Insomnia as a predictor of depression: A meta-analytic evaluation of longitudinal epidemiological studies.

ContextInsomnia is a prevalent health complaint in older
adults. Behavioral and pharmacological treatments have their benefits
and limitations, but no placebo-controlled study has compared their
separate and combined effects for late-life insomnia.ObjectiveTo evaluate the clinical efficacy of behavioral and
pharmacological therapies, singly and combined, for late-life insomnia.Design and SettingRandomized, placebo-controlled clinical trial,
at a single academic medical center. Outpatient treatment lasted 8
weeks with follow-ups conducted at 3, 12, and 24 months.SubjectsSeventy-eight adults (50 women, 28 men; mean age, 65
years) with chronic and primary insomnia.InterventionsCognitive-behavior therapy (stimulus control, sleep
restriction, sleep hygiene, and cognitive therapy)
(n=18), pharmacotherapy (temazepam)
(n=20), or both (n=20) compared with
placebo (n=20).Main Outcome MeasuresTime awake after sleep onset and sleep
efficiency as measured by sleep diaries and polysomnography; clinical
ratings from subjects, significant others, and clinicians.ResultsThe 3 active treatments were more effective than placebo
at posttreatment assessment; there was a trend for the combined
approach to improve sleep more than either of its 2 single components
(shorter time awake after sleep onset by sleep diary and
polysomnography). For example, the percentage reductions of time awake
after sleep onset was highest for the combined condition (63.5%),
followed by cognitive-behavior therapy (55%), pharmacotherapy
(46.5%), and placebo (16.9%). Subjects treated with behavior therapy
sustained their clinical gains at follow-up, whereas those treated with
drug therapy alone did not. Long-term outcome of the combined
intervention was more variable. Behavioral treatment, singly or
combined, was rated by subjects, significant others, and clinicians as
more effective than drug therapy alone. Subjects were also more
satisfied with the behavioral approach.ConclusionsBehavioral and pharmacological approaches are
effective for the short-term management of insomnia in late life; sleep
improvements are better sustained over time with behavioral
treatment.

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Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial.

Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors.

Insomnia is a highly prevalent, often debilitating, and economically burdensome form of sleep disturbance caused by various situational, medical, emotional, environmental and behavioral factors. Although several consensually-derived nosologies have described numerous insomnia phenotypes, research concerning these phenotypes has been greatly hampered by a lack of widely accepted operational research diagnostic criteria (RDC) for their definition. The lack of RDC has, in turn, led to inconsistent research findings for most phenotypes largely due to the variable definitions used for their ascertainment. Given this problem, the American Academy of Sleep Medicine (AASM) commissioned a Work Group (WG) to review the literature and identify those insomnia phenotypes that appear most valid and tenable. In addition, this WG was asked to derive standardized RDC for these phenotypes and recommend assessment procedures for their ascertainment. This report outlines the WG's findings, the insomnia RDC derived, and research assessment procedures the WG recommends for identifying study participants who meet these RDC.

Derivation of Research Diagnostic Criteria for Insomnia: Report of an American Academy of Sleep Medicine Work Group

Practice guideline for the treatment of patients with obsessive-compulsive disorder.

The aim of the study was to assess prevalence and treatment modalities of insomnia in general practice. To investigate the course of insomnia, a longitudinal study design was adopted. Two thousand five hundred and twelve patients (age 18–65 years) were investigated with a questionnaire in general practice (T1). Four months later (T2) and again 2 years later (T3) a questionnaire was sent to all patients who had complained about severe insomnia at the time of the first inquiry. To assess insomnia, operationalized diagnostic criteria were applied (DSM-III-R). Eighteen point seven percent suffered from severe, 12.2% suffered from moderate and 15% suffered from mild insomnia. In the course of 2 years insomnia appeared as a chronic health problem. A high comorbidity of severe insomnia was found with chronic somatic and psychiatric disorders, especially with depression. Of the severely insomniac patients, 23.9% used prescribed hypnotics habitually, mainly benzodiazepines. The use of prescribed hypnotics remained rather stable during the whole study period. More than half of the patients reported a daily use of the hypnotics for 1–5 years or longer, but only 22% of the severely insomniac patients reported at the time of the third inquiry a significant improvement of insomnia due to the administration of sleeping pills. Thus, the long-term administration of benzodiazepine hypnotics seems to be an inadequate treatment strategy in chronic insomnia. Whether the occurrence of rebound insomnia after benzodiazepine withdrawal may be one of the main factors for chronic hypnotic use requires discussion. Although insomnia may be an important symptom of many somatic and psychiatric disorders, the general practitioner was unaware in more than half of the cases that the patients suffered from a sleep problem. Severe insomniac patients displayed a higher mean number of medical consultations compared with good sleepers or patients with mild insomnia, indicating that insomnia constitutes a significant burden for the primary care physicians.

Prevalence and treatment of insomnia in general practice. A longitudinal study.

