Cognitive behavioural therapy for primary insomnia: a systematic review

AIM: This paper reports a systematic review of seven studies evaluating the efficacy of cognitive behavioural therapy (CBT) for persistent primary insomnia. BACKGROUND: Insomnia is one of the most common health complaints reported in the primary care setting. Although non-pharmacological treatments such as the CBT have been suggested to be useful in combating the persistent insomnia, the efficacy and clinical utility of CBT for primary insomnia have yet to be determined. METHOD: A systematic search of Ovid, MEDLINE, psychINFO, PsycARTICLES, CINAHL, and EMBASE databases of papers published between 1993 and 2004 was conducted, using the following medical subject headings or key words: insomnia, primary insomnia, psychophysiological insomnia, sleep maintenance disorders, sleep initiation disorders, non-pharmacological treatment, and cognitive behavioural therapy. A total of seven papers was included in the review. FINDINGS: Stimulus control, sleep restriction, sleep hygiene education and cognitive restructuring were the main treatment components. Interventions were provided by psychiatrists except for one study, in which the CBT was delivered by nurses. Among beneficial outcomes, improvement of sleep efficacy, sleep onset latency and wake after sleep onset were the most frequently reported. In addition, participants significantly reduced sleep medication use. Some studies gave follow-up data which indicated that the CBT produced durable clinical changes in total sleep time and night-time wakefulness. CONCLUSIONS: These randomized controlled trial studies demonstrated that CBT was superior to any single-component treatment such as stimulus control, relaxation training, educational programmes, or other control conditions. However, heterogeneity in patient assessment, CBT protocols, and outcome indicators made determination of the relative efficacy and clinical utility of the therapy difficult. Therefore, the standard components of CBT need to be clearly defined. In addition, a comprehensive assessment of patients is essential for future studies.     

脑卒中并发失眠的治疗

失眠是脑卒中患者常见的不适主诉之一,发生率远高于普通人群。失眠对脑卒中患者的预后有明显影响,但对脑卒中后并发失眠的治疗尚未引起足够重视,临床上大多仍以使用镇静催眠药对症处理为主。国内外对该类失眠患者进行了不同药物、不同方法的治疗研究,结果各异。     

Sleeping through the night: are extended-release formulations the answer?

PURPOSE: To provide an overview of insomnia, including identification and current treatments, as well as review the efficacy and safety of extended-release sleep medication. DATA SOURCES: Published clinical research and review articles, DSM-IV criteria, and clinical trials. CONCLUSIONS: Insomnia is a highly prevalent and debilitating sleep disorder, which may present with one or more of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep, or waking too early without being able to return to sleep. Difficulty maintaining sleep throughout the night is the most common symptom of insomnia. The recently approved nonbenzodiazepine hypnotic, zolpidem extended-release, can be taken as long as medically necessary to improve sleep-onset and reduce sleep-maintenance difficulties in insomnia patients, without negatively affecting next-day functioning. IMPLICATIONS FOR PRACTICE: Insomnia continues to be an underdiagnosed and undertreated disorder. The nurse practitioner, through routine inquiry about patient sleep habits and consideration of the appropriate treatment of insomnia, can help restore the quality of life of patients experiencing the negative consequences of insomnia.     

Detection and assessment of insomnia.

Insomnia is one of the most common complaints encountered by the primary care physician. Yet, in many cases, physicians treat the symptom of insomnia rather than evaluating and treating the underlying causes of insomnia. Because the subjective complaint of insomnia does not always correlate with evidence of objective sleep disruption, a careful history and evaluation are required. Assessment of the duration of insomnia and quantification of the impact of nocturnal sleep disruption on daytime functioning provide the most reliable indices of severity. Primary insomnia may be due to a number of different causes, such as poor sleep hygiene or circadian rhythm disruption. Insomnia may also be the presenting symptom of other primary sleep disorders, such as sleep apnea syndrome or nocturnal myoclonus, or of a variety of medical or psychiatric illnesses. The treatment of the patient with insomnia should address the underlying cause, when identifiable. When the cause cannot be identified, treatment should be conservative; nonpharmacologic therapies should be used whenever possible. When pharmacologic approaches are indicated, short-acting benzodiazepines should be administered in concordance with strict prescribing guidelines. Frequent follow-up is necessary to ensure continued therapeutic efficacy of the prescribed therapy.     

