Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_41_библиотеки_им_акад_М_И_Перельмана
.pdf
276
https://t.me/medicina_free
G. C. Carlson et al.
disorder is characterized by poor sleep, with daytime consequences, that persists for
3months and occurs at least three times per week. Per the ICSD-3, a diagnosis of
chronic insomnia requires that a patient report sleep disturbance for at least
3months, with short-term insomnia characterized by sleep disturbance that is less
than 3 months in duration [5]. Consequences associated with sleep disturbance
include increased risk for other medical and mental health comorbidities, lost productivity and increased absenteeism, and increase risk for accident, injury, and
death [6].
Given the prevalence of and impairment associated with poor sleep, interventions have been developed to treat the symptoms of insomnia disorder [2, 7, 8].
Interventions include both behavioral (i.e., non-medication) treatments and medication treatments. This chapter describes the best practices for the treatment of insomnia disorder. Based on the AASM Clinical Practice Guidelines [8], Fig. 13.1
describes a decision-making framework for the treatment of insomnia disorder.
Evidence-based treatments, patients’ preferences, sleep disorder comorbidities, and
treatment responses will inform decision-making. The following sections describe
the treatments included in this framework and factors that may inuence treatment
delivery and referral.
Does the patient meet
diagnostic criteria for
insomnia disorder?
No
Evaluate for other sleep
disorders and refer for
sleep study if not
previously conducted
Pratice or refer to
CBT-I
Treatment
Response
Evaluate for other sleep
disorders and refer for
previously conducted
treatments for insomnia
NoYesNoYes
Non-Response
sleep study if not
Implementation of
other behavioral
Practice or
refer to CBT-I
Treatment
Response
Evaluate for other sleep
disorders and refer for
sleep study if not
previously conducted
Treatment
Non-Response
Consdier implementation
of other behavioral
treatments for insomnia
Are they interested in
behavioral treatment?
Provide medication with
lowest risk or refer to
prescriber
Yes
Continue treatment for
comorbid condition and
refer to CBT-I
Yes
Were there previous
attempts to treat this
condition(s)?
Yes
Was there a treatment
response?
Evaluate for other sleep
disorders and refer for
previously conducted
Are there comorbid
conditions that can be
treated simultaneously?
No
Pratice or refer to CBT-
I and implement
treatment for comorbid
conditions
No
sleep studt if not
Supplement
with medication
as needed
Fig. 13.1 Treatment decision-making framework for the treatment of insomnia disorder
Treatment
Consider
13 Management ofInsomnia Disorder
https://t.me/medicina_free
277
Behavioral Interventions
Cognitive behavioral therapy for insomnia The rst line treatment for insomnia
is cognitive behavioral therapy for insomnia (CBT-I) [7]. The AASM Clinical
Practice Guidelines strongly recommend clinicians use multicomponent CBT-I for
the treatment of chronic insomnia disorder in adults [9]. A “strong recommendation” indicates that clinicians should implement or refer to this treatment under
most circumstances. A “conditional” recommendation indicates that clinicians
should consider knowledge of the patient (i.e., patient values and preferences) and
clinical knowledge and experience to determine the best intervention. While multicomponent CBT-I is strongly recommended, individual components of CBT-I are
also conditionally recommended for the treatment of chronic insomnia disorder in
adults. The following sections will describe the components of CBT-I.
