AASM Membership Sections Newsletter Issue #3
8
American Academy
of Sleep Medicine
behavior therapy for insomnia
(
CBTI). CBTI has proved to be as
effective as hypnotics by mul-
tiple studies, and has a long-term
benefit. It plays a significant role
in assisting patients who cannot
tolerate the side effects of hypnot-
ics. However, patients have very
limited access to this service for
a number of reasons. A major
barrier is the lack of certified
practitioners in behavioral sleep
medicine.
Prescribing hypnotics is still
the most popular approach
for insomnia management by
physicians. There are not many
clinicians who can do behavior
therapy for insomnia patients.
Therefore, training physicians,
especially sleep specialists, about
basic behavior therapy skills such
as sleep hygiene, sleep restriction
or stimulus control is necessary.
Evidence-based complemen-
tary alternative sleep medicine
should be promoted. A national
survey conducted by the Na-
tional Center for Complementary
Alternative Medicine (NCCAM)
indicated that 1.6 million Ameri-
cans are using some form of CAM
to get good sleep. Mind-body
medicine, such as relaxation
techniques are the second most
common remedy. Relaxation tech-
niques include, but are not limited
to: progressive relaxation, guided
imagery, biofeedback, self-hypno-
sis, and deep breathing exercises.
They are similar to those practiced
by cognitive behavior therapists,
such as progressive relaxation,
abdominal breathing, guided im-
agery, yoga and meditation.
Primary care physicians and
practitioners need be updated
about the basics of sleep medi-
cine. They should be aware that
insomnia is associated with a
number of other diseases, includ-
ing: hypertension, diabetes, heart
disease and stroke. Referral to a
sleep specialists is always encour-
aged for complicated cases.
New hypnotics should be
explored. Current approved
hypnotics are acting on GABA,
histamine or melatonin recep-
tors. A new class of potential
insomnia hypnotics, which act
on the orexin system have been
under investigation since the
1990
s. The phase two clinical
trial has indicated that the novel
orexin antagonist suvorexant is
very effective for sleep efficiency
improvement (Herring et al,
2012).
Moreover, there are few
side effects, with dose-dependent
somnolence the most common.
This new finding opens a door for
effective low side effect pharma-
cological treatment of insomnia.
Family or bed partner educa-
tion should not be forgotten.
Severe insomnia patients can
also disturb the sleep pattern
of their bed partners, imposing
negative impacts on family life.
Behavior sleep treatment, such as
sleep hygiene, sleep restriction,
or stimulus control therapy is not
successful without the coopera-
tion of bed partners.
Given the lack of well-quali-
fied practitioners for CBT, the lat-
est technical development makes
online treatment of insomnia
possible. It provides access to
patients with insomnia, especially
in rural areas. A recent study
from the United Kingdom has
shown significant improvement
in sleep efficiency and day time
performance, compared with
placebo control group (Espie et
al, 2012). This approach is very
convenient, efficient, effective and
fast. However, this new non-face
to face model may raise concerns
of reimbursement and malprac-
tice. It could also be very expen-
sive in certain conditions. More
work needs to be done.
Public education about
over the counter (OTC) herbal
supplements and antihistamine
medication is necessary. People
frequently use OTCs to improve
sleep, but many are not aware of
the potential anticholinergic side
effects which can affect cognitive
functioning. Although herbal
supplements are considered “nat-
ural,” they do carry side effects.
The future of insomnia medi-
cine is optimistic and challenging.
As the estimated national annual
cost of insomnia could be around
$100 billion (Rosekind and
Gregory, 2010), insomnia man-
agement can be very cost-effec-
The Future Directions of
Insomnia Medicine continued