Lynda Bélanger

The natural history of insomnia: a population-based 3-year longitudinal study.

BACKGROUND Despite its high prevalence, little information is available about the natural history of insomnia. The extent to which episodes of insomnia will persist or remit over time is difficult to predict. We examined the natural history of insomnia and describe the most common trajectories over 3 years. METHODS Three hundred eighty-eight adults (mean [SD] age, 44.8 [13.9] years; 61% women) were selected from a larger population-based sample on the basis of the presence of insomnia at baseline. They completed standardized sleep/insomnia questionnaires at 3 annual follow-up assessments. For each follow-up assessment, participants were classified into 1 of 3 groups (individuals with an insomnia syndrome, individuals with insomnia symptoms, and individuals with good sleep) on the basis of algorithms using standard diagnostic criteria for insomnia. Rates of persistent insomnia, remission, and relapse were computed for each group. RESULTS Of the study sample, 74% reported insomnia for at least 1 year (2 consecutive assessments) and 46% reported insomnia persisting over the entire 3-year study. The course of insomnia was more likely to be persistent in those with more severe insomnia at baseline (ie, insomnia syndrome) and in women and older adults. Remission rate was 54%; however, 27% of those with remission of insomnia eventually experienced relapse. Individuals with subsyndromal insomnia at baseline were 3 times more likely to remit than worsen to syndrome status, although persistence was the most frequent course in that group as well. CONCLUSION These findings indicate that insomnia is often a persistent condition, in particular when it reaches the diagnostic threshold for an insomnia disorder.

Prevalence of Insomnia and its Treatment in Canada

Objectives: To estimate the prevalence of insomnia and examine its correlates (for example, demographics and physical and mental health) and treatments. Methods: A sample of 2000 Canadians aged 18 years and older responded to a telephone survey about sleep, health, and the use of sleep-promoting products. Respondents with insomnia were identified using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and the International Classification of Diseases, Tenth Edition, criteria. Results: Among the sample, 40.2% presented at least 1 symptom of insomnia (that is, trouble falling or staying asleep, or early morning awakening) for a minimum of 3 nights per week in the previous month, 19.8% were dissatisfied with their sleep, and 13.4% met all criteria for insomnia (that is, presence of 1 insomnia symptom 3 nights or more per week for at least 1 month, accompanied by distress or daytime impairment). Insomnia was associated with female sex, older age, and poorer self-rated physical and mental health. Thirteen per cent of respondents had consulted a health care provider for sleep difficulties once in their lifetime. Moreover, 10% had used prescribed medications for sleep in the previous year, 9.0% used natural products, 5.7% used over-the-counter products, and 4.6% used alcohol. There were differences between French- and English-speaking adults, with the former group presenting lower rates of insomnia (9.5%, compared with 14.3%) and consultation (8.7%, compared with 14.4%), but higher rates of prescribed medications (12.9%, compared with 9.3%) and the use of natural products (15.6%, compared with 7.4%). Conclusions: Insomnia is a prevalent condition, although few people seek professional consultation for this condition. Despite regional differences in the prevalence and treatments used to manage insomnia, prescribed medications remain the most widely used therapeutic option.

Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: a randomized controlled trial.

OBJECTIVE To examine the unique contribution of behavior therapy (BT) and cognitive therapy (CT) relative to the full cognitive behavior therapy (CBT) for persistent insomnia. METHOD Participants were 188 adults (117 women; M age = 47.4 years, SD = 12.6) with persistent insomnia (average of 14.5 years duration). They were randomized to 8 weekly, individual sessions consisting of BT (n = 63), CT (n = 65), or CBT (n = 60). RESULTS Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%). Remission rates followed a similar trajectory, with higher remission rates at post treatment in CBT (57.3%) relative to CT (30.8%), with BT falling in between (39.4%); CT made further gains from post treatment to follow up (30.9% to 51.6%). All 3 therapies produced improvements of daytime functioning at both post treatment and follow up, with few differential changes across groups. CONCLUSIONS Full CBT is the treatment of choice. Both BT and CT are effective, with a more rapid effect for BT and a delayed action for CT. These different trajectories of changes provide unique insights into the process of behavior change via behavioral versus cognitive routes.

Clinical Management of Insomnia Using Cognitive Therapy

Cognitive therapy has been shown effective in the treatment of several psychological and health-related disorders. It is also increasingly used in the management of insomnia. This article outlines some principles and applications of this therapeutic approach as adapted to the treatment of insomnia. Based on Becks model, this psychotherapeutic approach seeks to modify sleep-related dysfunctional beliefs and thoughts and maladaptive cognitive processes involved in the exacerbation and perpetuation of insomnia. This is accomplished through the use of several cognitive restructuring procedures. After outlining a conceptual model of insomnia, which emphasizes the mediating role of dysfunctional cognitions in the development and maintenance of chronic insomnia, the rationale and general principles of cognitive therapy for insomnia are presented, followed by a description of the treatment procedures, clinical case illustrations, and practical implementation issues. Future directions include the need to refine cognitive interventions and to examine the unique contribution of this therapeutic component to the overall efficacy of multifaceted cognitive–behavioral therapy.

Validation of the Insomnia Severity Index in Primary Care

Background: Although insomnia is a prevalent complaint with significant consequences on quality of life, health, and health care utilization, it often remains undiagnosed and untreated in primary care settings. Brief, reliable, and valid instruments are needed to facilitate screening for insomnia in general practice. This study examined psychometric indices of the Insomnia Severity Index (ISI) to identify individuals with clinically significant insomnia in primary care settings. Methods: A sample of 410 patients recruited from 6 general medical clinics completed the ISI before their appointment with a primary care physician. A subsample of 101 individuals also completed a semistructured clinical interview by telephone to determine the presence or absence of an insomnia disorder. Reliability and validity indices were computed, as was the discriminative capacity of each individual item. Convergence between ISI total score and the diagnosis derived from the interview was investigated. Receiver operator characteristic analyses were used to determine the optimal ISI cutoff score that correctly identified individuals with an insomnia disorder. Results: ISI internal consistency was excellent (Cronbach α = 0.92), and each individual item showed adequate discriminative capacity (r = 0.65–0.84). The area under the receiver operator characteristic curve was 0.87 and suggested that a cutoff score of 14 was optimal (82.4% sensitivity, 82.1% specificity, and 82.2% agreement) for detecting clinical insomnia. Agreement between the ISI cut score and the diagnostic interview was moderate (κ = 0.62). Conclusions: These findings suggest that the ISI is a valid screening instrument for detecting insomnia among patients consulting in primary care settings.

Sleep disturbances in bipolar disorder during remission

BACKGROUND While sleep disturbances associated with bipolar disorders depression and mania phases are well documented, the literature regarding sleep during remission phases is less consistent. The present studys aim was to describe the nature and severity of sleep difficulties in individuals with bipolar disorder (BD) during remission phases. METHODS Fourteen participants with BD were compared to 13 participants with primary insomnia and 13 without mental health disorders or insomnia on different sleep and daytime functioning parameters using actigraphy, sleep diaries and self-report measures. RESULTS Results suggest that sleep of individuals with BD was similar to that of individuals without mental health disorders or insomnia, but differed from that of individuals with insomnia. Nevertheless, participants with BD still presented sleep complaints and, like individuals with insomnia, were less active in the daytime, carried on their daily activities at more variable times from day to day, and reported more daytime sleepiness. LIMITATIONS Patients were taking medications and the limited sample size did not permit comparison of sleep parameters between bipolar I and bipolar II patients. CONCLUSIONS Psychological interventions aimed at encouraging the adoption of more stable sleep and daily routines might be helpful in helping individuals with BD cope more efficiently with some of these complaints.

