Treatment Of Chronic Insomnia Research Articles

Insomnia.

This article provides updated information regarding the diagnosis and treatment of chronic insomnia disorder. In addition to discussing the latest recommendations regarding pharmacotherapeutic options for insomnia, this article also discusses the increased use of nonpharmacologic treatment approaches, including cognitive-behavioral therapy intervention, integrative medicine, mindfulness and meditation, and other therapeutic options in clinical practice. Insomnia is one of the most common sleep disorders in patients with other neurologic disorders. The definition and criteria for insomnia were updated with the release of the International Classification of Sleep Disorders, Third Edition. The American Academy of Sleep Medicine has updated clinical practice guidelines for the pharmacologic treatment of chronic insomnia in adults. New diagnostic and therapeutic options (eg, pharmacologic and behavioral therapies, at-home devices) have emerged to optimize and personalize the evaluation and management of sleep disorders such as insomnia. Although some of these devices and treatment options are still in the early stages of development, several are currently in clinical trials or will soon be available. This article emphasizes complexities related to the evaluation and management of patients with chronic insomnia disorder and describes alternative therapeutic options for patients with this common sleep disorder.

Effect of Tongdu Tiaoshen needling in treatment of chronic insomnia by regulating the hypothalamic-pituitary-adrenal axis

To investigate the clinical effect of Tongdu Tiaoshen needling in the treatment of chronic insomnia and its mechanism based on the hypothalamic-pituitary-adrenal (HPA) axis. A total of 60 patients with chronic insomnia were randomly divided into treatment group and control group, with 30 patients in each group. In addition to the health education on sleep, the patients in the treatment group were given Tongdu Tiaoshen needling, i．e., electroacupuncture at Baihui (GV20), Shenting (GV24), Yintang (EX-HN3), bilateral Shenmen (HT7), and bilateral Sanyinjiao (SP6), and those in the control group were given superficial acupuncture at Shousanli (LI10), Futu (ST32), and Feiyang (BL58) at both sides, once every other day and three times a week for 4 consecutive weeks. Before and after treatment, the Pittsburgh Sleep Quality Index (PSQI) was used to assess the quality and efficiency of sleep, and ELISA was used to measure the serum levels of corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and corticosterone (CORT). After treatment, the treatment group had significant reductions in the total PSQI score and the score of each component of PSQI (P<0.01), and the control group had significant reductions in the total PSQI score (P<0.01) and the scores of all components except sleep duration (P<0.05); compared with the control group, the treatment group had significantly lower total PSQI score and the score of each component (P<0.01). After treatment, the treatment group had significant reductions in the serum levels of CRH, ACTH and CORT (P<0.05，P <0.01), and compared with the control group, the treatment group had significant reductions in the serum levels of CRH, ACTH and CORT (P<0.01，P<0.05). Tongdu Tiaoshen needling has a good clinical effect in the treatment of chronic insomnia and can significantly improve the sleep condition of patients with chronic insomnia, possibly by reducing the hormones associated with the HPA axis.

Long-term benefits of digital cognitive behavioural therapy for insomnia: Follow-up report from a randomized clinical trial.

Digital cognitive behavioural therapy (dCBT) is an effective treatment for chronic insomnia and also improves well-being and quality of life (QoL). We assessed whether these benefits are sustained and if the effects of dCBT extend to the use of sleep medication and healthcare. In total 1,711 adults (48.0±13.8years, 77.6% female) with complaints of chronic insomnia participated in a previously published randomized controlled trial (ISRCTN 60530898) comparing dCBT (n=853) with sleep hygiene education (SHE, n=858). At weeks 0, 4, 8, 24, 36 and 48, we assessed functional health (Patient-Reported Outcomes Measurement Information System: Global Health Scale); psychological well-being (Warwick-Edinburgh Mental Well-being Scale) and sleep-related QoL (Glasgow Sleep Impact Index), prescribed and non-prescribed sleep medication use, and healthcare utilization. At week 25, those who received SHE at baseline were offered dCBT. dCBT improved functional health (difference: 2.45, 95% confidence interval [CI]: 2.03; 2.88, Cohen's d: 0.50, p<.001), psychological well-being (difference: 4.34, 95% CI: 3.70; 4.98, Cohen's d: 0.55, p<.001) and sleep-related QoL (difference: -44.61, 95%CI: -47.17; -42.05, Cohen's d: -1.44, p<.001) at week 48 compared to baseline. At week 24 dCBT, compared to SHE, also reduced use of prescription and non-prescription sleep medication up to week 24 (adjusted rate ratio [RR]: 0.64, 95% CI: 0.42; 0.97, p=.037 and adjusted RR: 0.52, 95% CI: 0.37; 0.74, p<.0001, respectively), but not healthcare utilization. Uncontrolled follow-up suggests that these effects were sustained for non-prescribed sleep medication (RR: 0.52, 95% CI: 0.40; 0.67, p<.001). In conclusion, this study suggests that dCBT results in sustained benefits to insomnia and its daytime outcomes.

