although sleep prob-lems are common, they are often undiagnosed; patients who have insomniaseldom volunteer their concerns with their physician. Insomnia can usuallybe diagnosed with clinical suspicion and complete histories and examina-tions. Sleep problems often coexist with psychiatric and medical conditions.
The initial treatment of chronic insomnia most often should be cognitiveand behavioral therapies. Clinicians need to either become skilled in the be-havioral treatments, or refer to providers who can offer these valuable 1. Determine if insomnia causes daytime problems for patient 2. Identify and treat the causes of insomnia if present.
3. If insomnia persists, use behavioral treatments first (learn how to counsel or where to refer patient).
Behavioral treatment is ineffective or the person is unwilling Person is suffering insomnia-related distress and beginning Insomnia is temporary or short-termInsomnia is expected or occurs with known condition (use of steroids) or event (traveling across time zones),and course is limited For short periods only (few days or intermittent 3Â/wk)Lowest effective doseCheapest (no firm evidence of differences in the effects of zaleplon, zolpidem (Ambien), zopiclone, and theshorter-acting benzodiazepines) Don’t prescribe a different one if first doesn’t work unless 6. Close follow-up whether behavioral, pharmacologic treatments. If pharmacologic treatment is needed, careful guidelines shouldbe adhered to minimize harm. Since The National Center on Sleep Disor-ders Research was established in 1993, sleep and sleep disorders are betterunderstood, but much work remains to be done to understand the mecha-nisms that link sleep to health and how we can improve both for ourpatients.
[1] National Sleep Foundation. Sleep in America poll. Washington, DC: National Sleep Foun- [2] Pearson NJ, Johnson LL, Nahin RL. Insomnia, trouble sleeping, and complementary and alternative medicine: analysis of the 2002 National Health Interview Survey data. ArchIntern Med 2006;166(16):1775–82.
[3] Almeida OP, Pfaff JJ. Sleep complaints among older general practice patients: association with depression. Br J Gen Pract 2005;55(520):864–6.
[4] Archbold KH, Pituch KJ, Panahi P, et al. Symptoms of sleep disturbances among children at two general pediatric clinics. J Pediatr 2002;140(1):97–102.
[5] Johnson EO, Roth T, Schultz L, et al. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics 2006;117(2):e247–56.
[6] Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. Sleep 1999;22(2):S347–53.
[7] American Psychiatric Task Force on DMS-IV. Diagnosis and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association; 1994.
[8] Sateia MJ, Nowell PD. Insomnia. Lancet 2004;364:1959–73.
[9] Graeber RC. Jet lag and sleep disruption. In: Kryger MH, Roth T, Dement WC, editors.
Principles and practice of sleep medicine. Philadelphia: WB Saunders; 1994. p. 463–70.
[10] Zee PC, Turek FW. Sleep and health: everywhere and in both directions. Arch Intern Med [11] Peppard PE, Szklo-Coxe M, hia KM, et al. Longitudinal association of sleep related breath- ing disorder and depression. Arch Intern Med 2006;66:1709–15.
[12] Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disor- ders: an opportunity for prevention? JAMA 1989;262:1479–84.
[13] Breslau N, Roth T, Rosenthal L, et al. Sleep disturbances and psychiatric disorders: a longi- tudinal epidemiological study of young adults. Biol Psychiatry 1996;39:411–8.
[14] Balter MB, Uhlenhuth EH. New epidemiologic findings about insomnia and its treatment.
[15] Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness.
Arch Intern Med 1998;158(10):1099–107.
[16] Hauri PJ, Fisher J. Persistent psychophysiologic (learned) insomnia. Sleep 1986;9:38–53.
[17] Gislason T, Reynisdottir H, Krisbjarnarson H, et al. Sleep habits and sleep disturbances among the elderlydan epidemiological survey. J Intern Med 1993;234(1):31–9.
[18] Roberts RE, Shema SJ, Kaplan GA. Prospective data on sleep complaints and associated risk factors in an older cohort. Psychosom Med 1999;61(2):188–96.