Background We investigated whether the combination of multi-modal behaviour therapy (BT) with fluvoxamine is superior to BT and placebo in the acute treatment of severely ill in-patients with obsessive-compulsive disorder (OCD). Method In a randomised, double-blind design, 30 patients were treated for nine weeks with BT plus placebo and 30 patients with BT plus fluvoxamine (maximum dosage 300 mg, mean dose 288.1 mg). BT included exposure with response prevention, cognitive restructuring and development of alternative behaviours. Results Both groups showed a highly significant symptom reduction after treatment. There were no significant differences between the groups concerning compulsions. Obsessions were significantly more reduced in the fluvoxamine and BT group than in the placebo and BT group. Furthermore, the group BT plus fluvoxamine showed a significantly higher response rate (87.5 v. 60%) according to a previously defined response criterion. Severely depressed patients with OCD receiving BT plus placebo presented a significantly worse treatment outcome (Y-BOCS scores) than all other groups. Conclusions The results suggest that BT should be combined with fluvoxamine when obsessions dominate the clinical picture and when a secondary depression is present.

Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: Results of a multicentre study.

The present study investigated the temporal stability of insomnia patterns during a 4-month study period, classifying insomnia as sleep-onset insomnia, sleep-maintaining insomnia or insomnia with early morning awakening. In a longitudinal study design, 2,512 general practice attenders were investigated at the time of the first inquiry (T1) with a questionnaire. Four months later (T2), all patients complaining of difficulties in initiating and/or maintaining sleep and/or early morning awakening (n = 328) were again contacted by mail and received the same questionnaire as at T1. According to the reported symptoms, patients were assigned to the different subtypes of insomnia. The diagnosis at T1 was then compared with the diagnosis at T2 4 months later. Only about half of all patients who complained of difficulties in initiating sleep at T1 still exclusively reported sleep-onset insomnia 4 months later, whereas the remaining patients were distributed to different subtypes. The stability of sleep-maintaining insomnia and insomnia with early morning awakening was even lower. Comorbidity with a somatic or psychiatric disorder at T1 and change in hypnotic treatment did not account for the instability of the respective subgroup of insomnia. These findings illustrate that cross-sectional studies focusing on subtypes of insomnia, e.g. sleep-onset insomnia, may lead to erroneous results.

Sleep Onset Insomnia, Sleep Maintaining Insomnia and Insomnia With Early Morning Awakening—Temporal Stability of Subtypes in a Longitudinal Study on General Practice Attenders

This study aimed to assess the prevalence and treatment modalities of elderly practice attenders. A total of 330 patients aged over 65 years were investigated with a questionnaire in general practice. To assess insomnia, operationalized diagnostic criteria according to DSM-III-R were applied. Twenty-three percent of the elderly patients suffered from severe, 17% from moderate and 17% from mild insomnia. More than 80% of the patients reported suffering from insomnia for 1-5 years or longer, which indicates a chronic course. Elderly patients showed unrealistic expectations concerning duration of sleep and spend more time in bed than they realistically can expect to sleep. More than half of the elderly patients reported habitual daytime napping. Sleep-disturbed elderly patients did not differ significantly from good sleepers in their habit of taking daytime naps, but even when taking daytime naps, good sleepers slept significantly longer than the sleep-disturbed patients. A significant association was found between insomnia and mental disorders, i.e., depression and organic brain syndrome according to the diagnosis of the general physician. In about half of the cases the primary care physician was not aware that the elderly patient suffered from severe insomnia. More than half of the elderly severe insomniacs took prescribed hypnotics habitually, mainly benzodiazepines.

Prevalence of insomnia in elderly general practice attenders and the current treatment modalities

The major aim of this study was to investigate links between chronic insomnia and mental and personality disorders using the DSM-III-R classification. Of a sample of 2512 general practice attenders, 105 with a chronic insomnia complaint over a 4-month period were evaluated for mental and personality disorders. In addition, the significance of other factors such as personality traits, social functioning and the patient's own estimation of sleep quality was studied. Sixty-six patients got a diagnosis of a current insomnia using a structured interview for DSM-III-R. Fifty percent of them had at least one additional current Axis I or II diagnosis. Affective disorders were most common as principal psychiatric diagnosis followed by substance use disorders. The general practitioners were poor in recognizing their patients' chronic insomnia complaints and the high percentage of substance abusers among them. The important role of psychopathology in chronic insomnia sufferers was indicated by the high number of patients who displayed prominent personality traits. The predominant personality pattern was characterized by a pattern of internalization of problems combined with an anxious-depressive reaction style. In summary, strong associations between chronic insomnia, mental disorders and psychopathology were confirmed by this investigation.

Christoph Käppler

Papers

Prevalence and treatment of insomnia in general practice. A longitudinal study.

Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: Results of a multicentre study.

Sleep Onset Insomnia, Sleep Maintaining Insomnia and Insomnia With Early Morning Awakening—Temporal Stability of Subtypes in a Longitudinal Study on General Practice Attenders

Prevalence of insomnia in elderly general practice attenders and the current treatment modalities

Mental comorbidity of chronic insomnia in general practice attenders using DSM-III-R.