University of Groningen. Insomnia in perspective Verbeek, Henrica Maria Johanna Cornelia

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1 University of Groningen Insomnia in perspective Verbeek, Henrica Maria Johanna Cornelia IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2004 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Verbeek, H. M. J. C. (2004). Insomnia in perspective: diagnosis, treatment and education Groningen: s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date:

2 Chapter 8 General discussion Introduction Given the high prevalence and seriousness of the daytime complaints that chronic insomnia causes, accurate diagnosis and effective treatment of insomnia is vital. Chronic insomnia involves difficulties in initiating or maintaining sleep, poor sleep quality, or a combination of these symptoms. Tiredness and problems with mood, concentration, and memory are the most common daytime complaints associated with insomnia. Judgment of sleep as good or poor is primarily a subjective assessment. Large differences in subjective sleep quality are typically observed between individuals and also between nights for one individual. This also applies to the daytime complaints. Although these complaints often are experienced as very inconvenient, they seldom lead to clear defects or clear somatic or psychiatric symptoms. This contributes to the fact that many general practitioners (G.P.s) in their daily practice seldom execute specific diagnostic examinations, and therapy is often restricted to reassuring comments, possibly along with the prescription of hypnotics. This is a pity, because the literature shows that the effects of untreated chronic insomnia may be severe (e.g., more psychiatric complaints, severe traffic and work accidents, and higher absenteeism) (Stoller, 1994; Chilcott and Shapiro, 1996; Léger et al, 2002). For many physicians, hypnotics are still the first choice of treatment. Although the short-term efficacy is positive, there are concerns about the long-term treatment of chronic insomnia with hypnotics. As insomnia often is a chronic or recurrent condition, the clinician is left with the absurd therapeutic situation of prescribing effective short-term treatments for a long-term disorder. In the last decade, non-pharmacological treatment strategies have been established as a substitute for pharmacological treatment in insomnia. The most important ingredients of this non-pharmacological treatment are the use of self-registered sleep logs, sleep education, sleep hygiene guidelines, stimulus control, sleep restriction, relaxation exercises, cognitive restructuring, and the discontinuation of hypnotic drugs (see introduction for more details). The duration of treatment is short (on average six sessions, excluding follow-up). In recent years, the name used in the literature has changed from non-pharmacological treatment to cognitive behavioral treatment (CBT) of insomnia. This term will be used from now on in this discussion. Despite substantial evidence supporting the efficacy of CBT in both the short term and the long term, this treatment is still relatively unknown to the public and underused by general practitioners, while the accessibility is limited. A main disadvantage of this treatment is also that it is expensive, due to the time-consuming therapist client interactions. There remains a need to develop effective interventions that are readily accessible and not too expensive. Diagnosis As already mentioned, insomnia is a subjective complaint about the quality and quantity of sleep. This subjective experience of sleep should be explored carefully 95

3 when diagnosing insomnia. Although polysomnography (PSG) has always been considered the golden standard in sleep research, the role of objective measurement of sleep in insomnia is limited. Recently the American Academy of Sleep Medicine published an update of the practice parameters for using PSG to evaluate insomnia (Littner et al., 2003, ASDA, 1995). Insomnia is diagnosed clinically primarily with a detailed medical, psychiatric, and sleep history. PSG is indicated when either a sleep-related breathing disorder or periodic limb movement disorder is suspected, initial diagnosis is uncertain, treatment fails, or arousals occur with violent or injurious behavior. PSG is not indicated for the routine evaluation of insomnia. For the reason that PSG is very time consuming and expensive, alternative techniques have been sought to measure sleep more objectively than the sleep log does. One of the most studied alternatives is actigraphy. In chapter 2 we focused on the usefulness of actigraphy for clinical practice in insomnia. Although actigraphy is not burdensome and is easy to apply, its added value in the diagnosis of insomnia is limited. Automatic scoring of sleep by the actigraph is problematic in two kinds of patients: those who are awake but motorically very quiet, for whom actigraphy will overestimate sleep and underestimate the duration awake; and those who are asleep but motorically very restless, for whom actigraphy will underestimate the amount of sleep and overestimate the duration of awake. As both situations are likely in insomniacs, the question arises as to whether we should use automatic scoring of sleep by the actigraphy at all for clinical practice in insomnia. Insomnia is diagnosed clinically primarily with a detailed medical, psychiatric, and sleep history together with a selfregistered sleep log for at least one week. Subjective sleep is the starting point for both diagnosis and treatment and should therefore be seen as the golden standard. Non-pharmacological treatment of insomnia The most frequently applied and investigated non-pharmacological treatment of chronic insomnia is the cognitive behavioral treatment (CBT). Chapter 3 describes the results from our first study on the effects of short-term CBT for chronic insomniacs who were referred to the Centre of Sleep and Wake Disorders Kempenhaeghe. Already after four weeks of treatment, 85% of the patients reported feeling better despite the long duration of the sleep complaints (mean of 11 years). Futhermore, 35% of the patients had stopped hypnotic use and 38% had decreased hypnotic use. This positive subjective effect was confirmed by the sleep logs. A less positive effect of treatment seemed to be related to a lower level of education and working at home. From these results it may be concluded that treatment should be adapted to the level of education and life situation of the patient. Furthermore, it is desirable to have insight in the daily activities and possible problems with that (e.g. boredom, overloading, social isolation). Already after four weeks of treatment it can be determined if treatment will be successful or not. Because the complaints often exist for many years, it is useful to monitor the effect of treatment in the long term. Furthermore, it is interesting to examine whether improvements in subjective sleep also lead to a better quality of life, because this may prevent relapse. The second study in a group of strictly selected patients (primary insomnia without chronic hypnotic use), showed that both 96

