Diagnosis and management of chronic insomnia in primary care continued

Causes of insomnia

Physical

• Insomnia can be caused by an underlying physical condition such as:
  • primary sleep disorder, e.g. restless legs syndrome (RLS)
  • arthritis, headaches, back pain
  • menopausal symptoms
  • Parkinson's disease
  • gastrointestinal disorders, including acid reflux
  • pregnancy

Environmental

• Disruptions within the sleeping environment or to bedtime routines can cause insomnia:
  • noise
  • light
  • jet lag
  • shift work
  • uncomfortable mattress
  • bed partner moving or snoring

Psychological

• Psychological, e.g.:
  • bereavement
  • relationship problems
  • exam stress
  • work worries

Psychiatric

• Psychiatric, e.g.:
  • depression
  • dementia
  • anxiety
  • bipolar disorder
  • schizophrenia
  • substance/alcohol misuse

Pharmacological

• Pharmacological, e.g.:
  • some antidepressants, anxiolytics and antipsychotics
  • appetite suppressants
  • decongestants
  • beta-blockers
  • corticosteroids
  • caffeine
  • drug/substance withdrawal

Diagnosis and management of chronic insomnia in primary care continued

Patient tools and information

• Useful websites include:
• http://www.sleepwelllivewell.co.uk/healthcare_home.html
• http://www.sleepadvice.co.uk/hcp
• http://www.sleeping.org.uk/

Follow up

• After the initial assessment, follow up (2–4 weeks later) should cover the following:
  • review sleep diary, encourage and monitor appropriate behavioural change
  • advise and help the patient plan for better sleep hygiene
  • further consideration of co-morbid causes
  • manage appropriate co-morbid cases in primary care
  • refer suspected co-morbid cases to an appropriate specialist if necessary
  • manage primary insomnia in primary care (e.g. behavioural and psychological advice) or refer suspected primary sleep disorder to specialist
  • advise continuation of sleep diary

Non-pharmacological management

• Advice on good sleep health is fundamental. In addition, patient self-help intervention can be a useful and inexpensive addition to existing treatment options, particularly when integrated in a stepped care approach

Stepped non-pharmacological approach to insomnia care

• Access to cognitive behavioural therapy (CBT), and other non-pharmacological interventions, may be restricted by a lack of resources such as suitably trained providers and cost. CBT for insomnia is the gold standard non-pharmacological intervention

Main interventions

Sleep hygiene advice and self-help materials
Supported self help Changing behaviour plans Coping strategies Counselling Family therapy Problem solving Relaxation techniques	Sleep restriction Stimulus control Light therapy

Diagnosis and management of chronic insomnia in primary care continued

Pharmacological treatment

• None of the medicines used to treat insomnia is licensed for children. The doses prescribed should be those recommended within the Summary of Product Characteristics

Hypnotics

• Hypnotics provide symptomatic relief and a number are licensed to treat insomnia, including the benzodiazepines and the Z-hypnotics. They should be prescribed for short-term use and intermittent dosage is often preferred

Benzodiazepine hypnotics

• The Committee on Safety of Medicines recommends that the use of benzodiazepines for the treatment of insomnia should be restricted to severe insomnia. Treatment should be at the lowest dose possible and not continued beyond 4 weeks

Z-hypnotics

• The Z-hypnotics are non-benzodiazepine compounds with differing licensed indications and durations of treatment:
  • zaleplon is licensed for people with insomnia who have difficulty falling asleep, and only when the disorder is severe, disabling or subjecting the patient to extreme distress. Treatment should be for a few days to a maximum of 4 weeks
  • zolpidem is licensed for the short-term treatment of insomnia that is debilitating or is causing severe distress for the patient. Treatment should be a few days to a maximum of 4 weeks
  • zopiclone is licensed for the short-term treatment of insomnia (including difficulties falling asleep, nocturnal awakening, early awakening, transient, situational or chronic insomnia, and insomnia secondary to psychiatric disturbances) and if the insomnia is debilitating or causing severe distress for the patient. Long-term, continuous use is not recommended. A single period of treatment should not exceed 4 weeks

Prolonged-release melatonin

• Melatonin is a naturally occurring hormone important in the regulation of circadian rhythm and sleep function. Prolonged-release melatonin was licensed and approved for use in the UK from June 2008 as short-term monotherapy for primary insomnia in patients aged 55 years or over
• Before then, melatonin was only available in unlicensed products or imported from the US

Other medicines

• Sedative antihistamines, antidepressants, and antipsychotics are not recommended to treat primary insomnia:
  • a sedative antidepressant or antipsychotic may, however, be useful when insomnia is related to a psychiatric disorder
  • a sedative antihistamine may be appropriate for when insomnia is secondary to an allergy, or there is a tolerance to or dependence on benzodiazepine or Z-hypnotics, or when there is a history of substance/alcohol misuse

• Patients presenting with chronic insomnia may have been taking herbal preparations, antihistamines, and OTC medicines without prescription. It is always prudent to ask patients about such preparations

When to refer

• Referral should be considered for the following:
  • suspected primary sleep disorder, such as RLS
  • severe co-morbid (secondary) insomnia
  • failure to improve with primary care management

• The electrophysiological parameters of sleep can be assessed objectively in specialist sleep centres using polysomnography (PSG). Actigraphy can also be useful to monitor movement and delineate sleep and awake phases

Diagnosis and management of chronic insomnia in primary care continued

Comparison of interventions

Chronic insomnia management algorithm in primary care

about this working party guideline…
sponsor—	Supported by an educational grant from Lundbeck
working party members—	Dr John Shneerson (chair consultant physician), Dr Julian Bromly (general practitioner), Dr Peter Cannon (general practitioner), Ms Celia Feetam (psychiatric pharmacist), Dr Chris Idzikowski (sleep consultant), Dr Helen Oatway (adult psychiatrist), Professor David Taylor (professor of psychopharmacology), Dr Peter Venn (consultant anaesthetist), Dr Adrian Williams (consultant physician)
further information—	Call Munro & Forster (020 7815 3900) for further information and a copy of the full guideline June 2009