Insomnia Overview: Epidemiology, Pathophysiology, Diagnosis and Monitoring, and Nonpharmacologic Therapy

Key points

• Cognitive behavioral therapy for insomnia (CBTI) is the first-line treatment for chronic insomnia; it has more durable benefit and fewer adverse effects than drug therapy.
• Since ICSD-3 (2014), insomnia is classified as short-term (under 3 months) or chronic (3 or more times per week for 3 months or longer); the primary versus comorbid distinction was removed.
• Chronic insomnia is a clinical diagnosis; polysomnography is not needed unless another sleep disorder such as sleep apnea or restless legs syndrome is suspected.
• Sleep hygiene education alone is not recommended because it is less effective than CBTI or mindfulness training.
• The main barrier to CBTI is a lack of trained clinicians; digital CBTI (dCBTI) is emerging as a scalable option.

Overview

This American Journal of Managed Care supplement article reviews the epidemiology, pathophysiology, diagnosis and nondrug treatment of insomnia, with a focus on vulnerable patient groups. Insomnia is the most common sleep disorder; combined direct and indirect US costs exceed $100 billion annually, and insomnia diagnoses at US office visits rose 11-fold between 1993 and 2015, from 800,000 to 9.4 million. The main takeaway is that CBTI, including digital forms, should be central to managing chronic insomnia.

Diagnosis and the 3P model

The sleep history should describe how sleep is disturbed and its daytime consequences; tools include the Epworth Sleepiness Scale, the Insomnia Severity Index and sleep diaries. Insomnia often overlaps with other sleep disorders: 39% to 55% of patients with obstructive sleep apnea report insomnia symptoms. The 3P model explains how insomnia becomes chronic: predisposing factors (such as genetics and personality), precipitating factors (usually stressful life events) and perpetuating factors (maladaptive behaviors and beliefs such as daytime napping or spending too much time in bed).

Burden and vulnerable groups

In the American Insomnia Survey of more than 10,000 health plan members, 22.1% met DSM-IV criteria for insomnia; prevalence among working people was 27.1% in women versus 19.7% in men. About 1 in 5 cases of short-term insomnia becomes chronic, and insomnia persisted in 40% to 70% of patients for up to 4 years in longitudinal studies. Insomnia predicts later depression (OR 2.83) and anxiety (OR 3.23). Groups at particular risk include military personnel and veterans (more than 90% of veterans with PTSD report sleep disturbances), people with traumatic brain injury (insomnia in 30% to 65% with chronic symptoms), people with depression, alcohol or cannabis use, women in menopause and older adults.

Nondrug treatment

CBTI combines cognitive therapy, behavioral strategies (sleep restriction and stimulus control) and sleep hygiene education. Sleep restriction should be avoided in untreated sleep apnea or seizure disorders and may trigger mania in bipolar disorder. A 4-session brief behavioral treatment can be delivered without specialized training. In the Veterans Affairs CBTI program, the proportion of patients reporting suicidal ideation fell from 32% to 21%. In the DIALS trial of more than 1700 people, the digital program Sleepio improved sleep-related quality of life compared with sleep education, but almost 20% never attended the first session and fewer than 50% completed all sessions; in a small trial, in-person CBTI outperformed dCBTI.

Frequently asked questions

What is the first-line treatment for chronic insomnia?

CBTI, which practice guidelines recommend because its benefit is more durable and it has fewer adverse effects than sleep medication.

Is a sleep study needed to diagnose insomnia?

No. Polysomnography is indicated only if another sleep disorder such as sleep apnea or restless legs syndrome is suspected.

Is sleep hygiene advice enough on its own?

No. Guidelines recommend against sleep hygiene education as a stand-alone treatment because it is less effective than CBTI or mindfulness training.

Source

Dopheide JA. Insomnia Overview: Epidemiology, Pathophysiology, Diagnosis and Monitoring, and Nonpharmacologic Therapy. Am J Manag Care. 2020;26(4 Suppl):S76-S84. DOI: 10.37765/ajmc.2020.42769. Supplement supported by an educational grant from Eisai. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.