4 subjective sleep and daytime functioning improved through CBT (chapter 4). Although improvement in daytime functioning may be the result of improvement in sleep, CBT itself may lead to a better insight and management of daytime complaints. The third study showed that CBT can also be given in groups (chapter 5). Treatment is cost-saving from six participants per group. The results were comparable to individual treatment. CBT can be started if insomnia is the primary complaint (no clear psychopathology like severe depression or personality disorders), and when the patient is motivated for treatment. Group treatment has the advantage for the patient of meeting fellow patients, which may be helpful through sharing and putting into perspective one s own complaints. Evaluations of group treatment among participants showed that meeting other insomniacs was experienced as very helpful. This seemed to compensate for the fact that in a group there was less individual time from the therapist per patient than in individual treatment. On the other hand, the therapist was present longer in a group (2.5 hours compared to one hour in individual treatment). Of course, group treatment may also have disadvantages. When composing a group, an expert should be alert for possible psychopathology of patients that can interfere with the group process. Clinical significance From chapters 3 5 it may be concluded that short-term behavioral treatment improved subjective sleep parameters (see summary table). Nevertheless, the changes were modest; there were no large significant changes (see chapters 4 and 5). First of all, the high intra-individual variability of sleep complaints made it difficult to obtain clinical significance. Most patients did not become good sleepers according to the definition SOL 30 min and SE 85 % (Morin, 1993). Many patients dropped out because either sleep efficiency fell just below 85% or sleep onset latency was just larger than 30 min. Furthermore, there was no correction for age. Both sleep efficiency and sleep-onset latency should be adapted to age. Recently, Morin (2003) and Hauri (2003) pointed out that we have focused too long on substracting a few minutes from sleep latency or adding some time to total sleep. Effective treatment should also produce clinically meaningful changes in daytime functioning, fatigue, mood, and quality of life. The studies described in chapters 4 and 5 showed significant improvements in quality of life and dysfunctional beliefs and attitudes about sleep, both after treatment and at follow-up. Primary versus secondary insomnia According to both the International Classification of Sleep Disorders and the Diagnostic and Statistical Manual of Mental Disorders, there is no clear medical or psychiatric cause in primary insomnia (ASDA, 1997; APA, 2001). Secondary insomnia, however, can be attributable to a medical or psychiatric cause. The group of secondary insomniacs is therefore much larger and has different etiological factors than the primary insomniacs. The summary table shows that the percentage of good sleepers post-treatment was higher in study 2, in which only primary insomniacs were included. Several comments must be made. First of all, the definition of good sleeper was formulated differently in study 1 (according to Lacks & Powlishta, 1989) than in studies 2 and 3 (according to Morin,1993). Furthermore, the baseline values of the sleep parameters from the patients from study 2 (only primary insomniacs) seemed to be better than the baseline sleep 97