Feasibility and treatment effect of cognitive behavioral therapy for insomnia in individuals with multiple sclerosis: A pilot randomized controlled trial

BackgroundAt least 40% of individuals with multiple sclerosis (MS) exercise chronic insomnia, and the prevalence is likely higher due to underdiagnosis. Poor sleep quality has been associated with increased fatigue, anxiety, depression, and risk of relapse in individuals with MS. While cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia, the treatment effect of CBT-I in people with MS is unclear. ObjectiveThis pilot randomized control trial (RCT) assessed the feasibility and treatment effect of CBT-I to improve sleep quality and fatigue in individuals with MS with symptoms of insomnia. MethodsThirty-three individuals with MS (30 females, 3 males; 30 relapsing-remitting; 3 secondary-progressive; 53.0 ± 9.4 years old) with symptoms of insomnia were randomized into one of three arms: 1. 6-week CBT-I program, 2. 6-week active control, or 3. Single session of sleep education. Participants completed surveys to assess sleep quality, fatigue, sleep self-efficacy, depression, and anxiety. ResultsCBT-I in individuals with MS is feasible with high retention and adherence rate. All groups experienced a large magnitude of improvement in insomnia symptoms. The CBT-I and brief education groups experienced a large magnitude of improvement in sleep quality and fatigue. Only the CBT-I group demonstrated a large magnitude of improvement in sleep self-efficacy and depression. ConclusionThis is the first study to prospectively demonstrates that CBT-I is feasible in people with MS and produces promising improvements in insomnia severity, sleep quality, sleep self-efficacy and comorbid symptoms of fatigue, depression, and anxiety. Future studies are needed to determine mechanisms for these improvements and expand the scope of individuals with MS who may benefit from CBT-I. Furthermore, considering the moderate to large improvements experienced by the brief education group and the limited number of CBT-I providers, a stepped-care approach warrants consideration.

Heartfulness meditation improves sleep in chronic insomnia

ABSTRACT Background Chronic insomnia is characterized by disturbed sleep that occurs despite adequate opportunity and circumstances to sleep. Many patients with chronic insomnia have comorbid mental illnesses or medical illnesses that contribute and precipitate insomnia. Hallmark of chronic insomnia treatment includes non-pharmacological measures such as Cognitive Behavioral Therapy for Insomnia (CBT-I). Pharmacologic treatment (sedative or hypnotic agents) has been disappointing because of poor efficacy and numerous undesirable side effects. Other new therapies including meditation have been proven to be effective. Objective This study investigates the effectiveness of Heartfulness meditation coupled with sleep hygiene to treat chronic insomnia. Methods: In this prospective pre-post design cohort study, 32 adult patients with chronic primary insomnia engaged in Heartfulness meditation along with appropriate sleep hygiene for eight weeks. Insomnia Severity Index (ISI) scores, usage of sedative or hypnotic agents were measured at baseline and at the end of the eight-week period. Results There was a significant decrease in the mean ISI scores from 20.9 to 10.4 (p < 0.001) after eight weeks of Heartfulness meditation. Twenty four of 32 patients were initially on sedative or hypnotic medications. At week eight, 21 of 24 patients (87.5%) were off these medications or the dosage was reduced (p < 0.001). Conclusion This study demonstrated statistical improvements in the measures of ISI in patients undergoing a Heartfulness meditation program. Heartfulness meditation may facilitate the taper and eventual cessation of sedative hypnotics in patients suffering from chronic insomnia.

