Untreated Insomnia Research Articles

Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders

Insomnia is a pervasive problem for many patients suffering from medical and psychiatric conditions. Even when the comorbid disorders are successfully treated, insomnia often fails to remit. In addition to compromising quality of life, untreated insomnia may also aggravate and complicate recovery from the comorbid disease. Cognitive behavior therapy for insomnia (CBT-I) has an established efficacy for primary insomnia, but less is known about its efficacy for insomnia occurring in the context of medical and psychiatric conditions. The purpose of this article is to present a rationale for using CBT-I in medical and psychiatric disorders, review the extant outcome literature, highlight considerations for adapting CBT-I procedures in specific populations, and suggest directions for future research. Outcome studies were identified for CBT-I in mixed medical and psychiatric conditions, cancer, chronic pain, HIV, depression, posttraumatic stress disorder, and alcoholism. Other disorders discussed include: bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder. The available data demonstrate moderate to large treatment effects (Cohen's d, range = 0.35–2.2) and indicate that CBT-I is a promising treatment for individuals with medical and psychiatric comorbidity. Although the literature reviewed here is limited by a paucity of randomized, controlled studies, the available data suggest that by improving sleep, CBT-I might also indirectly improve medical and psychological endpoints. This review underscores the need for future research to test the efficacy of adaptations of CBT-I to disease specific conditions and symptoms.

Insomnia and Hypnotic Use, Recorded in the Minimum Data Set, as Predictors of Falls and Hip Fractures in Michigan Nursing Homes

To examine the relationship between insomnia, hypnotic use, falls, and hip fractures in older people. Secondary analysis of a large, longitudinal, assessment database. Four hundred thirty-seven nursing homes in Michigan. Residents aged 65 and older in 2001 with a baseline Minimum Data Set assessment and a follow-up 150 to 210 days later. Logistic regression modeled any follow-up report of fall or hip fracture. Predictors were baseline reports of insomnia (previous month) and use of hypnotics (previous week). Potential confounds taken into account included standard measures of functional status, cognitive status, intensity of resource utilization, proximity to death, illness burden, number of medications, emergency room visits, nursing home new admission, age, and sex. In 34,163 nursing home residents (76% women, mean age+/-standard deviation 84+/-8), hypnotic use did not predict falls (adjusted odds ratio (AOR)=1.13, 95% confidence interval (CI)=0.98, 1.30). In contrast, insomnia did predict future falls (AOR=1.52, 95% CI=1.38, 1.66). Untreated insomnia (AOR=1.55, 95% CI=1.41, 1.71) and hypnotic-treated (unresponsive) insomnia (AOR=1.32, 95% CI=1.02, 1.70) predicted more falls than did the absence of insomnia. After adjustment for confounding variables, insomnia and hypnotic use were not associated with subsequent hip fracture. In elderly nursing home residents, insomnia, but not hypnotic use, is associated with a greater risk of subsequent falls. Future studies will need to confirm these findings and determine whether appropriate hypnotic use can protect against future falls.

Toward cost-effectiveness analysis in the diagnosis and treatment of insomnia.

Insomnia is believed to have high prevalence, cost, and impact. However, comprehensive cost-effectiveness analyses (CEAs) of different diagnostic and treatment strategies have not been performed. Part of the reason is that limited data are available on prevalence, costs, and outcomes, each of which is key elements of any CEA. The authors conducted a MEDLINE search to review available literature. Epidemiological surveys have yielded variable results, depending on operational definitions and populations studied. Cost estimates have varied widely depending on whether indirect costs are included and which costs are considered. Impact on health-related quality of life appears to be substantial, but effects on utility scores-necessary to compare cost-effectiveness of insomnia management to that of other health care interventions-have not been reported. Furthermore, much of the data on health-related quality of life is cross-sectional, and cannot be used to test whether the identified associations are causal. The authors conclude that effective insomnia management holds promise as a cost-effective health care intervention. However, the CEA models that eventually may support this hypothesis will require accurate measures of direct and indirect costs, health state utility in treated and untreated insomnia, and prevalence data based on widely-accepted case definitions.