The “3-Ps” model underlies the rationale for CBT-I. This model proposes that
insomnia develops from and is maintained by predisposing factors, precipitating
factors, and perpetuating factors [10]. Predisposing factors increase an individual’s
risk of developing insomnia (e.g., family history of sleep disorders). Precipitating
factors include circumstances or events that lead patients to experience clinically
signicant sleep difculties (e.g., injuries/medical conditions, interpersonal events)
[11]. Attempts to cope with precipitating factors can lead to perpetuating factors
(e.g., compensatory daytime napping, prolonged time awake in bed at night, caffeine use during that day). According to the 3-Ps model, perpetuating factors lead to
chronic insomnia [10]. Insomnia is maintained by the interrelations among problematic emotions, thoughts, and behaviors. Patients can develop anxiety or other
emotions regarding their sleep difculties, experience inaccurate and unhelpful
thoughts about their sleep difculties, and engage in maladaptive behaviors to cope
with difculties initiating and maintaining sleep [12, 13]. CBT-I intervenes on this
problematic cycle by changing problematic behaviors and thoughts [8]. CBT-I sessions typically incorporate the following intervention components: (1) stimulus
control, (2) sleep restriction, (3) sleep hygiene recommendations, (4) relaxation
strategies, and (5) cognitive therapy exercises. Of these components, the strongest
evidence supports stimulus control and sleep restriction as stand-alone treatments,
while evidence for the other components remains more modest [14, 15].
Stimulus control
Stimulus control is a behavioral phenomenon that underlies mul-
tiple behaviors, including sleep [16]. In basic terms, sleep is considered an instrumental behavior, and cues (or stimuli) in a patient’s environment provide information
about whether sleep will be reinforced or not [17, 18]. Example of discriminative
stimuli for sleep include darkness/nighttime or being in bed. However, if these stimuli are inconsistently paired with sleep, difculty sleeping may be the result of inadequate discriminative stimulus control. Patients who undergo CBT-I are provided
with education about classical and operant conditioning to ensure they understand
the rationale for stimulus control therapy [19]. The provider and patient discuss the
associations that can develop between the bed (i.e., place of sleep) and anxiety and/
278
Complete on: Sun Mon Tues Wed Thurs Fri Sat [date] ______________
https://t.me/medicina_free
G. C. Carlson et al.
or other non-sleep behaviors/activities and how these associations lead to conditioned insomnia [14]. The intervention of stimulus control involves using the sleep
area only for sleeping, refraining from doing other activities in the sleep area, and
avoiding sleeping in areas other than the designated sleep area. Per the AASM
Clinical Practice Guidelines, it conditionally recommended that clinicians implement stimulus control as a single-component therapy for the treatment of insomnia
disorder.
Sleep restriction In addition to stimulus control, patients are oriented to the rationale for tracking sleep. Behavior monitoring is a common component of many
behavioral therapies [20]. Patients are oriented to the sleep diary and are asked to
complete a weekly sleep diary, which includes daily bedtimes, sleep onset latencies,
wake times after sleep onset, number of nighttime awakenings, rise times, and daytime awakenings (see Fig.13.2 for an example of sleep diary information). Based
on data on the sleep diary, patients are oriented to the concept of sleep efciency.
Sleep efciency is calculated by dividing total sleep time by total time in bed (minutes from bedtime to rise time) and converting the quotient to a percentage. Patients
and providers discuss how low sleep efciency can exacerbate problematic associations between bed and wakefulness, maintaining insomnia symptoms [15]. Patients
may develop inaccurate beliefs that more time in bed provides a greater opportunity
for sleep. In fact, excessive time in bed not sleeping can further contribute to inadequate stimulus control. Sleep restriction involves reducing the amount of time a
patient spends in bed in an effort to improve sleep efciency [18, 21]. This involves
setting a sleep window based on a patient’s sleep diary total time in bed. Patients are
Day 1
Morning questions
1. What time did you got to bod last night?
2. How long did it take you to fall asleep last night?
3. Did you wake up during the night last night?
a. If yes, How many times did you wake up?
b. If yes, What was the total amount of time that
you wereawake?
4. Last night, did you take any medication to help
you sleep?
a. If yes, What did you take? (write down any sleep aid below)
b. What time did you take this?
5. What time did you wake up for the last time this
morning?
6. This morning, what time did you get up for the
day?
Fig. 13.2 Example of information collected in sleep diary
___:___ am/pm
minutes
No Yes
times
minutes
No Yes
___:___ am/pm
___:___ am/pm
___:___ am/pm
Bedtime questions
7. Did you take any naps or doze off at any time today
before getting into bed for the night?
a. If yes, How many times did you spend napping or
dozing?
