Managing Chronic Insomnia

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.

Key Points

  • 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).

Comment

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.

CITATION(S):

  1. 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)
  2. 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)
  3. 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)
  4. 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)