Assessment and Management of Insomnia

INSOMNIA IS A COMMON TREATABLE disorder of insufficient or poorquality sleep, with adverse daytime consequences. Insomnia presents as trouble falling asleep (long-sleep latency), trouble staying asleep (excessive or prolonged awakenings), or feeling nonrestored from sleep. Insomnia can be a primary disorder emerging in childhood or later, a conditioned (psychophysiological) disorder, or comorbid with a psychiatric, medical, or other sleep disorder. Insomnia can be transient (related to stress, illness, travel) or chronic (occurring nightly for 6 months). Persistent untreated insomnia is a strong risk factor for major depression. Insomnia must be distinguished from sleep-state misperception and short sleep states without symptoms. More than 50 epidemiological studies have shown that one third of various general populations have insomnia symptoms and that 9% to 21% have insomnia with serious daytime consequences, such as bodily fatigue, diminished energy, difficulty concentrating, memory impairment, low motivation, loss of productivity, irritability, interpersonal difficulties (with family, friends, coworkers), increased worrying, anxiety, and depression. Chronic sleep loss, which occurs in untreated insomnia, is a major risk factor for fatigue-related automobile crashes and industrial accidents, loss of jobs, marital and social problems, poor health, metabolic and endocrine dysregulation with impaired ability to maintain weight control, coronary heart disease, major depression, and suicidality. Insomnia is associated with enormous direct and indirect costs, as much as $14 billion in the United States in 1995. Physicians should therefore establish an effective clinical strategy for eliciting and managing insomnia complaints. Use of a sleep-trained nurse, psychologist, or both on a consultation basis or as a member of the physician’s medical practice should be considered. One study has reported on the benefit of behavioral treatment of insomnia provided by a trained clinic nurse in a general medical practice. However, the cost-effectiveness of incorporating a sleep-trained nurse or psychologist into a medical practice has yet to be reported.

The Enchanted World of Sleep

Back to table of contents Previous article Next article Book Forum: Sleeping and DreamingFull AccessThe Enchanted World of SleepBRADLEY J. SCHNIEROW, , M.D., M.S., BRADLEY J. SCHNIEROWSearch for more papers by this author, , M.D., M.S., La Jolla, Calif.Published Online:1 Jul 2000https://doi.org/10.1176/appi.ajp.157.7.1190-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Interest and concern about sleep continue to capture the public’s imagination, as evidenced by magazine cover stories and record sales of herbal and over-the-counter sleep preparations. Sleep complaints are a frequent symptom reported to psychiatrists, and untreated insomnia is associated with greater risk of subsequent depression and substance abuse (1). Despite their prevalence, very little instruction is given to medical students and residents about the issues that disturb a good night’s slumber. This English translation of the 1993 Hebrew text provides a solid introduction to sleep and its disorders. It is a first-person narrative account of modern sleep research and sleep medicine, as told by a pioneer in the field. Throughout this volume, Dr. Lavie’s sincere passion as both a clinician and researcher is readily apparent.From the investigation of sleep stages and the endogenous circadian pacemaker to the discovery of the sleep- and wake-promoting centers of the hypothalamus, Dr. Lavie covers most of the major findings regarding the regulation and possible functions of sleep. The scientific drama behind these discoveries is nicely captured in the narratives of the personal lives and intellectual quests of modern sleep scientists like Michael Jouvet, William Dement, and Allan Rechtschaffen. Dreams, perhaps the most fascinating aspect of sleep, are examined from both philosophical and scientific points of view.In addition to weaving together the history of sleep and dreams, Dr. Lavie takes the reader through his own life journey as a sleep researcher and clinician: from his doctorate work, studying human circadian rhythms in isolation, under the tutelage of Bernie Webb at the University of Florida; to his present role as Dean of the School of Medicine and Director of the Sleep Laboratory at the Technion-Israel Institute of Technology in Haifa. Dr. Lavie addresses some very interesting public policy issues, such as the effect of nighttime SCUD missile attacks on the sleep of the Israeli populace during the Gulf War.The second half of the book is devoted to the clinical diagnosis and treatment of sleep disorders. There are chapters on common complaints like insomnia, circadian rhythm abnormalities, excessive sleepiness, and even “children who refuse to sleep.” Dr. Lavie has a very down-to-earth approach to these issues, and he is an advocate of avoiding sleeping pills in favor of promoting proper “sleep hygiene” or behavioral rules. There is also advice for dealing with such problems as jet lag and shift work.This book will appeal to anyone who is interested in the scientific and clinical aspects of sleep, including the practitioner as well as the general public. The subject matter is presented with humor, and frequent references to classic literature and ancient mythology make for lively reading.By Peretz Lavie; translated by Anthony Berris. New Haven, Conn., Yale University Press, 1996, 270 pp., $32.50; $15.00 (paper).