Feature Article on Insomnia Sponsored by Sanofi Synthelabo

by Dr. Gregg D. Jacobs

Insomnia is one of the most common complaints brought to a physician's office practice. Approximately 60 million adults experience occasional insomnia and about 10-20% experience it chronically.

These estimates are even higher in primary care patients, women, older adults, and those with coexisting medical or psychiatric illness. In the National Sleep Foundation's "2002 Sleep In America" poll, 35% of adults reported experiencing symptoms of insomnia every night and 58% reported insomnia at least a few nights per week. Insomnia affects both mood and performance; has economic repercussions in terms of diminished productivity, absenteeism, and tardiness; and, is associated with increased health problems, psychiatric disorders (including increased vulnerability to major depression), and medical costs.

The costs of insomnia place a tremendous burden on society as evidenced by the finding that the annual direct costs of insomnia to American society has been estimated at 14 billion dollars annually in 1995, an increase from 11 billion in 1990. Unfortunately, the vast majority of insomniacs are going undiagnosed and untreated. in part because physicians have received little training to diagnose or o treat insomnia. For example, in the 2002 "Sleep in America" poll, only 6% of those individuals who reported signs/symptoms of insomnia have ever been diagnosed with insomnia by a health care professional and only 4% have received treatment for their insomnia.

When treatment is initiated for insomnia, benzodiazepine hypnotics are the most frequently recommended intervention. They produces reliable improvements in multiple sleep parameters, including sleep-onset latency, wake time after sleep onset, and total sleep time. Although short-term use of benzodiazepine hypnotics are useful and indicated for acute insomnia, their chronic use is contraindicated due to (moderate) a reduced treatment efficacy and undesirable side effects that often outweigh benefits, including habituation, dependency, impairment of daytime psychomotor and cognitive performance, daytime drowsiness, iatrogenic sleep disturbance, rebound insomnia, and REM (rapid eye movement) sleep rebound.

Newer-generation non-benzodiazepine hypnotics such as zolpidem offer multiple advantages over traditional sedative-hypnotics including consistently documented efficacy, short half-life (2.4 hours) with no active metabolite and rapid onset of action of 30 minutes, and minimal residual effects. Furthermore, zolpidem does not accumulate during repeated administration, causes minimal disruption of sleep architecture, has lowered potential for abuse due to more selective binding properties at GABA receptor subtypes, and is the most commonly prescribed sedative hypnotic. For these reasons, zolpidem is the best choice of a hypnotic for sleep-onset insomnia.

There has also been increased emphasis on the development of effective non-pharmacological therapies for insomnia. Meta-analyses suggest that cognitive-behavioral therapy (CBT) is more effective than placebo and no-treatment controls in the treatment of insomnia and produces comparable effect sizes to pharmacotherapy. CBT is a time-limited, sleep-focused treatment that modifies the distorted sleep cognitions, maladaptive sleep behaviors, and psychophysiological arousal that maintain and strengthen insomnia. CBT produces significant improvements in sleep-onset latency, wake time after sleep onset, and sleep efficiency and total sleep time that are maintained effectively over time.

A recent randomized trial published in JAMA by Morin and his colleagues directly compared pharmacotherapy to CBT in the treatment of insomnia and found that a combined pharmacological and CBT intervention was more effective than either therapy alone. This suggests that the most efficacious treatment for insomnia may be pharmacotherapy and CBT in combination, which may enhance treatment efficacy by combining the more rapid improvements of pharmacotherapy with the more durable effects of CBT.

Additional research is needed to determine the optimal model for integrating pharmacotherapy and CBT. However, it is clear that, although insomnia is both prevalent and under-treated, it can be treated effectively with pharmacotherapy and CBT.