Effect of Transcranial Alternating Current Stimulation for the Treatment of Chronic Insomnia: A Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Clinical Trial

Background: Not all adults with chronic insomnia respond to the recommended therapeutic options of cognitive behavioral therapy and approved hypnotic drugs. Transcranial alternating current stimulation (tACS) may offer a novel potential treatment modality for insomnia. Objectives: This study aimed to examine the efficacy and safety of tACS for treating adult patients with chronic insomnia. Methods: Sixty-two participants with chronic primary insomnia received 20 daily 40-min, 77.5-Hz, 15-mA sessions of active or sham tACS targeting the forehead and both mastoid areas in the laboratory on weekdays for 4 consecutive weeks, followed by a 4-week follow-up period. The primary outcome was response rate measured by the Pittsburgh Sleep Quality Index (PSQI) at week 8. Secondary outcomes were remission rate, insomnia severity, sleep onset latency (SOL), total sleep time (TST), sleep efficiency, sleep quality, daily disturbances, and adverse events at the end of the 4-week intervention and at the 4-week follow-up. Results: Of 62 randomized patients, 60 completed the trial. During the 4-week intervention, 1 subject per group withdrew due to loss of interest and time restriction, respectively. Based on PSQI, at 4-week follow-up, the active group had a higher response rate compared to the sham group (53.4% [16/30] vs. 16.7% [5/30], p = 0.009), but remission rates were not different between groups. At the end of the 4-week intervention, the active group had higher response and remission rates than the sham group (p < 0.001 and p = 0.026, respectively). During the trial, compared with the sham group, the active group showed a statistically significant decrease in PSQI total score, a shortened SOL, an increased TST, improved sleep efficiency, and improved sleep quality (p < 0.05 or p < 0.001). Post hoc analysis revealed that, in comparison with the sham group, the active group had improved symptoms, except for daily disturbances, at the end of the 4-week intervention, and significant improvements in all symptoms at the 4-week follow-up. No adverse events or serious adverse responses occurred during the study. Conclusion: The findings show that the tACS applied in the present study has potential as an effective and safe intervention for chronic insomnia within 8 weeks.

Effects of acupuncture on the hypothalamus-pituitary-adrenal axis in chronic insomnia patients: a study protocol for a randomized controlled trial

BackgroundAcupuncture, as an important component of traditional Chinese medicine (TCM), has been widely applied in the treatment of chronic insomnia in China, while there is no clinical study related to its therapeutic mechanism.Methods/designA single-center, single-blind, randomized, placebo-controlled trial will be conducted at Jiangsu Hospital of Traditional Chinese Medicine. A total of 60 patients will be registered. Eligible participants will be randomly divided into acupuncture group and sham acupuncture group (n = 30 cases in each group). Patients in both groups will be treated once every other day, three times per week for 4 weeks. The primary outcome measures are Pittsburgh Sleep Quality Index (PSQI) and concentrations of adrenocorticotropic hormone (ATCH), corticotrophin-releasing hormone (CRH), and cortisol (CORT). Secondary outcome measures are Insomnia Severity Index (ISI) and Fatigue Severity Scale (FSS).DiscussionThis study aims to evaluate the therapeutic effects of acupuncture on chronic insomnia by using PSQI, ISI, and FSS. The mechanism of acupuncture on CIPs will be preliminarily discussed by analyzing the changes in concentrations of CRH, ACTH, and CORT before and after treatment.Trial registrationChinese Clinical Trials Register, ChiCTR1800020298.