8. Did you drink any beverages containing caffeine
today?
a. If yes, About how many cups or glasses?
b. If yes, What time did you have your last one?
9. Did you drink any beverages containing alcohol
today?
a. If yes, About how many drinks did you have?
(Please refer to the “Drink Conversion Table” on the inside back
cover)
b. What time did you have your last drink?
10. Did you remove the sleep watch for any reason
today?
a. If yes, what time?
Time off ____:____ am/pmTime on: ____:____ am/pm
b. Reason removed ______________________________________
No
minutes
No Yes
___ cups/glasses
___:___ am/pm
No Yes
_________ drinks
___:___ am/pm
No Yes
Yes
13 Management ofInsomnia Disorder
https://t.me/medicina_free
279
instructed to only sleep within this window of time (i.e., between prescribed bedtime and rise time). Patients should not go to bed earlier than their prescribed bedtime or wake up later than their prescribed rise time, and should avoid napping
outside of their sleep window [15, 22]. It is conditionally recommended that providers implement sleep restriction as a single-component treatment for insomnia disorder [9].
Sleep hygiene recommendations CBT-I providers present information about daytime and nighttime activities that can help or hinder good sleep. Patients receive
information about how factors (e.g., light exposure, alcohol/substances, medications, caffeine, food intake, and exercise) can impact wakefulness and sleepiness
[23]. The patient and provider also discuss the sleep environment and what environmental factors can help or hinder sleep (e.g., temperature, noise, light, bodily discomfort, bed partner, etc.). The patient and provider discuss changes the patient can
implement to improve their sleep [23]. Sleep hygiene education, as a standalone
intervention, has been shown to be less effective than multicomponent CBT-I [24];
however, sleep hygiene is conditionally recommended as a single-component treatment for insomnia disorder [8].
Relaxation strategies Anxiety and hyperarousal at bedtime serve as barriers to
sleep initiation. CBT-I providers educate patients about the problematic relationships among thoughts, emotions, and sleep behaviors that occur in the context of
insomnia. The goal of relaxation strategies in the context of insomnia is to reduce
hyperarousal at bedtime. Consistent with the principle of counter-conditioning, an
undesired response (i.e., arousal) is reduced as the stimulus (i.e., place of sleep) is
consistently paired with a more desired response (i.e., relaxation) [25]. Relaxation
strategies, including breathing exercises [26] and progressive muscle relaxation
[27], are often presented as part of CBT-I protocols [28]. Additionally, patients are
encouraged to implement a relaxing bedtime routine (i.e., buffer zone) each night in
an effort to (1) reduce anxious thoughts at bedtime [22] and (2) weaken the association between hyperarousal and bedtime that may have developed due to poor sleep
habits. Relaxation therapy is conditionally recommended as a single-component
treatment for insomnia disorder [8].
Cognitive therapy techniques
incorporates cognitive techniques to challenge unhelpful and inaccurate thoughts
that lead to problematic sleep behavior (i.e., “I have to go to bed early, and then I
will sleep more tonight”) [29]. To identify and adapt problematic thoughts related to
sleep, providers will utilize Socratic questioning [30]. Additionally, providers may
ask patients to examine their thoughts by looking at their sleep diary data (i.e., “Do
you actually sleep more if you spend more time in your bed?”) or encourage patients
to test these thoughts by engaging in a behavioral experiment. Sleep diary information can also help to challenge inaccurate or problematic thoughts about daytime
functioning (e.g., “If I don’t get eight hours of sleep, I will not be able to function
the next day”). By providing evidence to the contrary regarding the relationship
As a form of cognitive behavioral therapy, CBT-I
280
https://t.me/medicina_free
G. C. Carlson et al.
between total sleep time and daytime functioning, data gathered during CBT-I sessions can lessen anxiety about sleep difculties and the perceived consequences of
insomnia. Additionally, cognitive techniques can be used if patients express reluctance to engage in other components of CBT-I (e.g., sleep restriction). Other cognitive techniques include but are not limited to (1) evaluating the evidence for or
against a thought, (2) exploring alternative explanations or interpretation, (3) and/or
presenting new information to patients [31].
Multiple meta-analyses have demonstrated the effectiveness of CBT-I at improving wake/sleep patterns among patients with insomnia, including patients with
comorbid medical and psychiatric conditions [28, 32, 33]. The intervention components of CBT-I and their implementation are described in Table13.1. It should be
noted that the delivery of CBT-I is individualized for each patient, with the emphasis and timing of each intervention component depending on the clinical presentation of each individual patient.
Individual format CBT-I interventions have been most commonly studied using a
one-on-one, in person therapy format [28, 32]. Most protocols consist of four to six,
60-minute sessions with a trained CBT-I provider. However, CBT-I has also been
delivered using telemedicine platforms, with high feasibility and acceptability
reported by patients and providers [34]. Meta-analyses have consistently found
individual-based CBT-I to be an effective treatment for insomnia symptoms [32,
33]. As previously stated, the multicomponent, individual-based form of CBT-I is
strongly recommended by the AASM Clinical Practice Guidelines for the Treatment
of Insomnia [8]. This means that under most circumstances (or when possible),
providers should refer patients to or implement individual-based CBT-I [8].
Group format Despite the efcacy of this intervention, we recognize that there
are circumstances when one-on-one CBT-I may not be readily available or accessible to patients [35]. Fortunately, there is also research demonstrating the efcacy
for group-based CBT-I, though there is less evidence for group-based CBT-I compared to one-on-one CBT-I [36]. This form of CBT-I involves providing psychoeducation about sleep, including the rationales for stimulus control, sleep
restriction, and the other intervention components of CBT-I to a group of patients
[37]. Each patient tracks their sleep using a sleep diary, and sleep windows are
prescribed to each patient based on individual data from patients’ respective sleep
diaries.
Telehealth
Telehealth modalities have been used to deliver CBT-I in several stud-
ies and can increase access to treatment for patients with insomnia disorder who
many nd it difcult to travel to in-person sessions or to navigate a self-guided
treatment without provider support. There is evidence that CBT-I can be delivered
via telehealth in both individual and group format, and it is non-inferior to in-person
delivery [38, 39]; however, there are challenges to group delivery including privacy
consideration and technological challenges.
13 Management ofInsomnia Disorder
https://t.me/medicina_free
Table 13.1 Typical intervention components of cognitive behavioral therapy for insomnia (CBT-I)
Topics covered Session activities Homework
Getting started with CBT-I (sleep education, sleep hygiene, and stimulus control)
Sleep education: sleep regulation,
insomnia (3P model), sleep stages
and macrostructure
Introduce stimulus control concepts
Lifestyle habits that enhance or
hinder sleep
Introduce and explain daily sleep
diary
Scheduling sleep (sleep restriction therapy)
Learn about the homeostatic and
circadian sleep processes
Introduce sleep restriction
Thoughts about sleep (cognitive therapy)
Adjust time in bed
Discuss validity and utility of
unhelpful sleep-related thoughts
CBT-I: progress and obstacles (cognitive therapy)
Adjust time in bed
Review progress and obstacles
Use cognitive strategies to address
barriers to adherence
CBT-I: sleeping well over the long-term (relapse prevention)
Adjust time in bed
Discuss relapse prevention and
coping
Discuss classical
conditioning and insomnia
Action plan: sleep hygiene
changes, stimulus control
Review/discuss sleep diary
Action plan: daily sleep
schedule
Review/discuss sleep diary
Action plan: revise sleep
schedule, develop coping
cards
Review/discuss sleep diary
Addressing barriers and
obstacles using cognitivetherapy methods
Action plan: identify
obstacles and strategies to
address them
Review/discuss sleep diary
Action plan for relapse
prevention
Implement action plan
(sleep hygiene practices,
stimulus control)
Daily sleep diary
Implement action plan
(sleep schedule)
Daily sleep diary
Implement action plan
(sleep schedule, coping
cards)
Daily sleep diary
Implement action plan
(sleep schedule, strategies
to address obstacles)
Daily sleep diary
Use tools/skills for future
sleepless nights
281
Self-guided formats To increase access to CBT-I, online, self-guided protocols and
CBT-I informed apps have been developed. Evidence-based examples include the
Veteran Health Administration’s (VHA) “Path to Better Sleep” [40] and “CBT-I
Coach.” [41] Online behavioral interventions for insomnia have been shown to
improve sleep outcomes [42–44]. There is also evidence that face-to-face CBT-I is
more effective than guided online interventions [45]. That being said, CBT-I providers report using CBT-I Coach when delivering one-on-one CBT-I, and research
demonstrates that the app is viewed favorably by patients [46, 47]. It should be
noted that use of CBT-I Coach or other apps alone is not comparable to the delivery
of CBT-I by a trained provider.
