Chronic insomnia : recent advances and innovations in treatment development and dissemination

Insomnia is a prevalent public health problem that carries an important psychosocial and economic burden for those affected, their families, employers, and for society at large. Despite its negative impacts, insomnia often remains untreated and, when treatment is initiated, it is predominantly with medication, an option that is not always acceptable to people with insomnia. There is extensive evidence that psychological approaches, primarily cognitive behavioural therapy, are effective, produce durable and generalizable outcomes, and should be the first line therapy for chronic insomnia. Nonetheless, these approaches remain under utilised in clinical (medical) practise. Several innovative and cost-effective treatment delivery models (e.g., telephone consultations, Internet-based treatment) have yielded promising results but despite these advances, there remains a problem of supply. A significant challenge for the future will be to disseminate more efficiently validated therapies and practise guidelines and increase their use in clinical practise. Additional training opportunities are also needed for psychologists to develop expertise in a new emerging behavioural sleep medicine subspecialty. (PsycINFO Database Record (c) 2016 APA, all rights reserved

Actigraphy in the assessment of insomnia

Objective: The present study explores the clinical utility and sensitivity of actigraphy as an outcome measure in the treatment of chronic insomnia. Design: Following a screening-adaptation night, polysomnography, actigraphy, and sleep-diary data were collected in the sleep laboratory for 2 baseline nights and 2 posttreatment nights. Setting: A university-affiliated sleep disorders center. Participants: Seventeen participants with chronic primary insomnia. Mean age was 41.6 years. Interventions: Participants took part in a treatment protocol investigating different sequential treatments for insomnia (these results are reported elsewhere). Measurements and Results: Compared to polysomnography, both actigraphy and sleep-diary instruments underestimated total sleep time and sleep efficiency and overestimated total wake time. Also, actigraphy underestimated sleep-onset latency while the sleep diary overestimated it as compared to polysomnography. Actigraphy data were more accurate than sleep-diary data when compared to polysomnography. Finally, actigraphy was sensitive in detecting the effects of treatment on several sleep parameters. Conclusions: These results suggest that actigraphy is a useful device for measuring treatment response and that it should be used as a complement to sleep-diary evaluation

Cognitive impairment in individuals with insomnia : clinical significance and correlates

Study Objectives: The aims of this study were to (1) investigate the nature of cognitive impairment in individuals with insomnia, (2) document their clinical significance, (3) examine their correlates, and (4) explore differences among individuals with insomnia with and without cognitive complaints. Design: Participants underwent 3 consecutive nights of polysomnography. On the morning following the third night, they completed a battery of questionnaires and neuropsychological tests. Participants: The sample included 25 adults with primary insomnia (mean age: 44.4 ± 11.5 y, 56% women) and 16 controls (mean age: 42.8 ± 12.9 y, 50% women) matched for sex, age, and education. Intervention: N/A. Measurement and Results: Participants completed neuropsychological tests covering attention, memory, working memory, and executive functions, as well as questionnaires assessing the subjective perception of performance, depression, anxiety, fatigue, sleepiness, and hyperarousal. There were significant group differences for the attention and episodic memory domains. Clinically significant deficits were more frequent in the insomnia group. Within the insomnia group, individuals with cognitive complaints exhibited significantly poorer performance on a larger number of neuropsychological variables. All impaired aspects of performance were significantly associated with either subjective or objective sleep continuity, and some were also independently related to sleep microstructure (i.e., relative power for alpha frequencies) or selected psychological variables (i.e., beliefs or arousal). Conclusions: These findings suggest clinically significant alterations in attention and episodic memory in individuals with insomnia. Objective deficits were more pronounced and involved more aspects of performance in a subgroup of individuals with cognitive complaints. These deficits appear associated with sleep continuity, and may also be related to sleep microstructure and dysfunctional beliefs

