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What is Chronic Insomnia?

Scope of the problem 1,2 52 %–64% of primary care patients have sleep complaints 10%–14% experience severe insomnia that interferes with daytime functioning Essential components of insomnia 3,4 Difficulty initiating or maintaining sleep

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What is Chronic Insomnia?

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  1. Scope of the problem1,2 • 52%–64% of primary care patients have sleep complaints • 10%–14% experience severe insomnia that interferes with daytime functioning • Essential components of insomnia3,4 • Difficulty initiating or maintaining sleep • Nonrestorativesleep despite adequate opportunity for sleep • Distress or impairment of daytime functioning • Insomnia is chronic if it has lasted for at least 1 month3 What is Chronic Insomnia? Simon GE, VonKorff M. Am J Psychiatry. 1997;154(10):1417-1423. Terzano MG et al. Sleep Med. 2004;5(1):67-75. American Academy of Sleep Medicine. ICSD-2; Diagnostic and coding manual. 2005. American Psychiatric Association. DSM-5 Development.

  2. Ask about sleep • Identify insomnia • Recognize comorbid insomnia Diagnosing Chronic Insomnia

  3. Cognitive behavioural therapy for insomnia (CBT-I) • Recommended first-line therapy1-3 • Strategies allow biological sleep processes to operate without interference • Effective for adults, including elderly and patients with comorbidities4 • Benefit up to 2 years5 Treating Chronic Insomnia Canadian Medical Association. Guideline for Adult Primary Insomnia: Diagnosis to Management. Schutte-Rodin S et al. J Clin Sleep Med. 2008;4(5):487-504. Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600. Morin CM et al. Sleep. 2006;29(11):1398-1414. Morin CM et al. JAMA. 1999;281(11):991-999.

  4. CBT-I Strategies and Rationale • .

  5. Adjusting Time in Bed Based on Sleep Efficiency After the patient has restricted his/her time in bed to his/her initial sleep window for 1 week, the bedtime is adjusted based on the sleep efficiency attained.

  6. Benzodiazepine (BDZ) receptor agonists • Traditional BDZs • Z-drugs: zopiclone, zolpidem, zaleplon*, and eszopiclone* • Debate about duration of therapy • Safety • Potential for abuse and dependence • Lower with Z-drugs than with BDZs1-3 • However, use same precautions for both classes Pharmacotherapy * Not available in Canada Roth T, Roehrs T. Sleep Med Clin. 2010;5:529-539. Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600. Hajak G et al, Addiction. 2003;98(10):1371-1378.

  7. Sedating antidepressants • Paucity of research on use in nondepressed patients • Generally riskier than BDZ receptor agonists1 • Higher drop-out rates2 • Over-the-counter sleep aids • Little evidence of benefit in chronic insomnia3 • Melatonin • Prolonged use may be safe and effective; however, few long-term studies, and not available in Canada • Immediate-release generally not useful for chronic insomnia • Ramelteon shows promise,4 but not available in Canada Pharmacotherapy (cont) National Institutes of Health. Sleep. 2005;28(9):1049-1057. Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600. MendelsonWB et al. Sleep Med Rev. 2004;8(1):7-17. Mayer G et al. Sleep. 2009;32(3):351-360.

  8. Taper BDZ receptor agonists slowly to prevent rebound insomnia • Tapering is most successful when done in combination with CBT-I1 Tapering Medications Morin CM et al. Am J Psychiatry. 2004;161(2):332-342.

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