Insomnia is the most common sleep disorder, but despite advances in diagnosis and management, it often goes unrecognized and untreated. Left untreated, insomnia increases the risk of developing other illnesses including depression, diabetes, hypertension, and possibly even death in older adults. Therefore, much more needs to be done to identify and treat insomnia early, and to ensure that patients are treated according to clinical guidelines rather than with off-label drugs that have little evidence for their effectiveness, concludes a review of the evidence published Online First in The Lancet.
“In view of the high prevalence and substantial morbidities of insomnia, patients should routinely be asked about sleep problems by health-care providers,” say Charles Morin from the Université Laval, Québec City, Canada and Ruth Benca from the University of Wisconsin, Madison, USA, authors of the Seminar.
Approximately a quarter of the adult population have sleeping problems and an estimated 6% to 10% have an insomnia disorder. Individuals with insomnia experience difficulty falling or staying asleep, a lack of restorative sleep, and daytime symptoms such as fatigue, trouble concentrating, and mood disturbances.
Most individuals with the condition are vulnerable to recurrent episodes and longitudinal research suggests that nearly 70% of individuals with insomnia continue to experience symptoms a year later, and half still have insomnia up to 3 years later.
People with insomnia are more than five times as likely to experience anxiety and depression, are at more than double the risk of developing congestive heart failure and diabetes, and have an elevated risk of death. One study also found that individuals with insomnia are seven times more likely to abuse alcohol or drugs over the next three and a half years compared with those without the condition.
Insomnia also results in a substantial economic and societal burden through poor productivity, absence from work, and high health-care costs.
The authors observe that despite the widespread use of over-the-counter and prescription drug treatment, long-term use of such drugs is not well studied and there is little evidence of which drugs work best and for whom.
Moreover, they add, some of the most commonly prescribed drugs (antidepressants and antihistamines) have yet to be approved for treating insomnia, highlighting the great need for more research to evaluate efficacy of individual drugs in treating this condition.
This has prompted the National Institutes of Health in the USA to state that only two treatment options (cognitive behavioral therapy [CBT] and approved hypnotic drugs) have sufficient evidence to support their use for the treatment of insomnia.
CBT is a treatment that uses psychological and behavioral methods such as relaxation techniques, sleep restriction, stimulus control, and education about sleep hygiene (e.g., diet, exercise, and the bedroom environment). CBT has been shown to be highly effective at treating insomnia, does not carry risks of adverse side effects, and has long-lasting benefits, which is a clear advantage compared with drug treatment. But at present there is a shortage of health-care professionals trained in these therapies.
The authors say: “Although CBT is not readily available in most clinical settings, access and delivery can be made easier through the use of innovative methods such as telephone consultations, group therapy, and self-help approaches via the internet.”
They conclude: “There is an urgent need for more public education about sleep and broader dissemination of evidence-based therapies for insomnia, and education and training to prepare health-practitioners to attend and treat insomnia complaints according to clinical guidelines.”