Insomnia

Contents

Foreword: Insomnia xiii

Teofilo Lee-Chiong Jr

Preface: Insomnia xv

Jack D. Edinger

Section 1: Understanding the Nature, Impact and Etiology of Insomnia

Epidemiology of Insomnia: Prevalence, Course, Risk Factors, and Public Health Burden 281

CharlesM.Morin andDenise C. Jarrin

This article summarizes recent epidemiologic evidence on insomnia, including itsprevalence, incidence, and risk factors, as well as its course and consequences.Insomnia is a significant public health problem. It is a highly prevalent condition,both as a symptom and a syndrome, and is often a persistent condition over time.Its persistence is associated with increased risk for mental, physical, and occupa-tional health problems. Chronic insomnia also carries heavy economic burden.These findings have direct implications for community-based prevention and inter-vention programs and for future research.

Hyperarousal and Insomnia 299

Kai Spiegelhalder andDieter Riemann

In this article, the evidence for hyperarousal in insomnia is reviewed, with an empha-sis on neurobiological studies. Indicators of physiologic hyperarousal includeelectroencephalography-derived polysomnographic, autonomic, and neuroendo-crine variables and outcome parameters of neuroimaging studies. Most studiesdocumented an increased physiologic arousal in patients with insomnia, but it isnot known whether physiologic hyperarousal is a cause or consequence of insom-nia, what is the genetic basis of hyperarousal and what is the impact of early-lifestressors and other life events, and what is the neurobiological basis of hyperarousaland how can it be modified in the most efficient manner.

Insomnia With Short Sleep Duration: Nosologic, Diagnostic, and Treatment Implications 309

Alexandros N. Vgontzas andJulio Fernandez-Mendoza

We review evidence that insomnia with objective short sleep duration is associatedwith physiologic hyperarousal; higher risk for hypertension, diabetes, neurocognitiveimpairment, and mortality; and with a persistent course. We propose that objectivemeasures of sleep be included in the diagnosis of insomnia and its subtypes, objec-tive measures of sleep obtained in the home environment of the patient wouldbecome part of the routine assessment and diagnosis of insomnia in a clinician’soffice setting, and insomnia with short sleep duration may respond better to biologictreatments, whereas insomnia with normal sleep duration may respond primarily topsychological therapies.

The Role of Genes in the Insomnia Phenotype 323

Philip R. Gehrman, Cory Pfeiffenberger, and EndaM. Byrne

With the development of genetic model systems for sleep, it seems logical to usethem to screen human insomnia genetic studies for bona fide hits and to further

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characterize the mechanisms behind insomnia. This must be an important compo-nent of future research on the genetics of insomnia. Understanding of the role ofgenes in the insomnia phenotype is limited. There are several molecular genetictools available that were not in existence even a few years ago. The time is ripefor research on the genetics of insomnia that may finally shed light on the mecha-nisms of this common sleep disorder.

Section 2: Challenges and Methods in Insomnia Management

Optimizing the Pharmacologic Treatment of Insomnia: Current Status and FutureHorizons 333

JaredMinkel and AndrewD. Krystal

This article assists clinicians and researchers in optimizing the treatment of insomniathrough medication. Basic characteristics of medications used to treat insomnia arereviewed, followed by a review of the fundamental ways that individuals with insom-nia may differ and, thus, affect the choice of therapy. Discussions address how tobest choose a medication based on the characteristics of the available medications,the key differences among patients with insomnia, the available research literature,and future directions in the pharmacologic management of insomnia.

The Role of Bright Light Therapy in Managing Insomnia 351

Nicole Lovato and Leon Lack

Two types of insomnia, sleep-onset insomnia and early-morning-awakening insom-nia, have been associated with delayed and advanced circadian rhythms, respec-tively. These circadian rhythm abnomalies can be treated with morning bright lightin the case of sleep-onset insomnia, and evening bright light in the case of early-morning-awakening insomnia. Although robust evidence shows that appropriatelytimed light therapy can retime the body clock, evidence of the therapeutic valueof bright light therapy for these types of insomnia needs further development. Largerandomized controlled trials bright light and behavior therapies, alone and in combi-nation, are needed to improve the treatment of these debilitating disorders.

