Insomnia is a major health care problem encountered by a large majority of the adult population. It is defined as dissatisfaction with sleep quantity or quality and is associated with difficulty initiating or maintaining sleep and early-morning waking with inability to return to sleep. Approximately 6% to 10% of adults have insomnia that meets diagnostic criteria. Insomnia is more common in women and older adults and can occur independently or be caused by another disease. People with the disorder often experience fatigue, poor cognitive function, mood disturbance, and distress or interference with personal functioning. Insomnia also takes a toll on the economy in terms of loss of workplace productivity.
Chronic insomnia, also referred to as “chronic insomnia disorder” in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is diagnosed according to the DSM-5 and the International Classification of Sleep Disorders, which have similar criteria for making the diagnosis. These criteria specify that symptoms must cause clinically significant functional distress or impairment; be present for at least 3 nights per week for at least 3 months; and not be linked to other sleep, medical, or mental disorders. Symptoms of insomnia differ between older adults and the younger population. Older adults are more likely to report problems with waking after sleep onset (difficulty maintaining sleep) than they are to report problems with sleep onset latency (time to fall asleep).
In July 2016, The American College of Physicians (ACP) came out with clinical practice guidelines on management of chronic insomnia disorder in adults. Following are its major recommendations
Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)
Cognitive behavioral therapy for insomnia consists of a combination of treatments that include cognitive therapy around sleep, behavioral interventions (such as sleep restriction and stimulus control), and education (such as sleep hygiene). It can be performed in primary care. There are various delivery methods for CBT-I, such as individual or group therapy, telephone- or Web-based modules, or self-help books. Most studies focused on in-person CBT-I; however, the data suggest that other delivery methods are also effective.
Cognitive behavioral therapy for insomnia should be considered first-line treatment for adults with chronic insomnia disorder. Although the current evidence is insufficient to show the harms associated with behavioral interventions, any such harms are likely to be mild. Moderate-quality evidence showed that CBT-I improved global outcomes in the general population, including increased remission and treatment response and reduced ISI and PSQI scores compared with controls. Moderate-quality evidence showed that CBT-I also improved sleep outcomes in the general population, including reduced sleep onset latency and wake after sleep onset and improved sleep efficiency and sleep quality. Low- to moderate-quality evidence showed that CBT-I also improved global and sleep outcomes in older adults, including improved PSQI and ISI scores, reduced sleep onset latency, and improved sleep efficiency. Moderate-quality evidence showed that CBT-I reduced wake after sleep onset in older adults.
Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)
Benefits of pharmacologic treatment include improved sleep outcomes, such as sleep onset latency and total sleep time, and in some cases improved global outcomes in the general population and in older adults. Most studies have examined newer medications, whereas commonly used older and generic medications, such as diphenhydramine and trazodone, have not been studied. Low-quality evidence showed that both eszopiclone and zolpidem improved global outcomes in the general population, and low- to moderate-quality evidence showed that eszopiclone, zolpidem, and doxepin improved sleep outcomes, such as sleep onset latency, total sleep time, and wake after sleep onset. Moderate-quality evidence showed that suvorexant, an orexin antagonist recently approved by the FDA, improved treatment response and sleep outcomes in mixed general and adult populations. Low-quality evidence showed no statistically significant difference between ramelteon and placebo for sleep outcomes in the general population.
In older adults, low-quality evidence showed that eszopiclone improved global and sleep outcomes and both zolpidem and ramelteon decreased sleep onset latency. Moderate-quality evidence showed that doxepin improved ISI scores, and low- to moderate-quality evidence showed that it improved sleep outcomes.
Evidence was insufficient for melatonin in the general population and in older adults. Benzodiazepines, although widely used, were not addressed in this guideline because few studies met the inclusion criteria of the systematic review (insufficient evidence).
There was insufficient evidence overall on the comparative effectiveness and safety of the various pharmacologic treatments.
To read the complete guidelines, click on the following link: