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Insomnia
Insomnia is also associated with falls in the elderly and this may statement has led to a change in approach to treatment. Rather than
contribute to nursing home placement in these patients.
7
In simply treating the primary disorder, whereby symptoms of insomnia
consequence, insomnia increases healthcare utilisation,
7,18
which may go unadressed, there is now a push to acknowledge the existence
encompasses prescription and non-prescription medications, of chronic insomnia as a disorder that itself merits treatment.
12
physician visits and calls, laboratory work, emergency department
visits and hospitalisations.
55–58
In daily practice, treatment is rather simple. The most common
treatments used to manage insomnia are over-the-counter sleep aids
Diagnostic Tools for Insomnia such as antihistamines, herbal remedies and self-medication with
Diagnosis of insomnia is based primarily on clinical interview with the alcohol and prescription medications, including hypnotics and
patient or care-giver, with the presence of co-morbid conditions being sedating antidepressants. Cognitive–behavioural therapies are more
identified from medical history and physical examination.
13
rarely used by some specialists such as psychiatrists, psychologists or
Psychiatrists may also use specific techniques including questionnaires, sleep experts.
7,19,13,64,65
Psychiatrists often prefer the use of sedating
actigraphy and polysomnography. psychotropic drugs that are labelled for the treatment of other
psychiatric disorders such as psychosis or anxiety.
Psychiatrists in the Treatment of Insomnia
Sleep disorders such as insomnia are clearly defined diagnoses that can The Challenge of Pharmacological
be found in major psychiatric classification systems.
1,3
In recent years, Treatment of Chronic Insomnia
psychiatrists have been able to cover this area of medicine thanks to Medications have always played the most prominent role in the
well-proven concepts for diagnosis and treatment. However, treatment of insomnia. They still are the most easily used treatment
community surveys have demonstrated that more than three-quarters approach and are therefore widely accepted to fight sleeping
of people suffering from difficulties in initiating or maintaining sleep difficulties.
12,66–73
A particular challenge in the pharmacological
receive treatment from general practitioners, while very few insomniacs treatment of chronic insomnia is the long-term pattern of the disease,
are treated by mental health specialists or sleep experts. Surveys of since all of the hypnotics available on the European market have been
outpatient medical and mental health providers confirm that primary approved for short-term use only. Treatment guidelines as well as
care physicians are the de facto providers of treatment for patients with labelling by the European Medicines Agency have restricted duration
insomnia.
59,60
This crucial role of primary care in the treatment of of treatment while not always defining the time-frame for treatment.
psychiatric diseases has raised concerns about the quality of care and In this way, these regulatory authorities neglect the clinical need for
patient outcome.
61,62
Several studies point out significant deficiencies long-term treatment of chronically sick patients. This current state
such as non-recognition of treatment-seeking patients, neglect of of affairs leaves doctors without guidance as to how or whether
causal treatment, insufficient use of non-pharmacological therapy or to distinguish between short-term and chronic insomnia and how to
inadequate dosage and/or duration of hypnotic treatment.
21
manage insomnia patients when their difficulties extend beyond the
short-term period.
When clinicians decide to pursue long-term insomnia treatment, they
In terms of aetiology, most cases of
have to choose from a set of options, each of which is associated with
insomnia are co-morbid with other
significant challenges.
11
These options include: long-term nightly
treatment with hypnotic medications, against approval by regulators;
74
conditions such as medical and
long-term non-nightly treatment; off-label treatment with sedating
psychiatric disorders, medication use antidepressants, antipsychotics or antihistamine medications;
or other primary sleep disorders.
non-pharmacological therapies; and no treatment at all. Besides non-
nightly hypnotic treatment, recent research suggests upcoming
changes in the options for long-term hypnotic treatment, since
studies indicated that six months of treatment is associated with
A Multidimensional Approach to Treatment good efficacy, minimal next-day effects and no evidence of tolerance
Ample evidence suggests that a multidimensional approach is the or rebound.
73,75–77
It is of critical importance for chronic and co-morbid
most successful for the management of insomnia.
21
First, physicians insomnia patients that the treatment of the sleep problem by
must identify those patients who need treatment. Second, their hypnotics may improve outcome of the co-morbid disease, e.g.
diagnostic process should aim at identifying the underlying causes of depression or anxiety.
78,79
the complaints of these patients. Finally, insomnia treatment should
follow at least three routes: first, treating the cause; second, trying Conclusion
hypnotic treatment according to modern treatment concepts; and It is clear that long-lasting insomnia is highly prevalent and associated
third, using non-pharmacological treatment techniques, in particular with adverse sequelae, yet the treatment of this condition faces
for chronic insomnia. a number of significant challenges. However, recent studies have
improved our understanding of chronic sleep difficulties and
The current expert consensus in treating insomnia reflects the evolving have begun to provide an empirical basis for decision-making in the
trend of considering insomnia as a disorder and not merely a treatment of patients with chronic insomnia. ■
symptom.
9,63
Also, experts state that insomnia rarely occurs in
isolation, but rather is typically co-morbid with other conditions. This Support provided by GlaxoSmithKline.
38 EUROPEAN PSYCHIATRIC REVIEW
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