The assessment and management of insomnia in primary care
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2899 (Published 27 May 2011) Cite this as: BMJ 2011;342:d2899
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We all agree that insomnia is a secondary symptom of Myalgic Encephalitis/ Chronic fatigue Syndrome ME/CFS. Indeed it is included in the Fukuda and Canadian Consensus criteria. However it should be noted that the debilitating fatigue seen in ME/CFS should not be solely attributed to insomnia.
It would be simple if not simplistic to treat ME/CFS with hypnotics, while certain sleep medicine do help, they are not "curative" of this devastating physical disease.
1 Kaushik Sanyal, The assessment and management of insomnia in primary care BMJ 2011;342:d2899
2.Watson NF,Kapur V ,Arguella LM,Goldberg J ,Schmidt DF,Armitage R,Buchwald DB.Sleep disorders in patient with chronic fatigue syndrome .Clin Infect Dis .1994 ;18:S68 - 72
3 Fukuda,K; . Straus, S; et al ; and International Chronic Fatigue Syndrome Study Group. The Chronic Fatigue Syndrome: A Comprehensive Approach to Its Definition and Study . Ann Int Med 1994 121 ; 12; 953-959
4 Carruthers BM, Jain AK, De Meirleir KL, et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical working case definition, diagnostic and treatment protocols. Journal CFS 2003;11:18- 154.
Competing interests: No competing interests
Chronic fatigue syndrome is associated with unrefreshing sleep, impaired ability to concentrate. This also has overlapping other sleep –related complaints .But we also need to carefully separate conditions like obstructive sleep apnoea (1) , upper airway resistance syndrome (2) and restless leg syndrome .Sleep related problem is the most common complaint amongst patients with severely medically unexplained fatigue (3).
Alpha wave appears instead of delta which is hypothesised to be associated with fibromyalgia .It was found that chronic fatigue syndrome patient, that there is an impaired sleep haemostasis with reduced cortical delta and alpha sleep activity. Reduced REM latency (period between sleep onset and the first stage of REM sleep) has been found as one of the features of sleep in depressed individuals (4).
People with chronic fatigue syndrome are sensitive to many treatment especially those affecting the central nervous system .Sleep is improved by low dose sedating tricyclic antidepressant like Amitryptiline .Antidepressant like trazodone are helpful .In restless leg syndrome , dopaminergic like sinemet is effective .
Reference:
1.Unger ER,Nisenbaum R,Moldofsky H,Cesta A,Sammut C,Reyes H,Reeve WC .Sleep assessment in a population –based study of chronic fatigue syndrome.BMC Neurol 2004;4:6.
2.Watson NF,Kapur V ,Arguella LM,Goldberg J ,Schmidt DF,Armitage R,Buchwald DB.Sleep disorders in patient with chronic fatigue syndrome .Clin Infect Dis .1994 ;18:S68 - 72.
3.Guilleminault C,Poyares D,Rosa A, Kirisoglu C,Almeida T,Lopes MC. Chronic fatigue , unrefreshing sleep and nocturnal polysomnography . Sleep Med.2006 ;7:513-20.
4.Benca RM, Obermeyer WH, Thisted RA et al: Sleep and psychiatric disorders.A metanalysis .Arch Gen Psychiatry 49:651 -668, 1992.
Competing interests: No competing interests
We welcome Dr Karen Falloons' recent review of assessment and
management of insomnia in primary care focusing on non-drug options (1).
Physicians managing patients both in primary and secondary care need to be
aware of the adverse effects of insomnia in all aspects of patient health.
In rheumatology poor sleep quality can adversely affect pain levels,
leading to escalation of drug therapies, including immunomodulatory drugs.
In general the role of the physician when assessing sleep problems is
to exclude secondary causes of insomnia such as depression and anxiety,
sleep apnoea, cardiac failure, alcohol and medications, and then to
consider prescribing hypnotic drugs. Lifestyle factors such as caffeine,
alcohol and sleep posture are not always considered. Reasons for this
include lack of time, knowledge and evidence. The impact of sleep posture
may be dramatic for example the importance of sleep posture in infants was
clearly demonstrated in 'The Back to Sleep Campaign,' where the change in
recommendation from prone to supine sleeping posture of infants has led to
a reduction in infant mortality by more than 50% (2).
We invited all rheumatology patients on our Disease Modifying Anti
Rheumatic Drugs (DMARD) monitoring database by letter to complete an
anonymous questionnaire about sleep, asking about sleep interruption,
sleep quality, effect of daytime sleepiness on concentration, mental and
physical function, and sleep posture.