Brief behavioral treatment for insomnia Given that stimulus control and sleep
restriction are the intervention components of CBT-I with the strongest evidence,
282
https://t.me/medicina_free
G. C. Carlson et al.
brief behavioral treatment for insomnia (BBT-I) was derived from CBT-I.BBT-I is
shorter than CBT-I [48, 49], typically involving four sessions, and focuses on helping patients to make behavioral changes to improve their sleep. BBT-I provides
education about homeostatic (i.e., sleep drive) and circadian drives (i.e., biological
clock) and how waking behaviors associated with insomnia disorder can interfere
with these processes [50]. Similar education is provided in CBT-I protocols as well
[22]. Intervention components of BBT-I include (1) sleep restriction to increase
sleepiness at the prescribed bedtime, (2) stimulus control to reduce time spent
awake in bed, (3) adherence to prescribed bedtimes and rise times, (4) and elimination/reduction of bad sleep hygiene behaviors and promotion of good sleep hygiene
behaviors. BBT-I encourages patients to modify waking behaviors to normalize
homeostatic and circadian drives. BBT-I does not target sleep-related thoughts and
does not incorporate cognitive strategies [50]. While CBT-I remains the rst line
treatment for insomnia disorder, a recent noninferiority clinical trial found no signicant differences between BBT-I and CBT-I on sleep-related outcomes [51]. The
AASM Clinical Practice Guidelines recommend that providers may use multicomponent brief therapies for insomnia [9].
Consistent with CBT-I, patients who undergo BBT-I complete a sleep diary each
week, which guides treatment recommendations. If a patient’s sleep onset latency is
>20minutes, it is recommended they leave their sleeping area and engage in a lowstimulating activity until they are sleepy, at which point they are instructed to return
to bed. Generally, if a patient is taking >30minutes to fall asleep or they are awake
>30minutes after sleep onset, it is recommended that the patient reduce their time
in bed by 15minutes. Alternatively, if the patient is taking <30minutes to fall asleep
or they are awake <30minutes after sleep onset, it is recommended that the patient
increase their time in bed by 15minutes [22, 50]. This is known as the 30/30 rule in
BBT-I [50, 52].
Due to the high incidence and persistence of untreated insomnia [53], an important part of both CBT-I and BBT-I is relapse prevention. Patients are encouraged to
consider the strategies they have learned in insomnia treatment and to identify a
plan for how they will intervene on their own behavior in the future should they
have trouble initiating or maintaining sleep again. A recent meta-analysis showed
the effects of CBT-I remain signicant a year after therapy [54]. The focus on
relapse prevention in the termination session highlights the importance of patient
education in both CBT-I and BBT-I, ensuring that patients understand the treatment
rationales and develop a sense of agency regarding their sleep.
Novel behavioral approaches
efcacy and effectiveness of CBT-I, challenges with treatment completion remain.