Meta-analysis of sleep changes in control groups of insomnia treatment trials

A meta‐analysis assessing the magnitude of sleep changes from baseline in placebo‐treated (psychological and pharmacological placebo) and untreated groups issued from independent trials was conducted. Comparisons were then performed to assess if the magnitude of sleep changes in the placebo control groups were significantly different than those of the untreated group. Medline, PsychInfo and Current Contents databases (1990–2004) were searched for primary insomnia treatment studies using a randomized controlled parallel‐group design. Effect sizes were computed for each end‐point variable based on subjective (patient‐reported) and polysomnographic measures. Thirty‐four studies (n = 1392 subjects) met inclusion criteria; twenty‐three used a pharmacological placebo (n = 1163), four used a psychological placebo (n = 81), and seven used a waitlist condition (n = 148). Between‐group comparisons were performed using a random effects model analysis. Significant pre–post changes were observed in the pharmacological placebo condition on several sleep parameters, both on objectively and subjectively measured outcomes [objective and subjective sleep onset latency (SOL) and total sleep time (TST) and subjective wake after sleep onset]. Although a tendency was observed for objective SOL, only the changes on subjective SOL and TST in the pharmacological placebo condition were significantly different from the corresponding changes in the untreated group. No differences were significant for the psychological placebo groups. Although the present findings suggest that sleep may significantly change in response to a pharmacological placebo, conclusions remain tentative because of possible confounds that may arise when comparing groups issued from different trials. Further research directly comparing placebo groups and untreated groups from the same randomized trials remains necessary.

Comparison of subjective and objective sleep quality in menopausal and non-menopausal women with insomnia

BACKGROUND Insomnia affects midlife women as they approach and experience menopause at a rate higher than most other stages of life. Insomnia is considered one of the climacteric symptoms of menopause, which can be controlled with hormone replacement therapy (HRT). This study examined the relationship between menopause and sleep in women with insomnia and compared the sleep quality of menopausal women with and without HRT. METHODS A total of 74 women (age range=40-59 years old) with insomnia who were either pre or peri/post menopause were evaluated at Laval Universitys Sleep Disorders Center as part of ongoing clinical trials of insomnia therapies. All participants completed daily sleep diaries for a 2-week period and a series of psychological and insomnia questionnaires, followed by three consecutive nights of polysomnographic evaluation (PSG). A detailed medical history interview was taken by the study physician. RESULTS PSG measures showed that menopausal women had significantly longer total wake time (TWT, 84.2 vs. 63.2 min, Cohens d=0.504) and lower sleep efficiency (SE, 81.8% vs. 86.0%, d=0.487) than the non-menopausal women. Women using HRT did not show significantly better sleep compared to those who did not use HRT. No significant difference was observed between menopausal groups on subjectively assessed sleep parameters. CONCLUSION Menopause may contribute to specific aspects of sleep disturbances in midlife women with insomnia. Use of HRT for menopausal symptoms does not seem to attenuate such disturbances, although further investigation using hormonal level dosing and a larger sample size is warranted.

Self-Efficacy and Compliance With Benzodiazepine Taper in Older Adults With Chronic Insomnia.

Better understanding of compliance with BZD taper is warranted. Compliance with a taper program and perceived self-efficacy (SE) in being able to comply with hypnotic reduction goals was monitored weekly in 52 older adults (mean age: 63.0 years) with chronic insomnia (average duration: 21.9 years) who underwent a 10-week physician-supervised medication tapering. One group received cognitive- behavior therapy for insomnia during discontinuation, whereas the other did not. Compliant patients showed higher SE ratings at Weeks 6, 8, 9, and 10. Medication-free patients at the end of the treatment also reported higher mean SE ratings at those 4 weeks. Differences remained significant when withdrawal symptoms and sleep efficiency were controlled for. These results have important clinical implications because SE may indicate key time points when patients are experiencing more difficulty during discontinuation.

Psychological distress and adaptational problems associated with discontinuation of benzodiazepines

This study compared subjects who had received standard tapered withdrawal of benzodiazepine (BZD) (group 1) with a group with comparable diagnosis still receiving BZD (group 2) and a control group of comparable diagnosis not yet receiving treatment (group 3). Sixty subjects aged 21-65 years with a diagnosis of nonpsychotic anxiety or insomnia were included. The assessment of psychological distress and quality of life was timed to coincide with the maximum immediate effect of BZD discontinuation, as calculated according to drug half-life. Subjects diagnosed with insomnia reported lower distress in all three groups. The pattern of distress experienced by group 1 was closer to group 3 than to group 2, indicating the potential importance of re-emergence of anxiety. High neuroticism, lower education level, and lower quality of life were associated with higher levels of distress during withdrawal.