New Guidelines Issued for Insomnia and Other Sleep Disorders

News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD


September 2, 2010 — The British Association for Psychopharmacology (BAP) has issued a consensus statement on evidence-based treatment of insomnia, parasomnias, and circadian rhythm disorders. The new recommendations, intended to guide psychiatrists and clinicians caring for those with sleep problems, are published online September 2 in the Journal of Psychopharmacology.
"Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners," write Sue J. Wilson, from the Psychopharmacology Unit, University of Bristol, Bristol, United Kingdom, and colleagues. "These ...BAP guidelines are designed to address this problem by providing an accessible yet up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. We limited ourselves to discussion of sleep problems that are not regarded as being secondary to respiratory problems (e.g. sleep apnoea – see NICE Guidance TA139), as these fall outside the remit of the BAP."
These guidelines also do not cover neuropsychiatric disorders, such as narcolepsy and restless legs, for which recent sets of guidelines already exist. The new recommendations were developed after a consensus meeting in London in May 2009 of BAP members, as well as clinicians, experts, and advocates in sleep disorders, based on literature reviews and a description of standard of evidence.
Recommendations for Diagnosis and Treatment
Specific evidence-based recommendations for diagnosis and treatment of insomnia and other sleep disorders, and their accompanying level of evidence rating, are as follows:

• The diagnosis of insomnia is primarily based on complaints provided in the clinical interview by the patient, family, and/or caregiver, ideally corroborated by a patient diary (level of evidence, A).
• Referral to a specialist sleep center may be indicated for other tests in some cases, such as actigraphy for differential diagnosis of circadian rhythm disorder (level of evidence, A), polysomnography for suspected parasomnia or other primary sleep disorder (level of evidence, A), or in the case of treatment failure (level of evidence, D).
• Insomnia should be treated because it impairs quality of life and many areas of functioning and is associated with an increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A). Treatment goals are to reduce distress and to improve daytime function. Choice of treatment modality is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
• For chronic insomnia, cognitive behavioral therapy (CBT)-based treatment packages are effective and should be offered to patients as a first-line treatment (level of evidence, A). CBT, which may include sleep restriction and stimulus control, should be made available in more settings.
• When prescribing hypnotic drug treatment, clinicians need to consider efficacy, safety, and duration of action (level of evidence, A). Other issues to consider may include previous efficacy or adverse effects of the drug and history of substance abuse or dependence (level of evidence, D).
• Recommendations for long-term hypnotic drug treatment are to use it as clinically indicated (level of evidence, A). To discontinue long-term hypnotic drug therapy, intermittent use should first be attempted if feasible. Depending on ongoing life circumstances and patient consent, discontinuation should be attempted every 3 to 6 months or at regular intervals (level of evidence, D). During taper of long-term hypnotic drug treatment, CBT improves outcome (level of evidence, A).
• When using antidepressants, clinicians should apply their knowledge of pharmacology (level of evidence, A). When there is a comorbid mood disorder, antidepressants should be used at therapeutic doses (level of evidence, A). However, clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
• Because of frequent adverse effects of antipsychotic drugs, as well as a few reports of abuse, there is no indication for use as first-line treatment of insomnia or other sleep disorders (level of evidence, D).
• Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia (level of evidence, D).

Recommendations for Certain Populations
Specific evidence-based recommendations for management of insomnia and other sleep disorders in special populations and conditions are as follows:

• After menopause, the incidence of sleep-disordered breathing increases, and the clinical presentation is different in women vs men and often includes insomnia. Informed, individualized treatment of symptoms is needed for use of hormone therapy, considering risks and benefits clarified in recent studies.
• Behavioral strategies are recommended for children with disturbed sleep (level of evidence, A). In children with attention-deficit/hyperactive disorder not treated with stimulant drugs, melatonin administration may help advance sleep onset to normal values (level of evidence, A).
• For children and adults with learning disabilities, clinical evaluation should describe the sleep disturbance and triggering and exacerbating factors (level of evidence, A). Recommended first-line therapy includes environmental, behavioral, and educational strategies (level of evidence, A). Melatonin is effective in improving sleep (level of evidence, A). The treatment plan should be based on a capacity/best-interests framework.
• For management of circadian rhythm disorders, clinical evaluation is essential in delayed sleep-phase syndrome and free-running disorder (level of evidence, A/B). In delayed sleep-phase syndrome, free-running disorder, and jet lag, melatonin may be useful (level of evidence, A), but other strategies such as behavioral regimens and scheduled light exposure (in sighted individuals) can also be used (level of evidence, B/C).