远程交互CBTI在慢性失眠患者中的应用研究进展

失眠认知行为治疗(Cognitive Behavioral Therapy for Insomnia,CBTI)是成人慢性失眠障碍的非药物治疗的一线治疗方案,传统CBTI在实施过程中存在难以克服的问题,远程交互CBTI是基于现代科技为载体,实现与患者远程交互。它最大的优势在于脱离了地域限制和专业医生人数的限制,让患者在家庭中自助实施,大大减少了患者往返医院的成本和医生的投入成本。实现实时的、柔性化的、满足患者个性化治疗需求,患者的依从性大大提高,治疗效率大大提高。     

网络化认知行为治疗对非器质性失眠的短期疗效观察

目的:探索网络化认知行为治疗对非器质性失眠的短期疗效及患者依从性.方法:经过微信平台招募失眠患者,经过CBT-I专业培训的治疗师电话访谈,排除严重躯体疾病、睡眠呼吸暂停综合征及严重抑郁患者,最后纳入65例患者,予以网络化认知行为治疗,观察其治疗前后失眠指数量表(Insomnia Severity Index,ISI)及...     

Insomnia in the geriatric patient

Insomnia in the geriatric patient is unique and complex, requiring a comprehensive and careful evaluation. Insomnia is the most common sleep complaint reported by persons > 60 years. It is defined as the inability to initiate or maintain sleep, and the etiology can be multifactorial. Insomnia in the geriatric patient may be due to a primary sleep disorder, such as obstructive sleep apnea, periodic limb movements in sleep, circadian rhythm disorders, or restless legs syndrome, or it may be secondary to underlying medical or psychiatric conditions, medication effects, or psychosocial factors. When insomnia becomes chronic, it may exacerbate medical and psychiatric illnesses. Insomnia can lead to excessive daytime sleepiness, which may result in disturbed intellect, impaired cognition, confusion, psychomotor retardation, or increased risk of injury, any of which can compromise the patient's quality of life and create social and economic burdens for caregivers. This article discusses the recommended diagnostic and treatment approaches that may be used by the clinician in treating the geriatric patient. Case studies are presented to illustrate diagnoses of insomnia and therapeutic interventions.     

Sleep and Migraine: Assessment and Treatment of Comorbid Sleep Disorders

The relationship of sleep and migraine is unequivocal and familiarity with the nature and magnitude of these associations may inform clinical practice. Recent prospective, longitudinal, and time‐series analysis has begun to unravel the magnitude and temporal patterns of sleep and migraine. Prospective evidence has shown that sleep variables can trigger acute migraine, precede and predict new onset headache by several years, and indeed, sleep disturbance and snoring are risk factors for chronification. The presence of a sleep disorder is associated with more frequent and severe migraine and portends a poorer headache prognosis. Interestingly, the disorders linked to migraine are quite varied, including insomnia, snoring and obstructive sleep apnea, restless legs, circadian rhythm disorders, narcolepsy, and others. Insomnia is by far the most common sleep disorder in headache patients. In fact, the majority of patients with chronic migraine presenting for treatment have insomnia. Despite a rapidly expanding literature, very few controlled treatment studies have been published to guide clinical practice. This paper focuses on clinical assessment and treatment of sleep disorders. An algorithm is presented for sleep disorders management in the migraine patient, which highlights major sleep disorders and psychiatric comorbidity. Diagnostic procedures are recommended that are conducive to clinical practice. Suggested tools include the sleep history, screening mnemonics, prediction equation, and sleep diary. New developments in treatment have produced abbreviated and cost‐effective therapies for insomnia and obstructive sleep apnea that may reach a larger population. Revisions in the diagnostic manuals for sleep and headache disorders enhance recognition of sleep‐related headache. Recommendations include behavioral sleep regulation, shown in recent controlled trials to decrease migraine frequency, management for sleep apnea headache, cognitive behavioral therapy (CBT) for insomnia abbreviated for the physician practice setting, sleep‐related headache trigger, and others. There is no empirical evidence that sleep evaluation should delay or supersede usual headache care. Rather, sleep management is complimentary to standard headache practice.     

Consensus for the pharmacological management of insomnia in the new millennium

Insomnia, a common symptom throughout the world, is characterised by difficulty initiating or maintaining sleep or non-restorative sleep and is associated with significant morbidity. A comprehensive medical and sleep history and physical examination are necessary before treating patients with insomnia; the presence of co-morbidities, including medical and psychiatric disorders, or the possible use of substances that may contribute to sleeplessness should be thoroughly investigated. Non-pharmacological approaches include correction of sleep hygiene as well as behavioural treatments. Pharmacotherapy includes benzodiazepine-receptor agonists, which are the drugs of choice for this disorder. They can be subdivided into classic benzodiazepines and non-benzodiazepines. Although many agents in these classes have been prescribed, potential shortcomings include residual sedation, rebound insomnia, and psychomotor and memory impairment. Novel pharmacological strategies that address limitations of the traditional treatment approach, combined with proven modes of behavioural therapy, offer the most successful results in the management of insomnia. These advances provide the opportunity to establish these current recommendations for the optimal management of insomnia. This report from the XXII Collegium Internationale Neuro-Psychopharmacologicum Consensus Workshop outlines recommendations to serve as the foundation for developing a therapeutic plan for each patient.     

Insomnia: An Underrecognized Nonmotor Symptom in Parkinson Disease

Insomnia is a highly prevalent nonmotor symptom among patients with Parkinson disease (PD) and significantly impacts their quality of life. It is typically an underdiagnosed and untreated symptom of PD. Accurate assessment, ruling out other potential etiologies, and a combination of nonpharmacologic and pharmacologic interventions are important strategies in the management of insomnia in patients with PD. The goal of treatment is to improve sleep duration, sleep quality, and overall quality of life. Nurse practitioners play an integral role in the recognition, assessment, and management of insomnia in PD.     

Longitudinal Course and Impact of Insomnia Symptoms in Adolescents With and Without Chronic Pain

This study aimed to 1) examine trajectories of insomnia symptoms in adolescents with chronic pain compared to their healthy peers; 2) evaluate psychological and behavioral risk factors for longitudinal insomnia symptoms; and 3) evaluate insomnia as a predictor of quality of life, activity limitations, and healthcare utilization over 12 months. Participants included 61 adolescents with chronic pain and 60 youths without chronic pain (12–18 years; 72% female). Questionnaires were completed at enrollment, 6 months, and 12 months and assessed pain intensity, insomnia symptoms, sleep hygiene, presleep arousal, depression, pubertal status, activity limitations, quality of life, and healthcare utilization. Insomnia symptoms persisted for both groups and remained higher at all time points for youths with chronic pain. Generalized estimating equations modeling identified 3 risk factors for longitudinal insomnia symptoms: having chronic pain, poorer sleep hygiene, and higher depressive symptoms. Insomnia symptoms also predicted poorer quality of life over time and were associated with more frequent healthcare utilization. Findings suggest that sleep problems are persistent and associated with negative impact for youths with chronic pain. Treatment of insomnia symptoms in youths with chronic pain may lead to improvements in quality of life and reductions in healthcare costs.     

The role of eszopiclone in the treatment of insomnia

Introduction  Insomnia is a common and underdiagnosed condition that can result in significant economic and clinical consequences. Despite numerous behavioral and pharmacotherapeutic treatment options available for insomnia, few receive adequate treatment, and sleep maintenance (staying asleep) remains a significant problem. To date, available sedative-hypnotic agents have limitations that have lead to inadequate treatment of insomnia. This review provides an overview of eszopiclone and its role in the treatment of insomnia. Methods  Electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts) were searched for applicable primary literature and review articles. Results  Mechanisms of action at the gammaamino butyric acid (GABA) receptor sites and pharmacologic and pharmacokinetic characteristics are presented. Eszopiclone, a nonbenzodiazepine S-enantiomer of racemic zopiclone, is highlighted as the first sedative-hypnotic agent to be approved by the United States Food and Drug Administration for the treatment of sleep onset latency and sleep maintenance insomnia with no short-term restrictions. Recently, the European Medicines Agency recommended marketing authorization of eszopiclone. Conclusion  Eszopiclone has been shown to be an efficacious and cost-effective option for the treatment of transient and chronic insomnia in adults.     

Insomnia in Adults: Etiology and Management

Insomnia is a significant problem in adults that frequently goes undiagnosed and untreated. Untreated insomnia is often associated with undiagnosed medical or psychiatric disorders that increase morbidity and mortality. Sleep patterns change with aging, and the presence of comorbid conditions leads to a higher prevalence of sleep disorders in older adults. Practitioners should inquire about sleep disorders with every patient encounter to increase diagnosis and treatment. Effective treatment of insomnia is available with nonpharmacologic and pharmacologic treatment modes.     

The mediating and moderating effects of sleep hygiene practice on anxiety and insomnia in hospital nurses

This study aimed to test the mediating and moderating effects of sleep hygiene practice on the relationship between anxiety and insomnia severity in hospital nurses. A cross‐sectional survey was employed, and a convenience sample was recruited from one regional hospital in Taiwan. Participants completed the following self‐report questionnaires over a 3‐month period in 2009: the Insomnia Severity Index, the Beck Anxiety Inventory, and Sleep Hygiene Awareness and Practice Scale. The results indicated that nurses with more anxiety tended to have higher insomnia severity. Further, nurses with poor sleep hygiene practice had more insomnia. Sleep hygiene practice partially mediated the effects of anxiety on insomnia severity. Also, sleep hygiene practice was a moderator in the relationship between anxiety and insomnia severity with age and work units as covariates. Sleep hygiene practice mediated and moderated the relationship between anxiety and insomnia severity after controlling the variables of age and work units. Continuing to learn and train sleep hygiene practice might promote nurses' sleep hygiene, and thereby ameliorate anxiety and reduce the risk of insomnia.     