5 parameters from study 1 (both primary and secondary inomniacs), but not better than those from study 3 (also primary and secondary insomniacs). Moreover, the effect of treatment for all three studies was comparable for both sleep-onset latency (decrease of respectively 34, 33 en 29 minutes for studies 1, 2 and 3) and sleep efficiency (increase of respectively 15, 18 and 15% for studies 1, 2 and 3). The values of wake after sleep onset in studies 2 and 3 were comparable, both at baseline (respectively 64 and 59 minutes) and treatment effect (decrease of respectively 31 en 20 min.). In study 1 both baseline value (137 min.) and treatment effect (decrease of 63 min.) were much higher. The percentage of decrease in wake after sleep onset was more comparable between the three studies (respectively 54, 51 and 66%). The improvements in total sleep time were highest in 2 (50 min.) in comparison with both study 1 (12 min.) and study 3 (21 min.). It remains unclear if the differences found should be explained from the difference in patient population (primary versus secondary), or from the format of the group. A group of primary insomniacs should be investigated to answer this question. For treatment itself, the etiological distinction between primary and secondary insomnia is not so important. Both primary and secondary insomnia patients are often caught in a vicious circle in which bad sleep leads to emotional, mental and physiological tension that leads to maladaptive thoughts and behavior which lead to more bad sleep. CBT focuses on breaking through the vicious circle of bad sleep, irrespective of the cause of the sleep complaint. Recruited versus clinically-referred The population in our three studies is rather unique because all patients were referred by their physician. Most insomnia studies recruit their subjects through newspaper advertisements, which may lead to a different population than the one seen at our sleep centre. The recruited patients from the studies of Morin et al. (1999) and Edinger et al. (2001) reflect an older patient population. The mean age of our patients was 45.1 years (individual treatment) and 43.7 (group treatment) compared to 64.4 (Morin et al.) and 55.3 (Edinger et al.). The mean age of onset of sleep complaints in our population ranged from years compared to years in the recruited studies mentioned before. It is well known that sleep deteriorates with age. Even without the correction for age, our patients have subjectively worse sleep than the recruited patients from the literature studies mentioned above. Espie et al. (2001) evaluated the clinical effectiveness of a primary-care-based insomnia service. They studied chronic insomniacs who were referred by general practitioners. The mean age of his group is unknown. Although about 40% reported problem durations of greater than ten years, it is unlikely that the mean duration of insomnia in his population is comparable with our population (range years). His clinical study seems to reflect a different population than the one seen in our sleep centre. Our studies are difficult to compare with the cited literature studies because of differences in patient population and methodology. Despite the differences in both patient age and the way of recruiting patients, the results of CBT are comparable between these studies. This means that there is a broad indication area for CBT. 98

6 Public education Although group treatment in groups of five to eight patients produces time savings, it is a drop in the ocean for the large group of insomniacs. One-third of the adult population experiences insomnia every now and then. The prevalence of insomnia combined with problems in daytime functioning is about 6% (Ohayon, 2002). Although prevalence figures, which depend on the definition of insomnia, vary from 6 33%, it seems important to inform the public about sleep, insomnia and its cognitive behavioral treatment. According to the World Health Organization (WHO), prevention of sleep complaints should be a national interest for all affiliated countries, given their high economic costs and health risks (Roth, 1999). In April 1998, the Sleep Line was introduced in The Netherlands. People could dial a telephone number for information and tips about sleep. Our study among callers of the Sleep Line showed that the telephone line fulfills a need. In the first nine months of its existence, 10,000 people called the line. Callers listened mostly to general information about sleep and treatment without hypnotics (chapter 6). The average caller was middle-aged and highly educated, and the mean duration of their sleep complaints was five years. Two-thirds of the callers with sleep complaints had visited their general practitioner before consulting the Sleep Line. This study shows that information about sleep and treatment without hypnotics should also be accessible to the elderly and less educated persons. The television would be the best medium for this group. Postbus 51 spots promoting healthier lifestyles (quit smoking, healthy food and sufficient exercise) might be extended with information about sleep and sleep hygiene guidelines. In an analysis of the estimated contribution of four factors to the ten most important causes of premature death, lifestyle factors are more than twice as important as organic factors (Everly, 1989). Daily activities like food, exercise and use of alcohol and cigarettes largely determine health and duration of life (Breslow, 1979). Seven habits are of importance: moderate and regular food, breakfast, non-smoking, exercise, moderate or no use of alcohol and seven to eight hours of sleep daily. It remains strange that sleep still receives so little attention in the media. The great success of the TELEAC television course You can learn to sleep might be seen as the evidence that there is need for sleep education and/or long-distance therapy among the population. Although less accessible for elderly and less educated people, CBT in a self-help format provided via the Internet holds promise as a potential treatment alternative for chronic insomnia (Ström et al., 2004). The information and advice from the Sleep Line are also available via Internet ( Education of general practitioners The figures of the Drug Information Project (Geneesmiddelen Informatie Project, GIP) from the Healthcare Insurance Board (College Voor Zorgverzekeringen, CVZ) estimate the amount of benzodiazepine users (both hypnotics and tranquilizers) in 1998 at nearly 1.9 million insured people in The Netherlands (12%). From this figure, 54% concerns tranquilizers only; 30%, hypnotics only; and 16%, both. About two-thirds are female and one-third are 65 years or older. The number of chronic users (three months or longer) of benzodiazepines is estimated at nearly 700,000 (37%). Roughly one-third of these chronic benzodiazpine users take tranquilizers, one-third take hypnotics, and the rest take both. In primary care, 99

