Although insomnia is highly prevalent in the US population and profoundly affects daytime functioning and overall health, the disorder is underrecognized and undertreated in primary care settings, according to recommendations published in the Primary Care Companion for CNS Disorders. Treatment decisions should consider the presence of comorbid medical and psychiatric illnesses, which are common in patients with insomnia, wrote the panel of experts convened by Haymarket Medical Education.
“The data demonstrating a relationship between insomnia disorder and significant medical disorders is growing, suggesting that clinicians need to take insomnia disorder seriously,” said coauthor Russell Rosenberg, PhD, FAASM, chief science officer and CEO of NeuroTrials Research, Inc.
“It is important to understand that insomnia and conditions such as chronic pain and depression have a bidirectional relationship. Thus, for example, to optimize treatment and prevent relapse of depression, an improvement in sleep is critical,” said Thomas Roth, PhD, founder of the Sleep Disorders and Research Center at the Henry Ford Hospital, and clinical professor, Department of Psychiatry, University of Michigan College of Medicine, Ann Arbor, MI.
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Many patients do not discuss sleep issues with their clinicians and few seek treatment; thus, primary care clinicians should proactively screen patients for insomnia and particularly those with a medical or psychiatric condition, according to the experts.
Sleep Problems in America
| In 2020, 14.5% of adults had trouble falling asleep most days or every day in the past 30 days |
| The percentage of adults with sleep problems decreased with increasing age, from 15.5% among adults aged 18–44 years to 12.1% among those aged 65 and older |
| Women (17.1%) were more likely to have trouble falling asleep than men (11.7%) |
| Non-Hispanic Asian adults (8.1%) were less likely than non-Hispanic Black (13.7%), Hispanic (14.3%), and non-Hispanic White (15.1%) adults to have trouble falling asleep |
The Insomnia Working Group met in March 2022 to review current clinical data and develop updated strategies for insomnia management. The group was led by Dr Rosenberg and in addition to Dr Roth included Ruth Benca, MD, PhD, chair of psychiatry and behavioral medicine at Wake Forest School of Medicine, Winston-Salem, NC; and Paul Doghramji, MD, FAAFP, family practitioner at Collegeville Family Practice and Ursinus College, Collegeville, PA. A patient with insomnia was also included in the panel discussions.
Personalized Treatment Is Best for Insomnia
Insomnia management requires a personalized approach with the overall goal of reducing time to sleep onset, maintaining sleep for an adequate duration, and/or preventing early awakening while improving daytime function. Effective treatment typically requires multimodal care with nonpharmacologic strategies and pharmacologic agents. Monitoring patients for potential side effects during treatment is an essential aspect of care, the panelists explained.
Insomnia Treatment Recommendations
Nonpharmacologic Strategies
The panel recommended using a combination of lifestyle changes, sleep hygiene techniques, and cognitive behavioral therapy (CBT) as first-line treatment for insomnia. Data from the National Sleep Foundation show that many Americans fall short of these recommended lifestyle and sleep hygiene:
- Nearly 50% of Americans are not exposed to the recommended levels of bright light when indoors in the morning and afternoon
- More than a third of Americans do not engage in the CDC’s recommendations for moderate or vigorous activity
- Four in 10 Americans eat meals at inconsistent times
- More than half of Americans have screen time within 1 hour of bedtime
Pharmacotherapy
For some patients, pharmacologic therapies may need to be added to the therapeutic strategy, according to the Insomnia Working Group. The antidepressant trazodone is the most frequently prescribed agent for insomnia in the primary care setting but is not FDA-approved for this indication and lacks clinical trial data to support the safety and efficacy of this use, the panelists noted.
Benzodiazepines and benzodiazepine receptor agonists are also used for sleep disorders and target the γ-aminobutyric acid (GABA) system; some but not all of these agents are indicated for insomnia. Adverse effects associated with use of these agents include impaired next-day functioning, dependence, tolerance, and rebound insomnia following drug discontinuation, the panelists noted.
The newest class of agents indicated for insomnia are dual orexin receptor antagonists (DORAs). These agents have a unique mechanism that promotes sedative effects by inhibiting the wakefulness effects of orexin on orexin-1 receptor (OX1R) and OX2R. Clinical studies suggest that long-term use of DORAs is safe and effective, and that these agents are not associated with clinically meaningful residual morning sleepiness or reduced next-day functioning. Adverse effects vary by agents in this class and range from headache and somnolence to worsening depression.
Other medications such as calcium-channel modulator anticonvulsants and atypical antipsychotics may be used off-label for sleep promotion in patients with comorbidities for which the agents are approved, the panelists explained.
The panelists provided a table showing how to guide treatment decisions based on insomnia subtype and patient comorbidities. For example, patients with comorbid insomnia and depression may benefit from an atypical antipsychotic may be the best choice, while patients with substance abuse disorder or Alzheimer’s disease may benefit from DORAs. The latter agents are also a good choice for older adults as they are associated with few safety concerns in this population. Agents that down-regulate the arousal and stress systems (such as trazodone, doxepin, or the DORAs) may help lower blood pressure in patients with hypertension, and treatment of hypertension may contribute to improved sleep, the experts explained.
OTC Agents and Supplements for Insomnia
Over-the-counter (OTC) agents are also commonly used for insomnia. For patients taking OTC antihistamines, clinicians should counsel them about the risk for cognitive impairment, hangover effects, dizziness, or falls, the panel noted. Prolonged-release melatonin has demonstrated efficacy in clinical studies and valerian has shown inconsistent findings.
Cannabis
Medical marijuana, including products containing delta-9 tetrahydrocannabinol (THC) and cannabidiol (CBD), has also shown efficacy in the treatment of insomnia, particularly in patients with comorbid pain and anxiety. “It is important for clinicians to keep current regarding data on the medical use of cannabis and to routinely question patients about their use of such products,” the panelists wrote.
“Ideally, a strategy that combines healthy lifestyle habits with judicious, well-monitored use of medication targeted for the individual patient’s specific insomnia complaint (and any existing comorbidities) will result in optimal outcomes,” the panelists concluded.
Disclosures: The initiative was supported by an independent educational grant from Eisai. The study author(s) declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Sources
Rosenberg RP, Benca R, Doghramji P, et al. A 2023 update on managing insomnia in primary care: insights from an expert consensus group. Prim Care Companion CNS Disord. 2023;25(1):22nr03385.
Haymarket Medical Education’s Insomnia Working Group publishes updated recommendations for managing insomnia disorder in Primary Care in Primary Care Companion for CNS Disorders. Business Wire. January 24, 2023. Accessed March 29, 2023. https://www.businesswire.com/news/home/20230123005775/en/Haymarket-Medical-Education%E2%80%99s-Insomnia-Working-Group-Publishes-Updated-Recommendations-for-Managing-Insomnia-Disorder-in-Primary-Care-in-Primary-Care-Companion-for-CNS-Disorders-Psychiatrist.com
