09.01 - Behavioral and Pharmacological Treatments for Insomnia

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Sleep: Neurobiology, Medicine, and Society

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University of Michigan

Sleep: Neurobiology, Medicine, and Society

63 notes

The objective of this course is to give students the most up-to-date information on the biological, personal, and societal relevance of sleep. Personal relevance is emphasized by the fact that the single best predictor of daytime performance is the quality of the previous night's sleep. The brain actively generates sleep, and the first section of the course is an overview of the neurobiological basis of sleep control. The course provides cellular-level understanding of how sleep deprivation, jet lag, and substances such as alcohol, ,caffeine, and nicotine alter sleep and wakefulness. The second section of the course covers sleep-dependent changes in physiology and sleep disorders medicine. Particular emphasis will be placed on disorders of excessive sleepiness, insomnia, and sleep-dependent changes in autonomic control. Chronic sleep deprivation impairs immune function and may promote obesity. Deaths due to all causes are most frequent between 4:00 and 6:00 a.m., and this second section of the class highlights the relevance of sleep for preventive medicine. The societal relevance of sleep will be considered in the final section of the class. In an increasingly complex and technologically oriented society, operator-error by one individual can have a disastrous negative impact on public health and safety. Fatigue-related performance decrements are known to have contributed as causal factors to nuclear power plant failures, transportation disasters, and medical errors.

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Unit 09 - Medicine: Treatments for Insomnia - (Standard Track)

Unit 9 further continues the Medicine section of the course with a lecture from J. Todd Arendt, Ph.D. on the range of available treatments for Insomnia.

09.01 - Behavioral and Pharmacological Treatments for Insomnia7:10

09.02 - Treatment Options for Insomnia4:36

09.03 - BzRA Hypnotics5:43

09.04 - Abuse Liability of Hypnotic Agents5:18

09.05 - Pharmacological Treatments for Insomnia3:57

09.06 - Nonpharmacological Treatments for Insomnia5:31

09.07 - How CBT-I Works6:27

09.08 - Pharmacological Treatments for Insomnia Part III6:26

09.09 - Summary 2:49

Rencontrer les enseignants

Ralph Lydic, Ph.D.
Professor Emeritus, Molecular and Integrative Physiology, Professor Emeritus, Anesthesiology
University of Michigan Medical School
Helen Baghdoyan, Ph.D.
Professor Emeritus, Anesthesiology, Professor Emeritus, Pharmacology, Professor of Psychiatry
University of Michigan Medical School

Hi, my name is Todd Arnedt.

I'm an Associate Professor of Psychiatry and Neurology and

Director of our accredited Behavioral Sleep Medicine Program

at the University of Michigan Medical School in Ann Arbor, Michigan.

Today, I'm going to talk about behavioral and

pharmacological treatments for insomnia.

I have four broad learning objectives I hope to cover today.

The first is to tell you why insomnia needs to be treated and

why it's important.

Then, I'll start covering information that tells us about the efficacy and

safety of drug and non-drug insomnia treatments.

I'll then help you understand the limitations of drug and

non-drug insomnia treatments.

Finally, I'll finish by helping you learn about future directions in insomnia

treatment research.

Let's start with the basics.

What is insomnia?

There have been a variety of different definitions.

One of the more recent consensus definitions that appears in our recent

diagnostic criteria for sleep disorders Is that, number one insomnia

requires a report of one or more of the following night time symptoms.

Difficulties initiating or falling asleep.

Difficulty maintaining or staying asleep.

Waking too early in the morning or earlier than one desires.

Or sleep that is chronically non-restorative or poor in quality.

In addition, this sleep difficulty must occur, despite adequate opportunity and

circumstances for sleep.

In this way it differentiates it from behavioral sleep deprivation.

In addition to nighttime reports, most people for

insomnia appear for treatment because they have complaints

of daytime impairments that are associated with their nighttime complaints.

And this definition takes that into account.

So for instance patients must report one of the following daytime impairments

that they attribute to their insomnia and nighttime complaints.

