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.