Psychosocial intervention for discontinuing benzodiazepine hypnotics in patients with chronic insomnia: a systematic review and meta-analysis

Summary Long-term benzodiazepine (BZD) use is not recommended in the treatment of chronic insomnia, and psychosocial interventions, particularly cognitive behavioral therapy for insomnia (CBT-I), are a potential treatment option for discontinuing BZDs. This systematic review and meta-analysis aimed to clarify whether psychosocial interventions are effective for discontinuing BZD hypnotics in patients with chronic insomnia. A literature search of major electronic databases was conducted up to July 2018. Two researchers independently selected relevant publications, extracted data, and evaluated methodological quality according to the Cochrane criteria. Eight randomized-controlled trials, all of which evaluated CBT-I, were included in this review, and meta-analyses were performed. The results indicated that short-term (≤3 mo) CBT-I plus gradual tapering was more effective than gradual tapering alone for discontinuing BZDs hypnotics (risk ratio: 1.68, 95% confidence interval [CI]: 1.19–2.39, p = 0.003) and for improving insomnia symptoms (g: −0.69, 95% CI: −1.09 – −0.28, p = 0.0009). However, the long-term (12 mo) efficacy of CBT-I for discontinuing BZDs was not significant (risk ratio: 1.67, 95% CI: 0.91–3.07, p = 0.10). Thus, CBT-I is effective for discontinuing BZD hypnotics for ≤3 mo. Further studies are needed to clarify the long-term efficacy of psychosocial interventions for discontinuing BZD hypnotics.

A mobile phone app administration of intensive sleep re-training treatment of chronic insomnia in the home environment

A mobile phone app administration of intensive sleep re-training treatment of chronic insomnia in the home environment

Sleep disorders in metropolitan residents

Every second patient has sleep disorder. Outcomes of decreased quality of sleep lead to serious medical and socioeconomic value. Population studies identify the main causes of sleep problems: stress, poor sleep hygiene, somatic disorders. The effect of stress on sleep is noted by 75% of responders. The most frequently sleep disorders are insomnia, obstructive sleep apnea and restless legs. Treatment of insomnia based on current standards for the management of patients with insomnia. The main methods for the treatment of chronic insomnia are cognitive behavioral therapy, short-term hypnotic pharmacotherapy or a combination of both. Z-hypnotics, benzodiazepine receptors agonists, melatonine and melatonine receptors agonists, antihistamines, antidepressants, neuroleptics, herbal and antiepileptic drugs are recommended for the treatment of chronic insomnia. Most of them are in tablet form. Cases of gradual cancellation of hypnotics, an increase in half-life of the drug and refusal of hypnotic drug for fear of lack of hypnotic side effects control, require individual selection of the dosage. Liquid form (in drops) of doxilamine from antihistamines group -Valocardine®-Doxilamine (Krewel Meuselbach GmbH, Germany) enables convenient dosing with addition potentiation of the effect due to combination with ethanol and mint oil.

Naturalistic Monitoring and Treatment of Chronic Insomnia

Naturalistic Monitoring and Treatment of Chronic Insomnia

Biofeedback Therapies for Chronic Insomnia: A Systematic Review.

The treatment of insomnia is still a challenge in clinical practice. This systematic review of randomized and quasi-randomized clinical trials aims to summarize the evidence for the use of biofeedback techniques in the treatment of chronic insomnia. Studies that compared biofeedback with other techniques of cognitive behavioral therapy, placebo, or absence of treatment were selected. The outcomes evaluated included sleep onset latency, total sleep time, sleep fragmentation, sleep efficiency and subjective sleep quality. Comparing to placebo and absence of treatment, some studies suggest possible benefits from the use of biofeedback for chronic insomnia in decreasing sleep onset latency and number of awakenings; however, there was marked divergence among included studies. There was no evidence of improvement in total sleep time, sleep efficiency and subjective sleep quality. Moreover, the maintenance of long-term benefits lacks evidence for any outcome. In the majority of outcomes evaluated, no significant differences in the effectiveness of biofeedback compared with other cognitive behavioral therapy techniques were observed. This systematic review found conflicting evidence for the effectiveness of biofeedback techniques in the treatment of chronic insomnia. Inter- and intra-group clinical heterogeneity among studies could be a reasonable explanation for the divergent results. These findings emphasize the need of performing further randomized clinical trials of higher methodological quality in order to better delineate the effectiveness of biofeedback on chronic insomnia treatment.