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The costs of the meeting were partly defrayed by unrestricted educational grants from Lundbeck and GlaxoSmithKline. All attendees completed conflict-of-interest statements held at the BAP office.
J Psychopharmacol. Published online September 2, 2010.
Additional Resource

The National Institutes of Health, National Heart, Lung, and Blood Institute's Web site has more information online about sleep disorders.

Clinical Context

Sleep disorders are common in the general population and even more so in clinical practice, yet they are relatively poorly understood by physicians and other healthcare practitioners. One of the most frequent complaints is insomnia. In the general population, one third of adults in Western countries experience difficulty with sleep initiation or maintenance at least once a week. Prevalence is between 1.5 and 2 times higher in women vs men. Approximately half of all diagnosed insomnia is related to a psychiatric disorder. The symptom prevalence of insomnia changes with age.
The BAP guidelines are designed to address this problem by providing an accessible up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. A consensus meeting was held in London in May 2009. The aim of this report was to discuss the diagnosis and treatment of insomnia as well as circadian rhythm disorders and the more common parasomnias.

Study Highlights

• Insomnia is a subjective disorder and is usually long term.
• The diagnosis of insomnia is primarily based on patient-derived and family or caregiver complaints, as determined by the clinical interview, ideally with a patient diary (level of evidence, A).
• In some circumstances, referral to a specialist sleep center may be necessary for other investigations, such as diagnosis of circadian rhythm disorder (actigraphy; level of evidence, A) or parasomnia (polysomnography; level of evidence, A), or in the case of treatment failure (level of evidence, D).
• Circadian rhythm disorders are sleep disorders in which there is a mismatch between circadian rhythms and required sleep-wake cycle.
• Parasomnias are unusual episodes or behaviors occurring during sleep, which disturb the patient or others such as night terrors, sleepwalking, nightmares, and rapid eye movement behavior disorder.
• It is important to treat insomnia because the condition causes decreased quality of life; is associated with impaired functioning in many areas; and leads to increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A).
• The goal of treatment is to lessen anguish and improve daytime function.
• Choice of treatment modality is patient guided and is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
• CBT-based treatment packages for chronic insomnia including sleep restriction and stimulus control are effective and therefore should be offered to patients as a first-line treatment (level of evidence, A). Increased availability of this therapy is required.
• Z-drugs (zaleplon, zolpidem, zopiclone, and eszopiclone) and short-acting benzodiazepines are efficacious for insomnia.
• Factors that clinicians need to take into account when prescribing medications for insomnia are efficacy, safety, and duration of action of the drug (level of evidence, A). Additional factors are previous efficacy of the drug or adverse effects, and a history of substance abuse or dependence (level of evidence, D).
• Hypnotic drug treatment encompasses the following guidelines:
  
  
  • Hypnotic drugs should be used when clinically indicated.
  • They should be limited to 2 to 4 weeks; however, they are often used for longer periods.
  • Safety (adverse events and carryover effects) are fewer and are less serious with decreasing half-lives (level of evidence, Ib).
  • Studies suggest that dependence (tolerance/withdrawal) is not inevitable with hypnotic therapy for up to 1 year with eszopiclone, zolpidem, and ramelteon. Intermittent dosing may reduce the risk for tolerance and dependence.
  • For discontinuation of hypnotics, intermittent use should be administered at first and then at regular intervals.
  • CBT during taper improves outcome.
• Prolonged-release melatonin improves sleep-onset latency and quality of life in patients older than 55 years (level of evidence, Ib).
• Antidepressants for insomnia should be considered when there is a coexistent mood disorder.
• There is limited evidence for the efficacy of doxepin, trimipramine, trazodone, and paroxetine in insomnia. Clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
• There is no indication for use of antipsychotics as first-line treatment.
• Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia.
• For the treatment of circadian rhythm disorders, melatonin is effective in jet lag disorder (level of evidence, Ia), delayed sleep-phase syndrome (level of evidence, Ib), and free-running disorder (level of evidence, IIa). Light therapy is effective in delayed sleep-phase syndrome (level of evidence, III).
• For parasomnias, drug treatment should be based on frequency and severity of events. Psychological treatments are effective for nightmares.