Of 1331 patients invited, 605 (46%) replied of whom 402 (67%) were female.
540 (89%) patients reported interrupted sleep, compared with 41% in a
general population (p < 0.0001) (3). 246 (53%) patients reported
daytime sleepiness affecting concentration, mental function and physical
function. 168 patients reported poor concentration on a daily basis. Of
these, 97 (57%) reported poor sleep posture compared with 46 of 426 (11%)
patients with good sleep posture (p < 0.0001).
143 (24%) patients reported poor sleep posture and 59 (10 %) had received
advice about sleep posture. Of those that had not received advice, 278
(53%) felt this would be helpful.
Rheumatology patients have increased sleep problems compared with the
general population. These problems can adversely affect concentration and
physical function. It is therefore important to optimise sleep in
rheumatology patients, and this advice can also be applied to other
patient groups with chronic illness. Patients need easy access to
education about optimal sleep posture, which we feel should be general
knowledge.
Back and neck pain are also important causes of morbidity and work
loss in the general population (4) and simple interventions that can
improve this should be adopted. For example, patients who complain of back
and neck pain can be advised to sleep with their neck in the neutral
position. Posters displaying sleep hygiene advice including sleep posture
could be displayed in surgery waiting areas in primary and secondary care,
to raise public awareness on simple interventions to improve sleep
quality.
References
1. Falloon K, Arroll B, Elley CR, Fernando A, III. The assessment and
management of insomnia in primary care. BMJ 2011; 342.
2. Mitchell EA, Hutchison L, Stewart AW. The continuing decline in
SIDS mortality. Arch Dis Child 2007; 92 (7): 625-6.
3. Klink M, Quan SF. Prevalence of Reported Sleep Disturbances in a
General Adult Population and their Relationship to Obstructive Airways
Diseases. Chest 1987; 91; 540-46.
4. Maniadakis N. Gray A. The economic burden of back pain in the UK.
Pain 2000; 95-103.
Competing interests: No competing interests
There are numerous sleep laboratories based on assessment and
management of sleep disorders related to obstructive sleep apnoea,
respiratory disorders, neurological disorders and other causes of
secondary insomnia.
It is worth trying organising sleep clinics for primary insomnia.
These clinics could focus on sleep hygiene, sleep diary and methods to
improve quality and quantity of sleep.
Other methods which can be included in sleep clinics are sleep
groups, on the patterns of group therapy, though such groups should be
conducted during daytime, and not during sleepless nights !
Competing interests: No competing interests
The high prevalence of insomnia means that initial management in
primary care is essential, and we welcome the timely review by Falloon et
al1. However we agree with Siriwardena that the article lacks guidance for
practitioners on how to implement changes in practice2.
Chronic insomnia is a complex, relapsing, multifactorial disorder,
with many causes. Lack of training and access to simple diagnostic tools
such as sleep diaries has led to a symptomatic approach to insomnia and
excessive hypnotic prescription in France. Recent attempts by the French
government to reduce prescribing have led to the production of national
guidelines encouraging non pharmacological management.
Managing insomnia in primary care requires a pluridisciplinary
approach, which is difficult to achieve in singlehanded or small group
practices. To overcome this France has trialled a health network approach
to the management of insomnia. The Morphee network provides on line
patient information, telephone advice for primary care physicians, rapid
access to behavioural therapy and triage of patients to sleep services in
order to maximise appropriate referral and minimise waiting times.
Behavioural therapy is proven to be effective in primary insomnia3
and group behavioural therapy for insomnia has practical advantages beyond
simple considerations of cost. Participation breaks down feelings of
isolation, offers support, and the positive experience of group members
encourages individuals to attempt sleep restriction4,5. We can confirm the
effectiveness and feasibility of primary care based CBT: our primary care
psychologists have run 40 three session groups for over 250 participants
and find a clinically and statistically significant improvement in
insomnia severity (measured with the ISI) between the first and last
sessions, maintained over 3 months. Many patients are able to stop or
reduce their hypnotic treatment6.
As in the UK, French sleep services are largely focused on sleep
apnea. Services are overloaded with demands from patients with insomnia,
leading to long waiting times. Many of these patients could be wholly
managed in primary care. An exciting possibility is to use the Morphee
network's expertise to triage patients before they contact hospital
services, redirecting patients who can be managed in primary care back to
their physician with an appropriate support package.