7 the general practitioner prescribes hypnotics and tranquilizers. Early diagnosis and behavioral treatment of acute insomnia may prevent chronic complaints, which in its turn may reduce chronic use of hypnotics. This means that specific attention to sleep by means of accurate diagnosis, sleep education, and sleep hygiene guidelines should be a task for the G.P. The Standards Sleeplessness and Hypnotics that are used by the Dutch College of General Practitioners (NHG) describe diagnosis and treatment of short-term and chronic sleeplessness (Springer and Eykelenboom 1989; Knuistingh Neven et al., 1998).It is common to manage this by giving sleep information and sleep hygiene guidelines for each sleep complaint. The course You can learn to sleep better from the National Association of Home Care is also referenced. This course has been given now for years in numerous cities throughout the country, often twice a year. A few years ago, the author conducted a survey among 62 G.P.s which showed that 44 of the G.P.s (71%) did not use the NHG-standards. Obviously, it is difficult to apply the guidelines from the NHG-standards. Furthermore, it appeared impossible for several G.P.s to include insomnia patients in our study about minimal intervention of chronic insomnia by G.P. because they did not see patients with primary sleep complaints. This is strange, in view of the fact that sleep complaints are among the top ten complaints for which patients visit their G.P. It seems that the G.P. investigate primarily the cause of insomnia and prescription of hypnotics (or not), while he/she could actually investigate the characteristics of the insomnia itself. He/she could use a sleep history and a sleep log for the diagnosis and give sleep education and sleep hygiene guidelines that are attuned to the individual patient. This was the reason we started a training program for G.P.s about sleep physiology, sleep pathology and the application of the sleep log and sleep hygiene guidelines. Whenever possible, it was agreed to use the sleep log and to give sleep education and sleep hygiene guidelines and not to prescribe hypnotics. Discontinuation from chronic benzodiazepine use was left out of consideration. For this we refer to the Dutch manual Discontinuation from benzodiazepines minimal intervention from the Dutch Institute for Proper Use of Medicine (DGV, Nederlands instituut voor verantwoord medicijngebruik). Our last study on the effects of our training showed that the G.P.s who used the sleep log found it a useful instrument that gave them important information about the severity of the sleep complaint and an approach to CBT that is attuned to the patient (chapter 7). The G.P.s expressed readiness to apply CBT strategies, provided that it does not take too much time and can be learned by a short training program. Of course, it is impossible to fully compensate the lack in education and experience in one short training. Maybe this lack in education and experience is responsible for the fact that, worldwide, about half of the insomniacs are not being recognized as such and only 20% of the insomniacs visit their G.P. for sleep complaints (Üstun & Sartorius, 1995;NIPO, 1998). This finding is in contrast to the Dutch finding that two-thirds of the callers of the Sleep Line had visited their G.P. Obviously the callers are actively seeking a solution for their sleep problems and still lack information about sleep even though they had already visited their G.P. Given the high prevalence of sleeplessness, the G.P.s should be educated more specifically about the (patho)physiology of sleep and CBT. Centres for sleep and wake disorders should be ready to support general practitioners. Edinger and Sampson (2003) showed that abbreviated cognitive behavioral insomnia therapy 100

