The insomnia landscape fundamentally shifted with the publication in 2013 of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5). The result is that insomnia is regarded as a distinct disorder that has profound implications for treatment. In the past decade, the definition of insomnia, as reflected in disease nosology systems and diagnostic criteria, has evolved. The Importance of Comorbid Insomnia in Psychiatric and Medical Conditions In another National Sleep Foundation survey (N = 1,506 US adults), 70% of respondents reported that their clinicians never asked them about their sleep. 12 Compounding the problem, primary care clinicians appear to be remiss in asking about sleep disturbances. 10,11 A random population survey conducted by the National Sleep Foundation showed that although almost 50% of primary care patients experienced insomnia, only 30% of them mentioned the problem to a physician, and only 6% reported that they had sought the help of a physician for their sleep difficulty ( Figure 1). 2 Although approximately half of patients in primary care experience insomnia, only a fraction of this group, about 25%–50%, discuss sleep issues with their primary care providers, and an even smaller percentage seek treatment for insomnia. People who experience disturbed sleep often fail to consult their primary care clinicians about the issue. ![]() 6–8 One study 9 found that the costs of managing patients with insomnia compared to those without insomnia were 46% higher after 1 year the costs were 80% higher if a comorbidity was present. In the United States, the costs of insomnia are estimated to be as high as $100 billion, most of which reflect indirect costs due to lost productivity (presenteeism/absenteeism), accidents (often involving drowsy driving), and disproportionate use of health care resources. Poor sleep is not only a problem at nighttime its impact also involves diminished daytime functioning and work performance, fatigue, and social isolation. The medical, psychiatric, psychosocial, and economic burdens of insomnia disorder-and the resulting diminished quality of life-are significant. 2 Insomnia disorder is highly prevalent in the general population, with estimates of 10% among adults, 3 and is particularly prevalent in primary care patients, with estimates ranging from 10%–20%. 1 Insomnia is underrecognized and undertreated, resulting in a significant health care burden (increased morbidity and mortality) and poorer quality of life for those who experience it. Insomnia disorder is a distinct chronic condition characterized by reports of difficulty initiating or maintaining sleep, which is present even when the patient has adequate opportunity and an appropriate environment in which to sleep, and has a significant impact on next-day functioning. Insomnia, Despite Its Myriad of Personal and Societal Consequences, Is Underrecognized in Primary Care Optimal outcomes for insomnia require a comprehensive approach that includes lifestyle and behavioral strategies to mitigate maladaptive thoughts and behaviors related to sleep and selection of pharmacotherapy based on individual patient complaints and characteristics. ![]() The dual orexin receptor antagonists have a novel mechanistic target and offer an alternative pharmacologic choice. ![]() ![]() Challenges exist in treating insomnia with commonly used on- and off-label drugs, including low-dose antidepressants, benzodiazepines, and benzodiazepine receptor agonists because of the risk of adverse effects, including impaired next-day functioning. The subtypes of sleep disturbance-reports of difficulty falling or staying asleep, insufficient sleep duration, early waking-and the presence of next-day impairment and common comorbid conditions require a targeted, individualized approach to therapy. It is increasingly recognized as a distinct disorder, not merely a symptom arising secondary to another medical or psychiatric illness. A patient with insomnia was also included.Ĭonsensus Process: The Insomnia Working Group met in March 2022 to review data on available therapies (including medications approved since publication of current guidelines) and share current best practices for evidence-based multimodal treatment of insomnia disorder.Ĭonclusions: Insomnia is highly prevalent but underdiagnosed and undertreated. Participants: Four insomnia experts representing primary care, psychiatry, and clinical research were selected based on clinical expertise, educational qualifications, and research experience. Objective: To evaluate the status of management of insomnia disorder, describe gaps in current recognition and treatment, identify current guidance for optimal management, and develop up-to-date educational recommendations for primary care providers.
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