Jamaluddin Moloo, MD, MPH reviewing Qaseem A et al. Ann Intern Med 2016 May 3. Kathol RG and Arnedt JT. Ann Intern Med 2016 May 3. wilt TJ et al. Ann Intern Med 2016 May 3. Brasure M et al. Ann Intern Med2016 May 3.
Sponsoring Organization: American College of Physicians (ACP)
Chronic insomnia is defined as insomnia that occurs for at least 3 nights weekly for ≥3 months, it must cause clinically significant functional distress or impairment and must not be linked to another medical or mental disorder. A new guideline from the ACP is based on a systematic review of randomized trials and provides recommendations on managing chronic insomnia.
- Options to manage insomnia include psychological, pharmacological, or combination therapy.
- Psychological therapy includes sleep hygiene, stimulus control, sleep restriction, relaxation training, and cognitivebehavioral therapy (CBT). Moderatequality evidence demonstrated that CBT improved multiple components of sleep and could be delivered by different methodologies including oneonone therapy, group therapy, selfhelp books, and Webbased modules.
- Pharmacological options approved by the FDA include benzodiazepines, nonbenzodiazepine hypnotics (i.e., zolpidem, eszopiclone, and zaleplon), an orexinreceptor antagonist (i.e., suvorexant [Belsomra]), a melatoninreceptor agonist (i.e., ramelteon), and doxepin. Various drug classes such as antihistamines, antipsychotics, and melatonin are used offlabel. Lowtomoderate quality evidence demonstrated that doxepin, suvorexant, eszopiclone, zolpidem, and extendedrelease zolpidem each improved total sleep time (by approximately 15–45 minutes). Zaleplon failed to extend total sleep time, and data were insufficient to evaluate efficacy of benzodiazepines, melatonin, or trazodone.
- ACP recommendations:
- All adults with chronic insomnia should receive CBT as firstline treatment (strong recommendation; moderate quality evidence).
- Clinicians should use shared decision making to determine whether short term pharmacologic treatment should be added if CBT alone is unsuccessful (weak recommendation; low quality evidence).
This guideline highlights the high prevalence of chronic insomnia and the relatively poor quality of evidence available to guide management. Although the guideline recommends CBT as firstline treatment, this recommendation might frustrate some clinicians: Most primary care practices are not equipped to deliver CBT, and affordable CBT is not readily available in many communities.
Personal comments: Insomnia is incredibly prevalent. There are many personal and general social reasons for this. We all live 24/7 lives, whether we realize it or not. We have 24/7 access to work, entertainment, friends anywhere in the world. Our phones let us take our virtual world with us, almost anywhere. It is very hard NOT to prescribe medication to a patient who needs to sleep. But at some point, trying the CBT route is highly recommended.
- Qaseem A et al. Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2016 May 3; [epub]. (http://dx.doi.org/10.7326/M152175)
- Kathol RG and Arnedt JT.Cognitive behavioral therapy for chronic insomnia: Confronting the challenges to implementation. Ann Intern Med 2016 May 3; [epub]. (http://dx.doi.org/10.7326/M160359)
- Wilt TJ et al. Pharmacologic treatment of insomnia disorder: An evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med 2016 May 3; [epub]. (http://dx.doi.org/10.7326/M151781)
- Brasure M et al. Psychological and behavioral interventions for managing insomnia disorder: An evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med 2016 May3; [epub]. (http://dx.doi.org/10.7326/M151782)