D Green MD

1. Review prevalence of chronic insomnia in primary care settings 2. Describe types of chronic insomnia 3. Learn about CBT-I 4. Review how it can be adapted for primary care 5. Review pharmacotherapy for chronic insomnia

 Estimated that 52%-64% of patients in primary care have sleep complaints  10%-14% have severe insomnia that interferes with daytime functioning  Tends not to resolve on its own  Consequence is: ◦ Psychiatric risk ◦ Workplace disability ◦ Increased healthcare utilization ◦ Decreased quality of life

 Complaint of difficulty initiating or maintaining sleep or  Nonrestorative sleep despite adequate opportunity for sleep  With associated distress or impairment of daytime functioning  “Chronic” insomnia applies if insomnia has lasted one month or more

 Routinely ask about it  Rule out other conditions that can cause it including medications, a medical condition or another sleep disorder  Note: insomnia is usually accompanied by fatigue, not sleepiness  Patients who are sleepy more often have another sleep disorder

 Chronic insomnia can co-occur with depression, anxiety and in a variety of medical conditions  Shift away from term “secondary insomnia”  Important to treat comorbid insomnia early and not wait for it resolve with treatment of the other condition  Difficult to know which condition came first in some cases and they can have reciprocal effects

 Unlike acute insomnia it is likely to be maintained by factors that are distinct from the initial triggers  Patterns of hyper-arousal and sleep difficulty are believed to be maintained by behavioural and cognitive factors

 Recommended first line treatment for chronic insomnia  Shown to be effective also in comorbid insomnia  Set of strategies that patients learn in order to allow their biological sleep processes to operate without interference

 Restrictive scheduling of time in bed ( sleep restriction therapy)  Associating the bed and bedroom with sleep (stimulus control therapy)  Cognitive and behavioural techniques to facilitate de-arousal (relaxation techniques and sleep-specific cognitive therapy)

 Can be offered in individual or group sessions  Can be delivered by psychologists but also by physicians, NPs, nurses and other health professionals  A Scottish study found it effective when delivered by nurses in family medicine settings  Longitudinal studies show benefits for up to 2 years and longer

 CBT-I is more than sleep hygiene  By the time insomnia becomes chronic most patients are already following guidelines for good sleep hygiene  Sleep hygiene by itself for chronic insomnia is not supported by the evidence

 Family physicians can learn CBT-I but may not have time to offer it  Can still offer some brief behavioural advice based on principles of CBT-I  Can also use a sleep diary

 Have patient complete a sleep diary for a week  Examine the sleep diary for variation in bedtimes and rise times so you can tailor your advice  Help the patient figure out an appropriate initial bedtime and rise time by estimating how much sleep they are getting at baseline

 Ask them to choose a representative night  For that night estimate the total time in bed and subtract the time awake  This provides an estimate of time asleep  You then suggest the patient be in bed for only this amount of time plus 30 minutes (“initial sleep window”)  Do not set this number below 5 hours

 Patients choose a rise time that can be maintained 7 days a week and the bedtime is set according to the initial sleep window  Send the patient home with blank sleep diaries and arrange a follow-up appt. in 1 week to review progress  Warn patient about excessive daytime sleepiness that can occur and caution them about driving if drowsy

 Between 2 and 4 appts may be needed to adjust sleep window according to patient’s progress in increasing “sleep efficiency’  The rise time stays constant while the bedtime is adjusted earlier as sleep efficiency rises  As sleep becomes more solid the sleep window is widened, usually by 15 minutes at a time  This continues until solid sleep is long enough for the patient to feel rested and function well during the day

 Treatment for acute, situational insomnia  However acute insomnia sometimes progresses to a chronic condition  BDZ s and “Z-drugs (zopiclone and zolpidem) are currently the standard medications for insomnia  Both classes carry risks and caution is warranted

 Trazodone  Mirtazapine  Paucity of research on dose-related efficacy and safety of these medications in non-depressed patients  Prolonged release melatonin may be helpful and safe although few long term studies available  Standard release melatonin, if carefully timed, can reduce eastbound jet lag, and help shift workers sleep during the day  Intermittent use of Z drugs may be an option for some

 Slow tapering is recommended to prevent rebound insomnia  Best done in conjunction with CBT-I, or at least behavioural advice  One study showed that 85% of patients receiving both medication taper and CBT-I successfully discontinued their BDZ compared with 48% with taper alone

 Chronic insomnia is common in primary care  CBT-I is an effective treatment for primary and comorbid insomnia  Elements of CBT-I can be adapted for primary care settings  Pharmacotherapy can be used but evidence limited for long term therapies

1. Davidson, Judith, Treating Chronic Insomnia in Primary Care – Early Recognition and Management. Insomnia Rounds. 2012; Vol 1ssue 3