[19] Ohayon M. Epidemiological study on insomnia in the general population. Sleep 1996; [20] Mellinger GD, Balter MB, Uhlenhuth EH. Insomnia and its treatment. Arch Gen Psychiatry [21] Simon GE, Vonkorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry 1997;154(10):1417–23.
[22] Foley D, Ancoli-Israel S, Britz P, et al. Sleep disturbances and chronic diseases in older adults: results of 2003 National Sleep Foundation Sleep in America Survey. J PsychosomRes 2004;56(5):497–502.
[23] Kupperman M, Lubeck DP, Mazonson PD, et al. Sleep problems and their corelates in a working population. J Gen Intern Med 1995;10:25–32.
[24] Zammit GK, Weiner J, Damato N, et al. Quality of life in people with insomnia. Sleep 1999; [25] McMurray SM, Vitello MV, Gibbons LE, et al. Factors associated with caregiver reports of sleep disturbances in persons with dementia. Am J Geriatr Psychiatry 2006;14:112–20.
[26] Ancoli-Israel S, Parker L, Sinaee R, et al. Sleep fragmentation in patients from a nursing [27] Bixler EO, Scharf MB, Soldatos CR, et al. Effects of hypnotic drugs on memory. Life Sci [28] Janson C, Linberg E, Gislason T, et al. Insomnia in menda 10 year prospective population based study. Sleep 2001;24(4):425–30.
[29] Ohayon MM, Zulley J, Guilleminault C, et al. How age and daytime activities are related to insomnia in the general population: consequences for older people. J Am Geriatr Soc 2001;49(4):360–6.
[30] Foley DJ, Monjan A, Simonsick EM, et al. Incidence and remission of insomnia among el- derly adults: an epidemiologic study of 6800 persons over three years. Sleep 1999;22(Suppl 2):S366–72.
[31] Benca RM, Ancoli-Israel S, Moldofsky H. Special considerations in insomnia diagnosis and management: depressed, elderly, and chronic pain populations. J Clin Psychiatry 2004;65(Suppl 8):26–35.
[32] Kravitz HM, Janssen I, Santoro N, et al. Relationship of day-to-day reproductive hormone levels to sleep in midlife women. Arch Intern Med 2005;165(20):2370–6.
[33] Santiago JR, Nolledo MS, Kinzler W, et al. Sleep and sleep disorders in pregnancy. Ann [34] Meltzer LJ, Mindell JA. Impact of child’s chronic illness on maternal sleep and daytime func- tioning. Arch Intern Med 2006;166:1749–55.
[35] Ohayon MM. Severe hot flashes are associated with chronic insomnia. Arch Intern Med [36] Diagnostic Classification Steering Committee. The International classification of sleep dis- orders, revised: diagnostic and coding manual. Rochester (MN): American Sleep DisordersAssociation; 1997.
[37] Reid S, Dwyer J. Insomnia in HIV infection: a systematic review of prevalence, correlates, and management. Psychosom Med 2005;67(2):260–9.
[38] Roth T. The relationship between psychiatric diseases and insomnia. Int J Clin Pract 2001; [39] Cricco M, Simonsick EM, Foley DJ. The impact of insomnia on cognitive functioning in older adults. J Am Geriatr Soc 2001;49(9):1185–9.
[40] Liu Y, Tanaka H. Overtime work, insufficient sleep, and risk of non fatal acute myocardial infarction in Japanese men. Occup Environ Med 2002;59:47–51.
[41] Drewes AM, Svedsen L, Taagholt SJ, et al. Sleep in rheumatoid arthritis: a comparison with healthy subjects and studies of sleep/wake interactions. Br J Rheumatol 1998;25:1191–7.
[42] Harding SM. Sleep in fibromyalgia patients: subjective and objective findings. Am J Med Sci [43] Leger D, Guilleminault C, Bader G, et al. Medical and socio-professional impact of insom- [44] Walsh JK. Clinical and socioeconomic correlates of insomnia. J Clin Psychiatry 2004; [45] Hatoum HT, Kania CM, Kong SX, et al. Prevalence of insomnia: a survey of enrollees in five managed care organizations. Am J Manag Care 1998;4:79–86.
