Journal Sleep: Psychological, behavioral therapies a reliable treatment for insomnia

The most common sleep disorder, insomnia can affect older and younger people differently

WESTCHESTER, Ill., October 25 – New studies in the November 1st issue of the journal SLEEP report the following findings:

PSYCHOLOGICAL AND BEHAVIORAL THERAPIES A RELIABLE TREATMENT FOR INSOMNIA

Psychological and behavioral therapies produce reliable changes in several sleep parameters of insomniacs, and are, therefore, considered an effective treatment for insomnia. This finding confirms a review paper published in 1999 by the American Academy of Sleep Medicine (AASM) regarding the efficacy of psychological and behavioral treatments for insomnia.

The latest study, conducted by Charles M. Morin, PhD, of Université Laval in Québec, Canada, focused on 37 treatment studies – enrolled by a total of 2,246 patients, 2,029 of which completed treatment – published between 1998 and 2004. Participants of the study were 18 years of age and older who suffered from insomnia and had at least one treatment of either psychological or behavioral therapy. Subjects kept a one-to-two-week diary for the duration of treatment and for an additional one-to-two-week period at post treatment and follow-ups.

The results consistently showed that treatments such as cognitive behavioral therapy and relaxation conditions were effective for primary insomnia, as well as insomnia associated with some medical conditions and, to a lesser extent, with psychiatric conditions. Treatment benefits are well sustained over time. There is still limited evidence, however, of clinically meaningful changes beyond the reduction of insomnia symptoms, such as improved daytime functioning or quality of life.

"Although behavioral interventions are not very well known and infrequently used in medical practice, the current findings clearly show that they are an effective method for treating a prevalent and costly health problem, and should be used as a first-line treatment for chronic insomnia," said Morin.

EFFECTS OF INSOMNIA ARE DIFFERENT IN OLDER AND YOUNGER PEOPLE

Insomnia produces side-effects that can negatively impact people of all ages, including physical illness, depression and anxiety. However, there are also differences in the way insomnia affects younger and older people.

The study, conducted by Robert Stewart, MD, of King's College London, UK, focused on the responses of 8,580 people aged 16 to 74 years to a cross-sectional national mental health survey. Of the 3,380 respondents (37 percent of those surveyed) with insomnia symptoms, 12 percent had moderate to severe symptoms, 13 percent reported insomnia with fatigue, and five percent had primary or secondary insomnia.

"The associations between insomnia and separated, divorced or widowed marital status were strongest in younger age groups," said Stewart. "On the other hand, longer bouts with insomnia were more common in the older population, who are also more likely to be taking types of sedatives that have particular problems with addiction and side-effects."

These findings come from a large, representative survey of people in England, Scotland and Wales carried out by the Office for National Statistics, London, added Stewart.

Insomnia, a classification of sleep disorders defined by difficulty falling asleep or staying asleep, waking up too early, or poor quality sleep, is the most common sleep complaint at any age. About 30 percent of adults have symptoms of insomnia. It is more common among elderly people and women. It affects almost half of adults 60 years of age and older.

MODAFINIL AN EFFECTIVE TREATMENT FOR THE ILL-EFFECTS OF SLEEP DEPRIVATION ON WORKING MEMORY

The wake-promoting drug modafinil serves as an effective countermeasure to the adverse effects of overnight sleep deprivation on working memory, but only when task difficulty is moderate. Despite the efficacy of this drug, modafinil should only be taken under the supervision of a sleep specialist.

Robert Joseph Thomas, MD, of Beth Israel Deaconess Medical Center in Boston, Mass., measured the effects of a single 200-mg dose of modafinil on the working memory of eight medication-free men, between the ages of 21 and 35, following overnight sleep deprivation. Performance was enhanced by modafinil only at an intermediate level of task difficulty and was associated with the recruitment of increased cortical activation volumes. Strong and consistent individual differences in performance were noted on the working memory tasks.

"The study results may serve as a reality check on the human quest for endless performance enhancement," said Thomas. "While there is probably room for further safe enhancement of cognition under a variety of stressors, ultimately it is an intricate interplay of our individual make-up and the biological limits to which a given system can be safely pushed. Such limits are well known for physical performance."

The larger question for society, as medically safe cognitive performance enhances are developed, is the limit of fair drug use in otherwise healthy individuals, noted Thomas, who suggests there will never be a "right" answer, although it will make for necessary and vigorous ethical debate. When sleep deprivation is intrinsic to a job, drugs like modafinil seem a reasonable option, as long as our expectations are biologically realistic, Thomas added.

Sleep deprivation is a common result of occupational demands such as rotating-shift work schedules and lifestyle choices that prevent an individual from getting sufficient sleep.

ICSD IS A RELIABLE GUIDE TO CLASSIFYING NARCOLEPSY

The International Classification of Sleep Disorders-2nd Edition (ICSD-2), a diagnostic and coding manual written and published by the AASM, is a proven effective method of classifying narcolepsy with cataplexy.

The study, conducted by Emmanuel Mignot, MD, PhD, of Stanford University, and colleagues at Catholic University of Korea in Suwon, focused on 163 patients with unexplained sleepiness, who underwent polysomnography and a multiple sleep latency test. (MSLT). The gold standard for diagnosis was ICSD-2. Also included in the study were 282 controls recruited at St. Vincent's Hospital, Korea.

The results showed that ICSD-2 was effective for classifying narcolepsy with cataplexy in 80 percent of patients. The remaining percentage of patients who could not be classified were without cataplexy, a condition characterized by a sudden weakness in a person's leg, arm or face muscles and is normally caused by strong emotions.

"A major finding of the study is that many patients with narcolepsy do not have just narcolepsy, but often have other associated sleep problems, such as disturbed nocturnal sleep or sleep apnea," said Mignot. "This makes the MSLT difficult to interpret, and is especially problematic in cases without typical, clear-cut cataplexy."

Narcolepsy is a sleep disorder that causes people to fall asleep uncontrollably during the day. It also includes features of dreaming that occur while awake. Other common symptoms include sleep paralysis, hallucinations and cataplexy.

Since its introduction in 1990, the ICSD has gained wide acceptance as a tool for clinical practice and research in sleep disorders medicine.

Although each person has an individual sleep need, most adults require an average of seven to eight hours of sleep each night to feel alert and well rested. Studies show that at least one in five adults reports getting an insufficient amount of sleep.

Research shows that sleep loss is linked to serious health problems such as cardiovascular disease, obesity, hypertension, depression, anxiety and diabetes.

Those suspecting they might a sleep disorder are encouraged to make an appointment with a specialist at a sleep facility accredited by the AASM.

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SLEEP is the official journal of the Associated Professional Sleep Societies, LLC, a joint venture of the AASM and the Sleep Research Society.

SleepEducation.com, a Web site maintained by the AASM, provides information about the various sleep disorders that exist, the forms of treatment available, recent news on the topic of sleep, sleep studies that have been conducted and a listing of sleep facilities.

To arrange an interview with an AASM spokesperson regarding any of these studies, please contact Jim Arcuri, public relations coordinator, at (708)492-0930, ext. 9317, or jarcuri@aasmnet.org.


Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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