0391 Mindfulness Based Stress Reduction as a Treatment for Chronic Insomnia in Traumatic Brain Injury Patients

0391 Mindfulness Based Stress Reduction as a Treatment for Chronic Insomnia in Traumatic Brain Injury Patients

Mindfulness Based Stress Reduction as a treatment for Chronic Insomnia in Traumatic Brain Injury Patients (P3.6-023)

Mindfulness Based Stress Reduction as a treatment for Chronic Insomnia in Traumatic Brain Injury Patients (P3.6-023)

Non-drug and drug alternatives to benzodiazepines for insomnia in primary care: Study among GPs and pharmacies in a Southwest region of France

Benzodiazepines and related drugs are the most commonly prescribed drugs in the treatment of insomnia, and referral to psychotherapy is rare when recommended as first-line treatment for chronic insomnia. The frequency of referral to psychologists, of use of alternative drugs to benzodiazepines, either prescribed by general practitioners (GPs) or dispensed by community pharmacies, is unknown in France. We aimed to describe the non-pharmacological approaches recommended, such as cognitive behavioral therapies (CBT), and the drugs, including alternatives drugs to benzodiazepines, used by GPs and community pharmacies for patients complaining of insomnia. A cross-sectional study was conducted during 3 months in 2015 on the management of individual GPs' patients and pharmacies' customers consecutively consulting for insomnia in the Midi-Pyrénées region of southwest France. Participating GPs and pharmacists completed a form, for each patient, on their management (drugs, sleeping advices, referral to psychotherapy). Fifty-five GPs included 263 patients and 43 community pharmacies included 354 customers in the study. Among patients, 193 (73,4%) had already used benzodiazepine. Thirty-eight patients (14.4%) and 2 customers (0.5%) were recommended non-drug therapies (mostly CBT). Benzodiazepines were prescribed 188 times (69.1% of the prescriptions) by GPs. Alternative drugs prescribed were mostly antihistamines (n=26; 9.6%) and antidepressants (n=17; 6.3%). Antihistamines were the most commonly dispensed drugs by pharmacists (n=149; 39.4%). While non-pharmacological treatments, such as CBT, are safe and widely recommended, benzodiazepines and antihistamines remain widely used despite the lack of long term benefit and the risk of adverse drug reactions.

Delivering Cognitive Behavioral Therapy for Insomnia in the Real World: Considerations and Controversies.

Cognitive-behavioral therapy for insomnia (CBT-I) has emerged as the first-line treatment for chronic insomnia but remains massively underused relative to the prevalence of insomnia disorder. This article focuses on 3 key issues in the delivery of CBT-I in the real world. First, where and how should CBT-I be delivered and who should deliver it? Second, who is an appropriate candidate for CBT-I? Third, how do you measure quality care with CBT-I? These issues give rise to targets for future research aimed at improving the implementation science of CBT-I in the real world.

Efficacy of pumpkin oil (a Persian medicine product) in the treatment of chronic insomnia: A randomized double-blind clinical trial

Context: According to Persian medicine text, there are some topical herbal remedies for insomnia such as pumpkin oil as a nasal drop. Aims: To evaluate the effect of pumpkin oil (a Persian medicine product) in patients with chronic insomnia. Methods: This study was conducted as a randomized double-blind clinical trial on pumpkin oil efficacy in 74 patients with chronic insomnia. The participants received two drops of intranasal pumpkin oil or placebo every night for two weeks. The effects of pumpkin oil and placebo on the pattern of sleep and sleep quality were assessed at baseline and at the end of two weeks of treatment by Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) questionnaires. Results: The scores of the ISI questioner were statistically different between groups after two weeks of intervention and patients in the pumpkin oil group had fewer scores for ISI questioner (p&lt;0.001). The reduction of the total score of the Pittsburgh questioner was 10.08 ± 3.21 in the pumpkin oil group and 0.28 ± 0.98 (p&lt;0.001) in the control group. Conclusions: Pumpkin oil could have a significant positive effect on the quantity and the quality of sleep in patients with chronic insomnia.

Chronic insomnia: A review

Chronic insomnia is a fairly common condition affecting one-fourth of the clinical population. It has been variously defined and is related to a large number of conditions. A thorough assessment of the patient presenting with chronic insomnia is of vital importance for the treatment. Treatment consists of modifying sleep habits to reduce autonomic and cognitive factors and education about healthier sleep practice. Drug treatment should be reserved for the short-term alleviation of insomnia. Appropriate treatment of chronic insomnia improves the quality of life. The prevention of insomnia consists of a balance of rest, recreational exercise in combination with stress management and a healthy diet.