8 (two sessions of 25 minutes with an interval of two weeks) gave a therapeutic result that was comparable to a six-session CBT intervention. This is a promising result for G.P.s, who do not have so much time for their patients. Backhaus et al (2002) showed that training G.P.s improved their diagnostic sensitivity for insomnia and led to the more frequent implementation of CBT and a referral to a sleep centre. These recent literature studies confirm the view that short-term CBT can take place in primary care. An interesting question remains why one advice may be an eye opener for one patient, while for another patient, no advice seems to work. Critical elements for CBT seem to be the reported home use of stimulus control, sleep restriction, and cognitive restructuring (Harvey et al., 2002). In other words, readiness to really change one s behavior might be at least as important as the behavioral technique itself. Besides the active CBT ingredients, outcome is also determined by nonspecific factors (e.g. self-monitoring and therapist attention) (Morin, 2004). Other nonspecific factors are: hope to cure, gain new experiences, promote success experiences, practical procedure and convincing rationale (van Kalmthout, 1998). The relative contribution of specific and non-specific factors in the efficacy of CBT should be investigated further. Although until now only G.P.s have been mentioned, other primary-care providers (e.g. psychologists) should not be forgotten. Since sleep disorders were added in 1987 as a distinct diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM), sleep complaints can also be considered to be within the domain of psychotherapists (DSM-IV-R, 2001). As was the case with the G.P.s, most psychologists in primary care are not well enough informed about the (patho)physiology of sleep and the cognitive behavioral treatment of chronic insomnia. The subject of sleep is seldom addressed in training courses for Healthcare (Gezondheidszorg, GZ) psychologists. Many clinicians see insomnia as only a symptom or epi-phenomenon of another disorder. This view may deprive many patients of treatment that might not only cure their insomnia but also reduce symptoms associated with the assumed primary disorder (Harvey, 2001). Protocolled cognitive behavioral treatment of several psychological disorders (e.g. depression, panic disorder, post-traumatic stress disorder and phobias) already exist. It is about time that short-term CBT of chronic insomnia become one of them, given the many validation studies that showed its effectiveness. Conclusions and Considerations for the future Although significant advances have been made in the evaluation and treatment of insomnia in the past decade, CBT does not move the average patient into the good-sleeper range, and the degree of change is lower than observed for CBT for a range of other psychological disorders. Therefore, there is substantial room for the growth and development of CBT for insomnia (Harvey & Tang, 2003). The main question is: What should be an optimal outcome when treating insomnia and how should we measure such an outcome? (Morin, 2003). Clinicians should evaluate treatment outcome with daily sleep logs and selected self-report questionnaires. Outcome measures should include sleep, daytime functioning, mood, and quality of life. In our studies, we included parameters of daytime functioning and found long-term improvements in quality of life, attitudes about sleep, and sleep evaluation in general. In the long run, it seems that CBT is more effective in improving attitudes about sleep than in improving sleep parameters. 101

9 This is an important finding, because it suggests that improvement of insomnia treatments should focus more on improving coping skills. Recent studies already suggest the incorporation of clinical methods designed to teach effective stress appraisal and coping skills (Ellis & Cropley, 2002; Morin et al, 2003). In addition to improvement of CBT itself, it is desirable to give treatment on various levels. Given the high prevalence of insomnia and the fact that only one out of five patients visits their G.P. for the sleep complaint, there should be more information available to the public. To prevent chronic sleep complaints, sleep education and sleep-hygiene guidelines should be easily accessible. Both a Sleep Line and the television suits this purpose. In 2005, TELEAC has planned to broadcast an updated course You can learn to sleep better. Furthermore, G.P.s should be informed about the diagnosis and CBT of insomnia. A structured sleep history combined with a sleep log are valuable instruments to assess the subjective sleep complaint and to give sleep education and sleep-hygiene guidelines that are attuned to the patient. Stimulus control and sleep restriction instructions are easily applicable for G.P.s. The G.P. can also refer to the course You can learn to sleep better from the Association of Home Care or to psychologists in primary care. When polysomnography is indicated, or for therapy-resistant insomnia, referral to a Centre for Sleep and Wake Disorders is indicated. At this time, however, many G.P.s and psychologists in primary care are insufficiently educated in the (patho)physiology of sleep and the CBT of chronic insomnia. There should be more attention to sleep in the training of G.P.s and psychologists in primary care. Moreover, the task of Centres of Sleep and Wake Disorders is to give training courses about sleep. Services can be set up where employees of sleep centres visit practitioners in primary care to discuss cases of patients. In this way, diagnosis and CBT of chronic insomnia can take place primarily in primary care. G.P.s no longer have to restrict themselves mainly to the prescription (or not) of hypnotics. Chronic use of benzodiazepines may be reduced when they know how to use alternatives like sleep history, sleep log, sleep education and sleep-hygiene guidelines. Hopefully, this thesis contributes to the enlargement of diagnostic and treatment possibilities of chronic insomnia in primary care. 102

10 Summary table (chapters 3-5). Sleep parameters of our three studies before treatment, post-treatment and at follow-up (fu=10 months). SOL=sleep onset latency, TST=total sleep time, SE=sleep efficiency (total sleep time/time in bedx100), WASO=wake after sleep onset. Study 1 N=86 Study 2 N=18 Study 3 N=40 Individual Individual Primary 72 18? Secondary 14? Age (years) 46,0 45,1 43,7 Duration insomnia (years) 11,4 17,8 13,2 SOL (min.) before post follow-up TST (min.) before post follow-up SE (%) before post follow-up WASO (%) before post follow-up % good sleepers 19 SOL,WASO < 30&SE>85% SOL 30, tst 300& SE 85% 2 Group (5-7) % attrition fu According to Lacks & Poslishta (1989). 2 According to Morin (1993). 16 SOL 30, tst 300& SE 85% 2 103

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