Optimising insomnia management is a challenge. More information for
patients, better training for primary care teams, accessibility to
psychology services and rethinking sleep services are all key elements and
lessons can be learned from international experience
1. Falloon K, Arroll B, Elley CR, Fernando A, III: The assessment and
management of insomnia in primary care. BMJ 2011, 342: d2899.
2. Siriwardena AN, Rapid response to Falloon et al 2011
www.bmj.com/content/342/bmj.d2899.extract/reply#bmj_el_262089
3. Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME et
al.: Efficacy of brief behavioral treatment for chronic insomnia in older
adults. Arch Intern Med 2011, 171: 887-895.
4. Morgan K, Dixon S, Mathers N, Thompson J, Tomeny M. Psychological
treatment for insomnia in the management of long-term hypnotic drug use: a
pragmatic randomised controlled trial. Br J Gen Pract. 2003
Dec;53(497):923-8.
5. Espie CA, MacMahon KM, Kelly HL, Broomfield NM, Douglas NJ,
Engleman HM, McKinstry B, Morin CM, Walker A, Wilson P. Randomized
clinical effectiveness trial of nurse-administered small-group cognitive
behavior therapy for persistent insomnia in general practice. Sleep. 2007
May;30(5):574-84
6. Royant-Parola Sylvie, Hartley Sarah, Colas Des Francs Claire,
Dagneaux Sylvain, Escourrou Pierre Management of sleeping disorders: the
Morphee network BMJQS 19:A131-A133 doi:10.1136/qshc.2010.041624.85
Competing interests: No competing interests
The clinical review on management of insomnia in primary care by
Falloon and colleagues is welcome.[1] Although the authors discuss what
general practitioners (GPs) should do and begin to address the question of
how they might do this, they do little to explain how this might be
achieved in routine practice.
Despite their worries about prescribing for insomnia, GPs often
resort to hypnotics early because they think newer hypnotics are safer,
feel under pressure to prescribe, have limited education, training and
access to resources for assessment and psychological treatment of
insomnia, and may be concerned that it is too complicated to deliver in
the consultation.[2-6] Patients, however, often wish to stop hypnotics and
would welcome access to psychological treatments.[3,5]
The authors state that cognitive behavioural therapy for insomnia
(CBTi) is not designed to be administered by a GP and emphasise sleep
hygiene, which though an important component of CBTi, is probably
ineffective by itself.[7] In fact, CBTi has been shown to be effective
when delivered as a brief intervention by GPs[8] and nurses,[9] to
individuals or groups of patients[10]and early results suggest that CBTi
can be feasibly delivered in routine general practice.[11] The discussion
of stimulus control and sleep restriction is helpful.
Specialist referral is also advised but, in the UK, psychological
services are often poorly equipped to deal with insomnia and sleep clinics
tend to be focussed on sleep apnoea; sleep medicine is not well
established in the UK, so referral for more difficult primary or comorbid
insomnia or parasomnias may simply not be available.
More needs to be done to help patients with insomnia in primary care
and in the NHS more widely. The Resources for Effective Sleep Treatment
project aims to do just this (http://www.restproject.org.uk) and an e-
learning programme (http://elearning.restproject.org.uk), freely available
to practitioners, shows how better care might be delivered in practice.
References
1. Falloon K, Arroll B, Elley CR, Fernando A, III: The assessment and
management of insomnia in primary care. BMJ 2011, 342: d2899.
2. Siriwardena AN, Qureshi Z, Gibson S, Collier S, Latham M: GPs'
attitudes to benzodiazepine and 'Z-drug' prescribing: a barrier to
implementation of evidence and guidance on hypnotics. Br J Gen Pract 2006,
56: 964-967.
3. Siriwardena AN, Qureshi MZ, Dyas JV, Middleton H, Orner R: Magic
bullets for insomnia? Patients' use and experiences of newer (Z drugs)
versus older (benzodiazepine) hypnotics for sleep problems in primary
care. Br J Gen Pract 2008, 58: 417-422.
4. Siriwardena AN, Apekey T, Tilling M, Dyas JV, Middleton H, Orner
R: General practitioners' preferences for managing insomnia and
opportunities for reducing hypnotic prescribing. J Eval Clin Pract 2010,
16: 731-737.
5. Dyas JV, Apekey TA, Tilling M, Orner R, Middleton H, Siriwardena
AN: Patients' and clinicians' experiences of consultations in primary care
for sleep problems and insomnia: a focus group study. Br J Gen Pract 2010,
60: 180-200.