[46] Carskadon MA, Dement WC, Mitler MM, et al. Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints of chronic insomnia. Am J Psychiatry 1976;133:1382–8.
[47] National Sleep Foundation. Survey of primary care physicians. Available at: [48] Montplaisir J, Boucher S, Poirier G, et al. Clinical, polysomnographic, and genetic charac- teristics of restless legs syndrome: a study of 133 patients diagnosed with new standardcriteria. Mov Disord 1997;12:61–5.
[49] Walsh JK, Benca RM, Bonnet M, et al. Insomnia: assessment and management in primary care. National Heart, Lung, and Blood Instititue Working Group on Insomnia. Am FamPhysician 1999;59:3029–38.
[50] Meyer TJ. Evaluation and management of insomnia. Hosp Pract 1998;33:75–8, 83–6.
[51] Brower KJ, Aldrich MS, Robinson EA, et al. Insomnia, self medication and relapse to alco- holism. Am J Psychiatry 2001;158(3):399–404.
[52] Ancoli-Israel S. All I want is a good night’s sleep. Chicago: Mosby-Year Book Inc.; 1996.
[53] Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. an update. Arch Intern Med 1997;157(14):1531–6.
[54] American Sleep Disorders Association. Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. Standards of Practice Committee of the Amer-ican Sleep Disorders Association. Sleep 1994;17:372–7.
[55] Bonnet MH, Arand DL. We are chronically sleep deprived. Sleep 1995;18:908–11.
[56] National Sleep Foundation. Sleep in America poll. 2002. Washington, DC: National Sleep [57] Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55þ years of age.
Health Psychol 2006;25(1):3–14.
[58] Li R, Fisher KJ, Harmer P, et al. Tai chi and self-rated quality of sleep and daytime sleepiness in older adults: a randomized controlled trial. J Am Geriatr Soc 2004;52(5):892–900.
[59] Treatment guidelines from the medical letter. The Medical Letter on Drugs and Therapeutics.
[60] National sleep Foundation. Sleep in America poll. Data from 1997 and 2001, 2002 sleep poll.
[61] Holbrook AM, Crowther R, Lotter A, et al. Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ 2000;162:225–33.
[62] Glass J, Lanctot KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331:1169–73.
[63] Gray SL, LaCroix AZ, Hanlon JT, et al. Benzodiazepine use and physical disability in com- munity-dwelling older adults. J Am Geriatr Soc 2006;54(2):224–30.
[64] Roth T, Seiden D, Sainati S, et al. Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia. Sleep Med 2006;7(4):312–8.
[65] Ramelteon Ramelteon (Rozerem) [package insert]. Lincolnshire (IL): Takeda Pharmaceuti- cals North America; 2005. Available at: . Accessed August 8, 2005.
[66] Smith M, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5–11.
[67] Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treat- ment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA2006;295(24):2851–8.
[68] Soares CN, Joffe H, Rubens R, et al. Eszopiclone in patients with insomnia during perime- nopause and early postmenopause: a randomized controlled trial. Obstet Gynecol 2006;108(6):1402–10.
[69] Buscemi N, Vandermeer B, Hooton PR, et al. Melatonin for treatment of sleep disorders.
Evidence report/technology assessment No 108. AHRQ Publication No. 05-E002-1. Rock-ville (MD): Agency for Healthcare Research and Quality; 2004.
[70] National Institutes of Health State-of-the-Science Conference statement: Manifestations and management of chronic insomnia in adults. 2005. Available at: [71] Buscemi N, Vandermeer B, Friesen C, et al. Manifestations and management of chronic insomnia in adults. Evidence report/technology assessment. Agency for Healthcare Re-search and Quality 2005;125:1–11.
[72] National Institute for Clinical Excellence (NICE). Zaleplon, zolpidem and zopiclone for short-term management of insomnia. Available at: .

Source: http://www.spbu.com.uy/pdf/Curso_EMC_2008/insomnia_an_ignored_problem_Prim_Care_Clin_Office_Pract_07_Dra_Labraga.pdf