Estimates of treatment dropout in clinical settings range from 13.7% to 34.0% [55,
56]. Shorter total sleep time and greater depression symptoms at baseline predict
treatment attrition in clinical trials of CBT-I.Adherence challenges have also led
practitioners and researchers to explore adaptations of CBT-I [57]. Mindfulness and
acceptance-based approaches (so-called third-wave cognitive behavioral therapies)
Despite the body of research demonstrating the
13 Management ofInsomnia Disorder
https://t.me/medicina_free
283
are receiving growing attention. Kabat-Zinn (1994) dened mindfulness as “paying
attention in a particular way: on purpose, in the present moment, and nonjudgmentally”
(p.4) [58]. Components of mindfulness (e.g., present moment awareness, observation, description) have been incorporated into cognitive behavioral therapies, with
the goal of noticing thoughts, rather than challenging or changing said thoughts [59].
Mindfulness-based Ong etal. (2012) proposed a model of insomnia consist with
third-wave approaches. The model suggests that sleep-related arousal is caused rst
by sleep difculties and their consequences, and then the arousal is exacerbated by
“meta-cognitive” factors, such as distress about concerns regarding the insomnia
[60]. Addressing meta-cognitive factors may improve the general effectiveness of
treatment and reduce non-adherence through increased tolerance of discomfort
[60]. Mindfulness-based therapy for insomnia (MBTI) incorporates (1) experiential
mindfulness practices (e.g., body scan, sitting meditation), (2) education about
mindfulness, and (3) behavioral strategies to improve insomnia (i.e., stimulus control, sleep restriction, and targeted sleep hygiene recommendations). Similar to
CBT-I and BBT-I, patients undergoing MBTI are asked to keep a sleep diary, but
they are also asked to keep a meditation diary [61]. MBTI has been found to be
effective at improving insomnia symptoms [62].
Acceptance-based A third-wave cognitive behavioral therapy that incorporates
mindfulness is Acceptance and Commitment Therapy (ACT) [63, 64]. CBT and
ACT have similarities and distinct differences. Both emphasize the role of cognition
in psychopathology, but each model proposes different mechanisms of change [65].
In CBT, adaptive changes in thoughts and behaviors contribute to therapeutic
change [66]. The ACT model suggests that thoughts do not directly cause problematic behaviors and a decrease in dysfunctional thoughts is not a prerequisite for
therapeutic change [67]. Therapeutic change occurs by changing the relationship
one has with “dysfunctional thoughts” through contacting the present moment, and,
based on what that situation affords, acting in accordance with one’s chosen values.
This process is referred to as psychological exibility [64].
Within the ACT framework, there are six interrelated processes which promote
psychological exibility including (1) present moment awareness, (2) acceptance of
current experience, (3) self as context (i.e., non-identication with thoughts), (4)
cognitive defusion (i.e., creating “space” between self and thoughts), (5) values
(i.e., activities that give lives meaning), and (6) committed actions (i.e., behaviors in
service of these values) [63, 64]. While ACT has been used to treat multiple psychiatric conditions and improve distress among individual with multiple comorbid
medical conditions, few studies have examined insomnia as a primary outcome
variable [68]. However, there was a recent meta-analysis that examined the impact
of ACT on insomnia and sleep quality, and ndings indicated that engagement in
ACT was associated with improved sleep outcomes [69]. While case studies and
developmental study ndings for ACT-based insomnia treatment are promising [70,
71], additional clinical trials are needed.
284
https://t.me/medicina_free
G. C. Carlson et al.
Behavioral Treatment forInsomnia: Safety Considerations
The risks associated with participation in CBT-I or other behavioral treatments for
insomnia are minimal [8]. However, there are times when sleep restriction is contraindicated. For instance, if a patient has a history of bipolar disorder, disruptions to
the sleep schedule can trigger hypomanic/manic symptoms [72, 73]. Generally, it is
not recommended that providers prescribe a sleep window less than 5hours [22],
even when patients are reporting total sleep time of less than 5hours. BBT-I guidelines recommend a sleep window of no less than 6hours [50]. CBT-I providers and
patients should also discuss the utility of sleep outside of the prescribed sleep window when patients are sleepy and they must engage in activities where sleep deprivation is dangerous (e.g., driving).
