The New England Journal of MedicineManagement of Insomnia

Chronic Insomnia: A Multifaceted Disorder with Far-Reaching Health Implications

Insomnia, a prevalent sleep disorder affecting approximately 10% of adults, poses significant challenges for both patients and healthcare providers. The article offers a comprehensive overview of insomnia management, comparing cognitive behavioral therapy for insomnia (CBT-I) with pharmacological interventions. It highlights the complex interplay between insomnia and other medical and psychiatric conditions, emphasizing the need for tailored treatment approaches.

Key Points:

• Insomnia disorder is characterized by dissatisfaction with sleep quality or duration, difficulty falling or staying asleep, and substantial distress or daytime impairments.
• The disorder affects about 10% of adults, with another 15-20% reporting occasional insomnia symptoms.
• Insomnia is more prevalent among women, individuals with mental or medical problems, and its incidence increases in middle age and later.
• Chronic insomnia is associated with increased risks of major depression, hypertension, Alzheimer’s disease, and work disability.
• Assessment and diagnosis of insomnia rely on a careful history, 24-hour sleep-wake behavior documentation, and patient-reported assessment tools.
• Current treatment options include prescribed and over-the-counter medications, CBT-I, and complementary therapies.
• CBT-I is recommended as the first-line treatment for persistent insomnia by several professional organizations.
• CBT-I components include sleep restriction, stimulus control, relaxation methods, cognitive interventions, and sleep hygiene education.
• Meta-analyses show CBT-I produces substantial improvements in insomnia symptom severity, sleep-onset latency, and time awake after sleep onset.
• Approximately 60-70% of patients have a clinical response to CBT-I, defined as a 7-point reduction on the Insomnia Severity Index.
• Digital CBT-I (eCBT-I) has shown similar efficacy to face-to-face CBT-I in clinical trials.
• Medications for insomnia include benzodiazepine receptor agonists, sedating heterocyclic drugs, orexin receptor antagonists, and melatonin receptor agonists.
• Benzodiazepine receptor agonists are effective but can cause side effects such as anterograde amnesia, next-day sedation, and complex sleep behaviors.
• Orexin receptor antagonists are effective for sleep-onset and sleep-maintenance symptoms with fewer cognitive side effects than benzodiazepines.
• Melatonin and melatonin receptor agonists have a small effect on sleep onset but little effect on wakefulness during sleep or total sleep time.
• Combined CBT-I and medication therapy may produce quicker improvements, but CBT-I alone shows more sustained benefits over time.
• Guidelines recommend CBT-I as first-line treatment and medications as alternative or adjunctive treatment.

HCN Medical Memo
Chronic insomnia is a complex disorder requiring a multifaceted approach to treatment. Although both CBT-I and pharmacological interventions show efficacy, CBT-I demonstrates more sustained benefits over time. Physicians should consider individual patient factors and preferences when selecting treatment strategies, and may opt for combination therapy in some cases.

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