Sleepiness and fatigue following traumatic brain injury

Objectives : To compare individuals with traumatic brain injury (TBI) to healthy controls (CTLs) on measures of sleepiness, fatigue, and sleep, and explore correlates of sleepiness and fatigue separately for each group. Methods : Participants were 22 adults with moderate/severe TBI (time since injury ⩾1 year; mean = 53.0 ± 37.1 months) and 22 matched healthy CTLs. They underwent one night of polysomnographic (PSG) recording of their sleep followed the next day by the Maintenance of Wakefulness Test (MWT). They also completed a 14-day sleep diary, the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire (FOSQ), and the Multidimensional Fatigue Inventory (MFI). Results : There were no significant group differences on measures of objective (MWT) or subjective (ESS) sleepiness, both groups being quite alert. However, TBI participants reported greater consequences of sleepiness on their general productivity (FOSQ), spent more time in bed at night, and napped more frequently and for a longer time during the day. Subjective fatigue was significantly higher in TBI participants on the general, physical, and mental fatigue MFI subscales. There were no between-group differences on any sleep parameters derived either from PSG or sleep diary. Conclusions : Fatigue appeared to be a more prominent symptom than sleepiness when assessed between 1 and 11 years after TBI. Participants with TBI used compensatory strategies such as increasing time spent in bed and daytime napping in this sample. Future research should document the time course of sleepiness and fatigue after TBI and investigate treatment options

Epidemiology of insomnia : prevalence, course, risk factors, and public health burden

This paper summarizes recent epidemiological evidence on insomnia, including its prevalence, incidence, and risk factors, as well as its course and consequences. There is now substantial evidence that insomnia is a significant public health problem. It is a highly prevalent condition, both as a symptom and a syndrome, and is often a persistent condition over time. Its persistence is associated with increased risk for mental (major depression), physical (hypertension), and occupational health problems (disability). Chronic insomnia also carries heavy economic burden, both in terms of direct healthcare costs and, more importantly, in terms of human resources loss due to the illness and lack of treatment. These findings have direct implications for community-based prevention and intervention programs and for future research including the need for: a) longitudinal, population-based studies aimed at evaluating whether we can prevent insomnia among at-risk individuals; b) clinical studies evaluating whether the morbidity associated with chronic insomnia is reversible; and c) prospective health economic evaluations of prevention programs using different dissemination technologies

Cognitive behavioral therapy for insomnia in older adults

Insomnia is associated with significant morbidity and is often a persistent problem, particularly in older adults. It is important to attend to this complaint and not assume that it will remit spontaneously. In many cases, unfortunately, insomnia remains unrecognized and untreated, often because it is presumed that insomnia is an inevitable consequence of aging. Although the sleep structure naturally changes with advancing age, these changes are not necessarily associated with complaints of poor sleep, distress, or daytime consequences, while chronic insomnia clearly is. There is increasing evidence that cognitive behavioral therapy (CBT) is effective for the management of chronic insomnia in the elderly and that it is of significant benefit for insomnia comorbid with medical and psychological conditions, also more prevalent in older age. The aim of this article is to familiarize clinicians working with older adults with the different components of CBT for insomnia and how to adapt the treatment to this population. A clinical case and session-by-session implementation of CBT for insomnia are described to illustrate information and guidelines provided in this article

Cognitive behavioral therapies for insomnia and hypnotic medications : considerations and controversies

- Insomnia is a prevalent and costly health problem that often remains untreated or is treated inadequately. There are, however, several evidence-based treatment options, including cognitive behavioral therapies (CBTs) and pharmacologic therapies, each with its own advantages and limitations. - Medications with specific indications for insomnia produce rapid symptomatic relief, but there is little to no evidence that sleep improvements are maintained after drug discontinuation or long-term, continued usage. Conversely, CBT takes longer than drugs to produce sleep improvements, but these improvements are well sustained over time. - Aside from their short-term and long-term benefits, other key considerations need to be taken into account when selecting among the different insomnia therapies. These include patients’ treatment preferences, how best to deliver CBT, whether to combine or sequence CBTs and medication therapies, and who should treat insomnia. These considerations may have a significant impact on efficacy, compliance, attrition, and access to treatment. - Several innovative treatment delivery methods relying on digital technology are increasingly used to treat insomnia. Although these self-help approaches may reduce cost and human resources and increase access, an important shortcoming is the high attrition rate during the course of these self-guided approaches. - The publications of clinical practice guidelines by several international medical and sleep organizations have reached the same recommendation, that is, CBT should be the first-line treatment of insomnia, and only when such treatment is not available or not effective should medication be considered for treating persistent insomnia. It is hoped that such strong and uniform endorsement by the medical and sleep community will help narrow the current gap between the available research evidence and clinical practices