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Scope of the problem 1,2 52 %–64% of primary care patients have sleep complaints 10%–14% experience severe insomnia that interferes with daytime functioning Essential components of insomnia 3,4 Difficulty initiating or maintaining sleep

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what is chronic insomnia

Scope of the problem1,2

    • 52%–64% of primary care patients have sleep complaints
    • 10%–14% experience severe insomnia that interferes with daytime functioning
  • Essential components of insomnia3,4
    • Difficulty initiating or maintaining sleep
    • Nonrestorativesleep despite adequate opportunity for sleep
    • Distress or impairment of daytime functioning
    • Insomnia is chronic if it has lasted for at least 1 month3

What is Chronic Insomnia?

Simon GE, VonKorff M. Am J Psychiatry. 1997;154(10):1417-1423.

Terzano MG et al. Sleep Med. 2004;5(1):67-75.

American Academy of Sleep Medicine. ICSD-2; Diagnostic and coding manual. 2005.

American Psychiatric Association. DSM-5 Development.

diagnosing chronic insomnia

Ask about sleep

  • Identify insomnia
  • Recognize comorbid insomnia

Diagnosing Chronic Insomnia

treating chronic insomnia

Cognitive behavioural therapy for insomnia (CBT-I)

    • Recommended first-line therapy1-3
    • Strategies allow biological sleep processes to operate without interference
    • Effective for adults, including elderly and patients with comorbidities4
    • Benefit up to 2 years5

Treating Chronic Insomnia

Canadian Medical Association. Guideline for Adult Primary Insomnia: Diagnosis to Management.

Schutte-Rodin S et al. J Clin Sleep Med. 2008;4(5):487-504.

Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600.

Morin CM et al. Sleep. 2006;29(11):1398-1414.

Morin CM et al. JAMA. 1999;281(11):991-999.

adjusting time in bed based on sleep efficiency

Adjusting Time in Bed Based on Sleep Efficiency

After the patient has restricted his/her time in bed to his/her initial sleep window for 1 week, the bedtime is adjusted based on the sleep efficiency attained.

pharmacotherapy

Benzodiazepine (BDZ) receptor agonists

  • Traditional BDZs
  • Z-drugs: zopiclone, zolpidem, zaleplon*, and eszopiclone*
  • Debate about duration of therapy
  • Safety
  • Potential for abuse and dependence
  • Lower with Z-drugs than with BDZs1-3
  • However, use same precautions for both classes

Pharmacotherapy

* Not available in Canada

Roth T, Roehrs T. Sleep Med Clin. 2010;5:529-539.

Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600.

Hajak G et al, Addiction. 2003;98(10):1371-1378.

pharmacotherapy cont

Sedating antidepressants

    • Paucity of research on use in nondepressed patients
    • Generally riskier than BDZ receptor agonists1
    • Higher drop-out rates2
  • Over-the-counter sleep aids
    • Little evidence of benefit in chronic insomnia3
  • Melatonin
    • Prolonged use may be safe and effective; however, few long-term studies, and not available in Canada
    • Immediate-release generally not useful for chronic insomnia
    • Ramelteon shows promise,4 but not available in Canada

Pharmacotherapy (cont)

National Institutes of Health. Sleep. 2005;28(9):1049-1057.

Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600.

MendelsonWB et al. Sleep Med Rev. 2004;8(1):7-17.

Mayer G et al. Sleep. 2009;32(3):351-360.

tapering medications

Taper BDZ receptor agonists slowly to prevent rebound insomnia

  • Tapering is most successful when done in combination with CBT-I1

Tapering Medications

Morin CM et al. Am J Psychiatry. 2004;161(2):332-342.