A Comparative Study of the Efficacy of Cognitive Behavioral Therapy and Zopiclone in Chronic Insomnia

Objectives. To assess the efficacy of the cognitive behavioral therapy of insomnia (CBT-I) compared with pharmacotherapy in chronic insomnia in the Russian population. Materials and methods. A crossover trial was performed in 42 patients with chronic insomnia (14 men and 28 women) aged 29–80 years old, who received two courses of treatment: using zopiclone and using an educational method with elements of CBT-I. All patients underwent nocturnal polysomnography studies. Treatment efficacy was evaluated using the Insomnia Severity Index, the Pittsburgh Sleep Quality Index questionnaire, the Dysfunctional Beliefs about Sleep Scale, the Sleep Hygiene Index, and the Beck Depression Scale. The efficacy of medication and nonmedication treatment methods in insomnia were found to be comparable. The insomnia severity index after CBT-I decreased by 3.6 (from 17.7 ± 5.3 to 12.8 ± 5.1) points, compared with a decrease by 4.9 (from 16.5 ± 5.8 to 12.9 ± 6.2) points after courses of zopiclone (p < 0.05). However, after two weeks, treatment results persisted only after use of CBT (12.9 ± 6.2 points); scores increased to 15.5 ± 4.6 points by the end of zopiclone administration. In addition, CBT-I was followed by significant decreases in values on the Beck Depression Scale (from 11.8 ± 6.9 to 8.5 ± 7.0 points), the Sleep Hygiene Index (from 26.9 ± 7.5 to 23.9 ± 5.7 points), the Dysfunctional Beliefs about Sleep Scale, (from 104.9 ± 29.7 to 84.4 ± 34.2 points) (p < 0.05). Patients responding to CBT-I were younger than nonresponders (40.5 ± 12.9 and 57.2 ± 11.7 years, respectively, p < 0.05), such that young age can be regarded as a predictor for CBT-I being effective. Conclusions. Treatment of chronic insomnia using CBT was as effective as pharmacotherapy, its use was accompanied by additional improvements in emotional status, and its effects lasted longer.

Direct activation of G-protein-gated inward rectifying K+ channels promotes nonrapid eye movement sleep.

A major challenge in treating insomnia is to find effective medicines with fewer side effects. Activation of G-protein-gated inward rectifying K+ channels (GIRKs) by GABAB agonists baclofen or γ-hydroxybutyric acid (GHB) promotes nonrapid eye movement (NREM) sleep and consolidates sleep. However, baclofen has poor brain penetration, GHB possesses abuse liability, and in rodents both drugs cause spike-wave discharges (SWDs), an absence seizure activity. We tested the hypothesis that direct GIRK activation promotes sleep without inducing SWD using ML297, a potent and selective GIRK activator. Whole-cell patch-clamp recordings from hypocretin/orexin or hippocampal neurons in mouse brain slices were made to study neuronal excitability and synaptic activity; spontaneous activity, locomotion, contextual and tone-conditioned memory, and novel object recognition were assessed. Electroencephalogram/electromyogram (EEG/EMG) recordings were used to study GIRK modulation of sleep. ML297, like baclofen, caused membrane hyperpolarization, decreased input resistance, and blockade of spontaneous action potentials. Unlike baclofen, ML297 (5-10 µM) did not cause significant depression of postsynaptic excitatory and inhibitory currents (EPSCs-IPSCs), indicating preferential postsynaptic inhibition. ML297 (30 mg/kg, i.p.) inhibited wake activity and locomotion, and preferentially increased NREM sleep without altering EEG delta power, REM sleep, inducing SWDs, or impairing conditioned memory and novel object recognition. This study finds that direct activation of neuronal GIRK channels modulates postsynaptic membrane excitability and prolongs NREM sleep without changing sleep intensity, inducing SWDs, or impairing memory in rodents. These results suggest that direct GIRK activation with a selective compound may present an innovative approach for the treatment of chronic insomnia.