Clinical Implications

• Insomnia is a common sleep disorder that affects up to one third of adults in Western countries, has a higher prevalence in women vs men, and is often associated with a psychiatric disorder.
• Z-drugs and short-acting benzodiazepines are efficacious for insomnia, and CBT-based treatment packages should be offered to patients as a first-line treatment of chronic insomnia.

http://cme.medscape.com/viewarticle/727938?src=cmemp&uac=100542PN

September 2, 2010 — The British Association for Psychopharmacology (BAP) has issued a consensus statement on evidence-based treatment of insomnia, parasomnias, and circadian rhythm disorders. The new recommendations, intended to guide psychiatrists and clinicians caring for those with sleep problems, are published online September 2 in the Journal of Psychopharmacology.
"Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners," write Sue J. Wilson, from the Psychopharmacology Unit, University of Bristol, Bristol, United Kingdom, and colleagues. "These ...BAP guidelines are designed to address this problem by providing an accessible yet up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. We limited ourselves to discussion of sleep problems that are not regarded as being secondary to respiratory problems (e.g. sleep apnoea – see NICE Guidance TA139), as these fall outside the remit of the BAP."
These guidelines also do not cover neuropsychiatric disorders, such as narcolepsy and restless legs, for which recent sets of guidelines already exist. The new recommendations were developed after a consensus meeting in London in May 2009 of BAP members, as well as clinicians, experts, and advocates in sleep disorders, based on literature reviews and a description of standard of evidence.
Recommendations for Diagnosis and Treatment
Specific evidence-based recommendations for diagnosis and treatment of insomnia and other sleep disorders, and their accompanying level of evidence rating, are as follows:

• The diagnosis of insomnia is primarily based on complaints provided in the clinical interview by the patient, family, and/or caregiver, ideally corroborated by a patient diary (level of evidence, A).
• Referral to a specialist sleep center may be indicated for other tests in some cases, such as actigraphy for differential diagnosis of circadian rhythm disorder (level of evidence, A), polysomnography for suspected parasomnia or other primary sleep disorder (level of evidence, A), or in the case of treatment failure (level of evidence, D).
• Insomnia should be treated because it impairs quality of life and many areas of functioning and is associated with an increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A). Treatment goals are to reduce distress and to improve daytime function. Choice of treatment modality is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
• For chronic insomnia, cognitive behavioral therapy (CBT)-based treatment packages are effective and should be offered to patients as a first-line treatment (level of evidence, A). CBT, which may include sleep restriction and stimulus control, should be made available in more settings.
• When prescribing hypnotic drug treatment, clinicians need to consider efficacy, safety, and duration of action (level of evidence, A). Other issues to consider may include previous efficacy or adverse effects of the drug and history of substance abuse or dependence (level of evidence, D).
• Recommendations for long-term hypnotic drug treatment are to use it as clinically indicated (level of evidence, A). To discontinue long-term hypnotic drug therapy, intermittent use should first be attempted if feasible. Depending on ongoing life circumstances and patient consent, discontinuation should be attempted every 3 to 6 months or at regular intervals (level of evidence, D). During taper of long-term hypnotic drug treatment, CBT improves outcome (level of evidence, A).
• When using antidepressants, clinicians should apply their knowledge of pharmacology (level of evidence, A). When there is a comorbid mood disorder, antidepressants should be used at therapeutic doses (level of evidence, A). However, clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
• Because of frequent adverse effects of antipsychotic drugs, as well as a few reports of abuse, there is no indication for use as first-line treatment of insomnia or other sleep disorders (level of evidence, D).
• Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia (level of evidence, D).

Recommendations for Certain Populations
Specific evidence-based recommendations for management of insomnia and other sleep disorders in special populations and conditions are as follows:

• After menopause, the incidence of sleep-disordered breathing increases, and the clinical presentation is different in women vs men and often includes insomnia. Informed, individualized treatment of symptoms is needed for use of hormone therapy, considering risks and benefits clarified in recent studies.
• Behavioral strategies are recommended for children with disturbed sleep (level of evidence, A). In children with attention-deficit/hyperactive disorder not treated with stimulant drugs, melatonin administration may help advance sleep onset to normal values (level of evidence, A).
• For children and adults with learning disabilities, clinical evaluation should describe the sleep disturbance and triggering and exacerbating factors (level of evidence, A). Recommended first-line therapy includes environmental, behavioral, and educational strategies (level of evidence, A). Melatonin is effective in improving sleep (level of evidence, A). The treatment plan should be based on a capacity/best-interests framework.
• For management of circadian rhythm disorders, clinical evaluation is essential in delayed sleep-phase syndrome and free-running disorder (level of evidence, A/B). In delayed sleep-phase syndrome, free-running disorder, and jet lag, melatonin may be useful (level of evidence, A), but other strategies such as behavioral regimens and scheduled light exposure (in sighted individuals) can also be used (level of evidence, B/C).

