Insomnia: Using cognitive behavioral therapy in primary care

Cognitive behavioral therapy may have long-term positive effects 
in patients with insomnia who have chronic use of hypnotic drugs.

Insomnia: Using cognitive behavioral therapy in primary care
Insomnia: Using cognitive behavioral therapy in primary care

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Insomnia is a common clinical illness that is defined by difficulty initiating or maintaining sleep.1 Insomnia often reduces quality of life and increases the risk of comorbid medical and psychiatric diseases, and it represents a serious economic burden worldwide.1,2

Approximately 30% of the adult population experiences insomnia,3 and 5% to 10% of adults are diagnosed with specific clinical sleep disturbances.1,3 Half of patients with insomnia may experience a chronic course of at least one year.4 Insomnia is one of the most prevalent conditions treated by primary care providers, with estimates of 10% to 50% of patients presenting with this condition.4

Most patients continue to use nonbenzodiazepine and benzodiazepine hypnotics in primary care for a duration of greater than one month, contrary to guideline recommendations to limit its use to two to four weeks.5 Sociodemographic factors associated with greater long-term use of hypnotics include age older than 65, female gender, and higher income levels.6

It is important to assess for these variables when identifying patients with insomnia. Because most hypnotic prescriptions are written in the primary care setting,3 behavioral strategies should be implemented in general practice as an alternative to long-term hypnotic use.


Identifying and evaluating patients with insomnia in primary care


Many patients present to their primary care provider with a chief complaint of insomnia. Other patients present with different comorbid conditions, including anxiety, depression, or chronic pain. To identify all patients with insomnia, the provider can inquire, “Do you have trouble falling asleep, staying asleep, or waking up too early?”

If the patient answers “yes,” it is reasonable to administer the seven-item Insomnia Severity Index (ISI) questionnaire. The ISI is a valid and reliable tool to quantify the degree of insomnia.7 Patients with a score greater than the cutoff of 14 are considered to have clinically significant insomnia.7


After identifying a patient with insomnia, the next step is to ask the patient to keep a two-week sleep diary to assess his or her sleep habits and differentiate between chronic insomnia or other comorbid conditions.6 A sleep diary also helps to identify insomnia triggers, and sleep hygiene habits should be kept for at least two months following the intervention to assess patient progress.6

The sleep diary should contain detailed information, including: bedtime, wake-up time, number of nighttime awakenings, activities before bedtime, medications, caffeine, or alcohol consumed before bedtime, and a subjective self-assessment of how refreshed the patient feels after awakening.


Chronic insomnia treatment: pharmacotherapy 


Pharmacotherapy is commonly offered as a first-line treatment for patients with chronic insomnia in primary care,8 despite guidelines that discourage the use of these agents.9 The National Institute for Clinical Excellence (NICE) recommends treatment with hypnotics only after nonpharmacologic alternatives have been exhausted, and only for severe insomnia that significantly impairs daily functioning.9 If pharmacotherapy is used for treatment, it is recommended to use the medications only for as long as four weeks and at the lowest necessary dosage.5

Nonbenzodiazepine hypnotics are newer benzodiazepine-like medications that are commonly prescribed in primary care for a long-term duration in spite of concerns due to a lack of evidence on adverse side effects, safety, and efficacy.10 These gamma-aminobutyric acid (GABA)A receptor agonists include the “Z-drugs”: zaleplon, zolpidem, and zopiclone.

During the past few decades, these Z-drugs have become the most prevalent hypnotic medications prescribed worldwide,11 with more prescriptions than for benzodiazepines.3 Although benzodiazepines and benzodiazepine-like agonists have similar safety concerns and side effect profiles, general practitioners often view these Z-drugs as more effective and safer with respect to tolerance, addiction, dependence, and other side effects, compared with benzodiazepines.12

These benzodiazepine-like agonists still have a high potential for abuse among all patients with insomnia,10 especially among those with a history of substance abuse.13

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