门诊失眠患者焦虑、抑郁情况及影响因素分析

目的分析医院门诊失眠患者焦虑、抑郁情况及其影响因素。方法采用一般资料及匹兹堡睡眠指数、焦虑与抑郁自评量表的调查问卷,对2010年1月至2012年4月235例精神科及心理咨询门诊失眠患者进行调查分析。结果失眠平均得分(12.63±4.03)分,失眠得分16分以下者占85.9%。失眠合并焦虑或抑郁者分别为40.0%和36.6%。失眠合并焦虑及抑郁者占30.6%,失眠与焦虑、抑郁呈正相关性(P<0.01)。受教育程度为失眠的影响因素,体质量指数、生活习惯为焦虑的影响因素,体质量指数为抑郁的影响因素。结论失眠与焦虑、抑郁相互影响,受教育程度低者失眠得分较高,低体质量指数为焦虑、抑郁的影响因素,不规律的生活习惯是焦虑的影响因素。     

儿童及青少年失眠的临床特征及治疗研究概况

儿童及青少年是生命历程的关键阶段,许多有助于确定当前和未来健康结果的行为模式在此间得以确立,儿童及青少年精神卫生保健至关重要。儿童及青少年失眠受青春期生理发育、学校及家庭等社会环境、心理行为等多种因素影响,囊括了入睡困难、睡眠时间不足、睡眠质量差和日间困倦等一系列症状,明显影响其精神状态和生活学习质量。儿童及青少年失眠的治疗方法以睡眠卫生教育、认知行为治疗和正念冥想等综合治疗为主。笔者从失眠的相关成因、症状和治疗方法3个方面对儿童及青少年失眠作一综述,为其临床诊疗提供参考。     

Nursing interventions to alleviate insomnia

Insomnia or disturbed sleep is experienced by many older people and has adverse effects on physical and psychological health. Nurses should be aware of insomnia and how they can help patients to get a good night's sleep. This article first examines normal sleep patterns and then insomnia. It discusses what nurses can do to assess sleep disturbances and suggests practical strategies to promote quality sleep in inpatients and care home residents.     

Medications and their effects on sleep

Only a few years ago, if patients complained of difficulty sleeping,medications that were often dangerous and addictive were prescribed to induce sleep, and the basis of the patient's complaint was not addressed. Now sleeping pills are safer, and our understanding of the sleep state has increased exponentially. Insomnia and daytime sleepiness are no longer diagnoses; they are complaints needing to be addressed-symptoms of a spectrum of sleep disorders with specific diagnostic criteria and appropriate treatments.     

“调肝安神方”治疗肝郁血瘀型失眠症的临床疗效及其对PSQI评分的影响

目的:观察调肝安神方治疗失眠症肝郁血瘀证患者的临床疗效及对匹兹堡睡眠质量指数(Pittsburgh Sleep Quality Index,PSQI)评分的影响。方法:选取南京中医药大学第二附属医院神经内科失眠专病门诊患者96例,采用随机数字表法随机分为2组。对照组48例,给予艾司唑仑1~2 mg睡前口服;治疗组48例,在对照组基础上加用调肝安神方治疗。比较2组中医证侯疗效及PSQI分值的变化。结果:治疗组临床痊愈9例,显效16例,有效18例,无效5例,愈显率65.8%,总有效率89.6%;对照组临床痊愈3例,显效10例,有效19例,无效16例,愈显率34.2%,总有效率66.7%。治疗组临床愈显率及总有效率均明显高于对照组(均P<0.05)。治疗后,对照组睡眠质量、入睡时间、睡眠时间、睡眠效率PSQI因子积分及总积分均较治疗前明显下降(均P<0.05);治疗组睡眠质量、入睡时间、睡眠时间、睡眠效率、睡眠障碍、日间功能PSQI各因子积分及总积分均较治疗前明显下降(均P<0.01),且均显著低于对照组(均P<0.05)。结论:调肝安神方治疗失眠症肝郁血瘀证患者疗效确切,能显著延长总睡眠时间,增加睡眠深度,减轻睡眠障碍,缓解日间功能,改善睡眠质量,显著提高睡眠效率,值得临床进一步研究。