6. Anthierens S, Habraken H, Petrovic M, Christiaens T: The lesser
evil? Initiating a benzodiazepine prescription in general practice. Scand
J Prim Health Care 2007, 25: 214-219.
7. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein
KL: Psychological and behavioral treatment of insomnia:update of the
recent evidence (1998-2004). Sleep 2006, 29: 1398-1414.
8. Edinger JD, Sampson WS: A primary care "friendly" cognitive
behavioral insomnia therapy. Sleep 2003, 26: 177-182.
9. Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME et
al.: Efficacy of brief behavioral treatment for chronic insomnia in older
adults. Arch Intern Med 2011, 171: 887-895.
10. Espie CA, MacMahon KM, Kelly HL, Broomfield NM, Douglas NJ,
Engleman HM et al.: Randomized clinical effectiveness trial of nurse-
administered small-group cognitive behavior therapy for persistent
insomnia in general practice. Sleep 2007, 30: 574-584.
11. Siriwardena AN, Apekey T, Tilling M, Harrison A, Dyas JV,
Middleton HC et al.: Effectiveness and cost-effectiveness of an
educational intervention for practice teams to deliver problem focused
therapy for insomnia: rationale and design of a pilot cluster randomised
trial. BMC Fam Pract 2009, 10: 9.
Competing interests: ANS is chief investigator for the Resources for Effective Sleep Treatment study (http://www.restproject.org.uk).
Re: The assessment and management of insomnia in primary care
Karen Falloon rightly stresses that “obstructive sleep apnea is a relatively common cause of sleep disturbance and can have a profound effect on daily functioning,” and gives it priority in her review. However I would like to supplement her remarks by pointing out that physicians need to be alert for a past head injury since it markedly increases the probability of sleep apnea, whether obstructive or central. [1,2]. It is particularly important to eliminate OSA or CSA before prescribing antidepressants and sedatives (including benzodiazepines, to which Ms Falloon gives guarded approval) since these drugs may dangerously aggravate breathing irregularities during sleep in this class of patient.[3,4]
My own experience may be relevant here. I had three head injuries between 1975 and 2003, and after the third trauma I could not sleep for more than three hours a night, awaking unrefreshed and suffering fatigue during the day. I was diagnosed among other ailments with chronic fatigue syndrome and prescribed amitryptiline and antidepressants, which I could not tolerate. Finally, after more than five years of great suffering both for myself and my family, I insisted on being given a polysomnography test. This showed that I had severe obstructive sleep apnea with some central involvement. I had an AHI of 36.8 an hour, which I understand means that I was unable to sleep for longer than 2 minutes without having to wake up to breathe. The test result has meant that, at long last, my condition is being addressed and I have been given a CPAP machine.
I think there are three conclusions to be drawn from my five-year quest for diagnosis which may prevent other patients suffering the same prolonged torture, and they are these:
· Past head injury should be one of the first things checked for in a patient with sleep problems.
· Past head injuries should be given the same prominence on a patient’s medical notes as allergies. If my TBIs had not been buried in 10 years of notes I might have stood a better chance of being diagnosed with sleep apnea, and also hypopituitarism, which is another not uncommon effect of brain injury.
· For any patient who has sleep problems but cannot tolerate sedatives and antidepressants, a polysomnography test should urgently be considered.
I sincerely hope that my comments will be incorporated into future protocol.
[1] Webster JB, Bell KR, Hussey JD, Natale TK, Lakshminarayan S. Sleep apnea in adults with traumatic brain injury: a preliminary investigation. Arch Phys Med Rehabil 2001;82:316-21
[2] Castriotta RJ Arch Phys Med Rehabil 20001;82 Sleep disorders associated with traumatic brain injury, :1403-6.
[3] Nakayama M et al, Obstructive sleep apnea syndrome as a novel cause for Menieres disease, Current Opinion in Otolaryngology and Head and Neck Surgery, 2013;21:5pp503-508 “Physicians routinely prescribe benzodiazepines or other drugs that have hypnotic, muscle relaxing, antianxiety, and anticonvulsant properties for insomnia, but these properties may have the effect of aggravating OSAS symptoms.”
[4] University of Maryland Medical Center website http://umm.edu/health/medical/reports/articles/obstructive-sleep-apnea Note on Sedatives. Sedatives, narcotics, antidepressants, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers.
Competing interests: No competing interests