Additionally, while CBT-I has been shown to be effective at treating insomnia in
patients with comorbid sleep conditions, assessment of sleep disorders (e.g.,
obstructive sleep apnea [OSA], restless leg syndrome) [8, 74, 75] is recommended
prior to initiation of behavioral insomnia treatment. This ensures that patients
receive treatments for their other sleep disorders (e.g., continues positive airway
pressure [CPAP], medications/supplements) and optimizes the effectiveness of
behavior treatments for insomnia. Research has also shown that participation in
CBT-I increases CPAP use in patients with comorbid insomnia and OSA [76].
Finally, research has demonstrated that insomnia is a risk factor for suicidal ideation
[77, 78]. While research has shown CBT-I and attendance of sleep medicine appointments reduces depression symptoms and lowers risk of suicide [79, 80], risk assessment and safety planning should be conducted prior to initiating CBT-I with patients
to ensure that patients are not a harm to themselves or others.
Behavioral Treatments forInsomnia: Considerations
forSpecial Populations
Since insomnia disorder is highly comorbid with a variety of medical and mental
health disorders [3, 81], special considerations should be made with some patients.
Providers should involve caregivers when patients with insomnia present with cognitive impairment or are dependent on caregivers to complete activities of daily
living. Caregivers may also benet from components of CBT-I to both optimize
their sleep and caregiving abilities [82]. Additionally, patients with limited mobility or pain may require modication to traditional stimulus control recommendations. Understanding the unique factors that contribute to nighttime awakenings
(e.g., pain, need to urinate, hot ashes) is critical in developing effective behavioral
treatment plans [3, 83, 84]. Patients with psychiatric comorbidities may require
greater emphasis on interventions for problematic thoughts related to sleep and
avoidance of sleep (e.g., patients with posttraumatic stress disorder [PTSD] may
avoid sleep due to fear of nightmares) [85]. Finally, for a patient to be diagnosed
13
https://t.me/medicina_free
Management ofInsomnia Disorder
285
with insomnia, the patient must report sleep problems, despite having the opportunity to sleep [4]. This differentiation is important when assessing patients who may
not have a consistent opportunity to sleep (e.g., parents of infants) and/or patients
who do not have a consistent/safe place to sleep (i.e., individual with unstable
housing). In these circumstances, it may be best to delay initiation of behavioral
treatments for insomnia and rst address barriers to consistent and safe opportunities for sleep.
Medication Treatments forInsomnia
While CBT-I is the gold standard rst line treatment for insomnia disorder, pharmacotherapy plays a role in several clinical situations. Medications are often used for
short-term insomnia, for individuals who cannot or choose not to undergo CBT-I,
for individuals who did not respond fully to CBT-I treatment, and for individuals
who require intermittent medication in addition to CBT-I. A limited number of
medications are FDA approved for treatment of insomnia (Table13.2), although
many other prescription medications, dietary supplements, and over-the-counter
medications with sedating properties are used off-label in clinical practice.
Importantly, off-label use of medications to treat insomnia but that are not FDA
approved is also not recommended for use in clinical practice guidelines, generally
due to the fact that the potential side effects from these medications outweigh the
potential benets for treating insomnia disorder [86, 87].
Table 13.2 FDA medications approved for treatment of insomnia disorder in adults
Prescription medications Over-the-counter agents
Ambien (zolpidem)
Belsomra (suvorexant)
Butisol (butabarbital)
Doral (quazepam)
Edluar (zolpidem)
Estazolam
Flurazepam
Halcion (triazolam)
Hetlioz (tasimelteon)
Intermezzo (zolpidem)
Lunesta (eszopiclone)
Restoril (temazepam)
Rozerem (ramelteon)
Seconal (secobarbital)
Silenor (doxepin)
Sonata (zaleplon)
Zolpimist (zolpidem)
Source: US Food and Drug Administration [104]
a
Note: agents also in many cold and headache combination products
Benadryl (diphenhydramine)
Unisom (doxylamine)
a
a
Соседние файлы в папке Библиотека им академика М.И. Перельмана