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The costs of the meeting were partly defrayed by unrestricted educational grants from Lundbeck and GlaxoSmithKline. All attendees completed conflict-of-interest statements held at the BAP office.
J Psychopharmacol. Published online September 2, 2010.
Additional Resource

The National Institutes of Health, National Heart, Lung, and Blood Institute's Web site has more information online about sleep disorders.

Clinical Context

Sleep disorders are common in the general population and even more so in clinical practice, yet they are relatively poorly understood by physicians and other healthcare practitioners. One of the most frequent complaints is insomnia. In the general population, one third of adults in Western countries experience difficulty with sleep initiation or maintenance at least once a week. Prevalence is between 1.5 and 2 times higher in women vs men. Approximately half of all diagnosed insomnia is related to a psychiatric disorder. The symptom prevalence of insomnia changes with age.
The BAP guidelines are designed to address this problem by providing an accessible up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. A consensus meeting was held in London in May 2009. The aim of this report was to discuss the diagnosis and treatment of insomnia as well as circadian rhythm disorders and the more common parasomnias.

Study Highlights

• Insomnia is a subjective disorder and is usually long term.
• The diagnosis of insomnia is primarily based on patient-derived and family or caregiver complaints, as determined by the clinical interview, ideally with a patient diary (level of evidence, A).
• In some circumstances, referral to a specialist sleep center may be necessary for other investigations, such as diagnosis of circadian rhythm disorder (actigraphy; level of evidence, A) or parasomnia (polysomnography; level of evidence, A), or in the case of treatment failure (level of evidence, D).
• Circadian rhythm disorders are sleep disorders in which there is a mismatch between circadian rhythms and required sleep-wake cycle.
• Parasomnias are unusual episodes or behaviors occurring during sleep, which disturb the patient or others such as night terrors, sleepwalking, nightmares, and rapid eye movement behavior disorder.
• It is important to treat insomnia because the condition causes decreased quality of life; is associated with impaired functioning in many areas; and leads to increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A).
• The goal of treatment is to lessen anguish and improve daytime function.
• Choice of treatment modality is patient guided and is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
• CBT-based treatment packages for chronic insomnia including sleep restriction and stimulus control are effective and therefore should be offered to patients as a first-line treatment (level of evidence, A). Increased availability of this therapy is required.
• Z-drugs (zaleplon, zolpidem, zopiclone, and eszopiclone) and short-acting benzodiazepines are efficacious for insomnia.
• Factors that clinicians need to take into account when prescribing medications for insomnia are efficacy, safety, and duration of action of the drug (level of evidence, A). Additional factors are previous efficacy of the drug or adverse effects, and a history of substance abuse or dependence (level of evidence, D).
• Hypnotic drug treatment encompasses the following guidelines:
  
  
  • Hypnotic drugs should be used when clinically indicated.
  • They should be limited to 2 to 4 weeks; however, they are often used for longer periods.
  • Safety (adverse events and carryover effects) are fewer and are less serious with decreasing half-lives (level of evidence, Ib).
  • Studies suggest that dependence (tolerance/withdrawal) is not inevitable with hypnotic therapy for up to 1 year with eszopiclone, zolpidem, and ramelteon. Intermittent dosing may reduce the risk for tolerance and dependence.
  • For discontinuation of hypnotics, intermittent use should be administered at first and then at regular intervals.
  • CBT during taper improves outcome.
• Prolonged-release melatonin improves sleep-onset latency and quality of life in patients older than 55 years (level of evidence, Ib).
• Antidepressants for insomnia should be considered when there is a coexistent mood disorder.
• There is limited evidence for the efficacy of doxepin, trimipramine, trazodone, and paroxetine in insomnia. Clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
• There is no indication for use of antipsychotics as first-line treatment.
• Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia.
• For the treatment of circadian rhythm disorders, melatonin is effective in jet lag disorder (level of evidence, Ia), delayed sleep-phase syndrome (level of evidence, Ib), and free-running disorder (level of evidence, IIa). Light therapy is effective in delayed sleep-phase syndrome (level of evidence, III).
• For parasomnias, drug treatment should be based on frequency and severity of events. Psychological treatments are effective for nightmares.

Clinical Implications

• Insomnia is a common sleep disorder that affects up to one third of adults in Western countries, has a higher prevalence in women vs men, and is often associated with a psychiatric disorder.
• Z-drugs and short-acting benzodiazepines are efficacious for insomnia, and CBT-based treatment packages should be offered to patients as a first-line treatment of chronic insomnia.

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