Insomnia Comorbid to Severe Psychiatric Illness 361

AdrianeM. Soehner, KatherineA. Kaplan, andAllison G. Harvey

Evidence indicates that sleep disturbances exert a detrimental influence on thecourse of psychiatric illness and contribute to impaired function. This review focuseson sleep in bipolar disorder and schizophrenia, and discusses the role of sleep dis-turbances and altered sleep architecture in relation to symptom status, functionalimpairment, quality of life, and the course of these disorders. Current evidenceregarding pharmacologic and psychological treatment approaches for insomnia inthese populations is presented. This review also notes considerations for adaptingCognitive Behavioral Therapy for insomnia procedures for severe mental illnessand proposes directions for future research.

Insomnia and Cancer: Prevalence, Nature, and Nonpharmacologic Treatment 373

Josee Savard andMarie-Helene Savard

Sleep disturbances are among the most common symptoms reported by patientswith cancer, and insomnia is a persistent condition in this context, especially at

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the syndrome level. This review summarizes available prevalence estimates andempirical evidence on the evolution of insomnia complaints throughout the cancercare trajectory. Potential etiologic factors (predisposing, precipitating, and perpetu-ating factors) are discussed. Available empirical findings on the efficacy of nonphar-macologic treatments for sleep difficulties in patients with cancer, in particularcognitive-behavioral therapy (CBT), are presented. Several areas for future researchare proposed, including strategies to improve accessibility to CBT for insomnia inclinical settings.

Insomnia and Obstructive Sleep Apnea 389

Jason C. Ong andMegan R. Crawford

Emerging evidence suggests that comorbid insomnia has a negative impact on thetreatment of obstructive sleep apnea (OSA), particularly with adherence to positiveairway pressure therapy. Furthermore, the two conditions together are associatedwith greater morbidity of psychiatric, medical, and other sleep disorders. In discus-sing the clinical implications of such evidence, sleep clinicians should conduct com-prehensive evaluations for both OSA and insomnia. Moreover, patient managementshould include considerations to treating both OSA and insomnia. Future researchshould include studies aimed at understanding the pathophysiology of the comorbidcondition, improving diagnostic tools and evaluating the effectiveness of treatmentcombinations.

Lessons Learned from the National Dissemination of Cognitive Behavioral Therapyfor Insomnia in the Veterans Health Administration: Impact of Training onTherapists’ Self-Efficacy and Attitudes 399

RachelManber,Mickey Trockel, Wendy Batdorf, Allison T. Siebern, C. Barr Taylor, Julia Gimeno,and Bradley E. Karlin

Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective and well-established treatment, but patient access is limited because few clinicians aretrained to deliver the therapy. The Veterans Health Administration (VHA) is nationallydisseminating CBT-I as part of its efforts to make evidence-based psychotherapieswidely available to Veterans. As part of this dissemination effort, the VHA hasimplemented a national, competency-based CBT-I training program. This articledescribes the training methods and the impact of training on therapists’ use ofCBT-I and on their self-efficacy to deliver and attitudes toward CBT-I.

Use of the Internet and Mobile Media for Delivery of Cognitive Behavioral InsomniaTherapy 407

Colin A. Espie, Peter Hames, and BrianMcKinstry

Cognitive behavioral therapy (CBT) is an effective treatment of insomnia disorder.CBT has traditionally been delivered by a therapist in a clinic; however, the ubiqui-tous nature of the Internet and increasing penetration of mobile devices offersnew possibilities. Moreover, there are limitations to face-to-face therapy, particularlyin relation to between-session home implementation. This article, therefore, pres-ents the opportunity afforded by technological development, not only to meet theneed and demand for CBT but also to improve insomnia care both at the level ofthe individual patient and at population level.

Index 421