By Ryan DuBosar
Insomnia is a common disorder that's steadily increasing in prevalence in a society that has deprioritized sleep, said Christopher Lettieri, MD, at a Friday session at Internal Medicine Meeting 2021: Virtual Experience.
And because insomnia is a contributing factor to numerous chronic comorbid conditions, it's particularly common among those seeking medical attention, added Dr. Lettieri, a professor of medicine in the division of pulmonary, critical care, and sleep medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md.
Nearly everyone has intermittent episodes of insomnia, he said. For most individuals, these are isolated events that are almost always self-resolving and don't warrant therapy. However, approximately 30% of adults will have chronic insomnia at some point in their lives, and approximately 15% of adults are experiencing chronic insomnia at any given time.
Dr. Lettieri recommended ACP’s clinical practice guideline on insomnia, published by Annals of Internal Medicine in 2016, which favors cognitive behavioral therapy (CBT-I) as a first-line treatment and says that pharmacological treatments should primarily be used as a short-term bridge.
He offered the following management pearls:
Make sure it's actually insomnia. Check that the patient’s sleep environment is conducive to good sleep and not actually a cause of sleep disruptions. Consider the sleep-related effects of medications and adjust doses or schedules to avoid them, if at all possible. Try to optimize the treatment of any medical disorder that could be mimicking insomnia, especially sleep apnea, he said.
Discuss healthy sleep habits. This conversation doesn't take very long, Dr. Lettieri said. Focus on a few key elements: having a regimented sleep-wake pattern involving the same bedtime and wake-up time every day; optimizing the sleep environment to be cold, dark, quiet, and comfortable; avoiding naps; and eliminating alcohol.
Advise against caffeine. Patients should especially avoid it in the afternoon. “If you're complaining about insomnia, maybe that caffeine isn't really helping you,” Dr. Lettieri advised.
Recommend regular exercise. While exercise absolutely helps with sleep onset and sleep continuity, it should be done no later than three hours before bed.
Look at evening light exposure. The body's production of melatonin is turned on in the dark and turned off in the light, Dr. Lettieri said. Patients should make sure they get as much light in the morning as possible. At night, screen time should be limited, but if they can't cut it out entirely, patients can use a filter readily available on most devices to eliminate light wavelengths that suppress melatonin production. “Some of those night filter settings turn your screen a little bluer, a little harder to see, but it will have less of an effect on suppressing melatonin onset,” he said.
CBT-I remains the best, most effective way to treat chronic insomnia and is recommended as first-line therapy by all published guidelines, Dr. Lettieri said. This therapy incorporates all of his pearls, in a formal program delivered by an expert in sleep behavior disorders, who combines therapeutic strategies with education about sleep regulation and hygiene, stimulus control, mindfulness, relaxation, and methods to counteract arousal. Most programs last about four to eight weeks.
While these programs are effective, Dr. Lettieri cautioned that they are resource intensive and not covered by many insurance plans, and the number of insomnia specialists in the United States is limited.
“Insomnia cannot be treated without behavioral change,” Dr. Lettieri concluded. “Patients have to embrace healthy sleep habits. … Medications, whether they're over the counter or prescription, are not as effective for long-term solutions for insomnia. They can absolutely be helpful with use occasionally, or for very limited periods of time.” ■