This can be things like fatigue or malaise which are extremely common.

Cognitive difficulties such as attention, concentration or memory impairment.

Mood disturbances such as irritability or frank daytime sleepiness.

So in addition to having complaints of nighttime difficulties, patients must also

complain of daytime impairments that contribute to their insomnia complaints.

So how common is insomnia?

Insomnia is one of the more common sleep disorders.

There have been a variety of studies that have looked at the prevalence of insomnia.

This is a recent study that evaluated more than 10,000 adults

of a managed healthcare plan and determined the number of individuals who

suffer from insomnia using common diagnostic criteria.

As you can see, the red box indicates that about 24 or 25% of

individuals met one of these diagnostic criteria for insomnia in the past 30 days.

These findings are in line with other large-scale prevalence studies that

indicate that roughly ten to 20% of individuals suffer from chronic insomnia

difficulties.

Let's talk about why it's important to treat insomnia.

There are several reasons why it's important to treat insomnia.

One important reason is that insomnia adversely affects quality of life.

This study looked at quality of life among primary care individuals

who suffer from insomnia as well as a common medical condition,

congestive heart failure and common mental health condition, depression.

What you're looking at is the results of responses from the SF 36,

a widely used measure of quality of life.

And you're looking at the eight sub-scales from this measure.

You could see by looking at the graph that the group was characterized by

severe insomnia in yellow reported significant

quality of life impairments that were equivalent in magnitude to those

individuals who suffered from congestive heart failure and depression.

So it's true that insomnia individuals have adverse quality of life experiences.

Another important reason to pay attention to insomnia and why it needs treatment is

because insomnia has been more recently associated with the increased risk for

various medical conditions.

This was a large scale study of more than a thousand adults from Pennsylvania.

It looked at the association between, not just subjective insomnia, but also

objective levels of sleep duration and their association with hypertension risk.

In this study of what they found, as you can see from the table,

the bottom row in the table, is that individuals who are classified as having

subjective insomnia complaints for more than one year and

you also had objective evidence of less than five hours of sleep duration

were more than five times more likely to be at risk for hypertension.

Compared to the reference group which included individuals who are enormously

per subjectively and had more than six hours of objective sleep duration.

So it's seems a suggested individual who have not only subjective insomnia, but

also objective indications of short sleep duration may be at particular risk for

a variety of different medical problems.

Several studies have also associated insomnia with mental health difficulties.

This is one of about 15 large scale epidemiological studies

that looked at the association between insomnia and mental health conditions.

In this particular study, individuals were interviewed at two different time points

roughly 3.5 years apart.

You can see from the graph, that individuals who had insomnia in yellow

were roughly four times more likely to go on to develop depression at time two.

About twice as likely to go on to develop anxiety and more likely to develop some

sort substance use disorder whether it was alcohol abuse or drug abuse.

These individuals had no evidence of mental health disturbances at base line.

But, by followup they where significantly more likely to then meet diagnostic

criteria for a variety of different mental health problems.

So this suggests insomnia may in fact be one pathway by which mental health

disorders can develop and suggests that targeting insomnia

might provide an opportunity for prevention of these devastating disorders.

Another reason why it's important to treat insomnia is because it's extremely costly

to our healthcare system.

This study looked at the direct healthcare services used by

insomnia individuals across one year.

And they found that across a variety of services, including physician services,

services for sleep specialists, mental health professionals and psychologists,

individuals with insomnia cost the healthcare system more than $1 billion

annually.

So the direct healthcare services used by insomnia individuals are quite substantial

and in need of treatment.

A final point is that insomnia is a chronic condition.

Individuals in this particular study,

85% of those individuals who reported severe insomnia at time one,

continue to report it, at a significant level, in a two year followup.

So if left untreated, it's very likely that insomnia difficulties will continue.

We've talked a little bit about the prevalence and

importance of treating insomnia.

Now we'll go ahead and move onto some of the treatment options that we have for

treating the disorder.

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