Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine

Insomnia is the most common sleep complaint reported to physicians. Treatment has traditionally involved medication. Behavioral approaches have been available for decades, but lack of physician awareness and training, difficulty in obtaining reimbursements, and questions about efficacy have limited their use. These practice parameters review the current evidence with regards to a variety of nonpharmacologic treatments for insomnia. Using a companion paper which provides a background review, the available literature was analyzed. The evidence was graded by previously reported criteria of the American Academy of Sleep Medicine with references to American Psychological Association criteria. Treatments considered include: stimulus control, progressive muscle relaxation, paradoxical intention, biofeedback, sleep restriction, multicomponent cognitive behavioral therapy, sleep hygiene education, imagery training, and cognitive therapy. Improved experimental design has significantly advanced the process of evaluation of nonpharmacologic treatments for insomnia using guidelines outlined by the American Psychological Association (APA). Recommendations for individual therapies using the American Academy of Sleep Medicine recommendation levels for each are: Stimulus Control (Standard); Progressive Muscle Relaxation, Paradoxical Intention, and Biofeedback (Guidelines); Sleep Restriction, and Multicomponent Cognitive Behavioral Therapy (Options); Sleep Hygiene Education, Imagery Training, and Cognitive Therapy had insufficient evidence to be recommended as a single therapy. Optimal duration of therapy, who should perform the treatments, long term outcomes and safety concerns, and the effect of treatment on quality of life are questions in need of future research.     

Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review

This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.     

Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report

The expanding science of circadian rhythm biology and a growing literature in human clinical research on circadian rhythm sleep disorders (CRSDs) prompted the American Academy of Sleep Medicine (AASM) to convene a task force of experts to write a review of this important topic. Due to the extensive nature of the disorders covered, the review was written in two sections. The first review paper, in addition to providing a general introduction to circadian biology, addresses "exogenous" circadian rhythm sleep disorders, including shift work disorder (SWD) and jet lag disorder (JLD). The second review paper addresses the "endogenous" circadian rhythm sleep disorders, including advanced sleep phase disorder (ASPD), delayed sleep phase disorder (DSPD), irregular sleep-wake rhythm (ISWR), and the non-24-hour sleep-wake syndrome (nonentrained type) or free-running disorder (FRD). These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the AASM to present recommendations for the assessment and treatment of CRSDs based on the two accompanying comprehensive reviews. The main diagnostic tools considered include sleep logs, actigraphy, the Morningness-Eveningness Questionnaire (MEQ), circadian phase markers, and polysomnography. Use of a sleep log or diary is indicated in the assessment of patients with a suspected circadian rhythm sleep disorder (Guideline). Actigraphy is indicated to assist in evaluation of patients suspected of circadian rhythm disorders (strength of recommendation varies from "Option" to "Guideline," depending on the suspected CRSD). Polysomnography is not routinely indicated for the diagnosis of CRSDs, but may be indicated to rule out another primary sleep disorder (Standard). There is insufficient evidence to justify the use of MEQ for the routine clinical evaluation of CRSDs (Option). Circadian phase markers are useful to determine circadian phase and confirm the diagnosis of FRD in sighted and unsighted patients but there is insufficient evidence to recommend their routine use in the diagnosis of SWD, JLD, ASPD, DSPD, or ISWR (Option). Additionally, actigraphy is useful as an outcome measure in evaluating the response to treatment for CRSDs (Guideline). A range of therapeutic interventions were considered including planned sleep schedules, timed light exposure, timed melatonin doses, hypnotics, stimulants, and alerting agents. Planned or prescribed sleep schedules are indicated in SWD (Standard) and in JLD, DSPD, ASPD, ISWR (excluding elderly-demented/nursing home residents), and FRD (Option). Specifically dosed and timed light exposure is indicated for each of the circadian disorders with variable success (Option). Timed melatonin administration is indicated for JLD (Standard); SWD, DSPD, and FRD in unsighted persons (Guideline); and for ASPD, FRD in sighted individuals, and for ISWR in children with moderate to severe psychomotor retardation (Option). Hypnotic medications may be indicated to promote or improve daytime sleep among night shift workers (Guideline) and to treat jet lag-induced insomnia (Option). Stimulants may be indicated to improve alertness in JLD and SWD (Option) but may have risks that must be weighed prior to use. Modafinil may be indicated to improve alertness during the night shift for patients with SWD (Guideline).     

Practice parameters for the use of light therapy in the treatment of sleep disorders. Standards of Practice Committee, American Academy of Sleep Medicine.

These clinical guidelines were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The guidelines provide recommendations for the practice of sleep medicine in North America regarding the use of light therapy for treatment of various sleep disorders. This paper is based on a series of articles in the Journal of Biological Rhythms and also includes evidence tables from an updated Medline review covering the period January 1994 to December 1997. Evidence is presented by grade and level. Recommendations are identified as standards, guidelines, or options. Recommendations are provided for delayed sleep phase syndrome (DSPS), advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome, jet lag, shift work, dementia, and sleep complaints in the healthy elderly. Light therapy appears generally safe if used within recommended intensity and time limits. Light therapy can be useful in treatment of DSPS and ASPS. Benefits of light therapy are less clear and treatment is an option in jet lag, shift work, and non-24-hour sleep-wake syndrome in some blind patients.     

Sleep disturbances of older persons: physicians' attitudes.

To determine their attitudes about sleep problems in older persons, 45 experienced geriatricians were surveyed. Disturbed sleep was a common and clinically important problem in their elderly patients, but most practitioners acknowledged no formal training in this area. Although historical information was nearly the exclusive diagnostic tool, a defined, comprehensive sleep history was not obtained routinely by nearly half of these clinicians. Most often, physicians attributed sleep complaints to conditions secondarily disrupting sleep and to the effects of medications. They rarely diagnosed primary sleep disorders and seldom obtained polysomnography to evaluate their patients. The hazards of pharmacologic therapy were widely recognized, but few clinicians employed predefined nonpharmacologic sleep hygiene programs in their practices. There is a critical need for improved education of clinicians about sleep problems of the elderly and for development of skills essential to their diagnosis and management.     

Evaluation of chronic insomnia. An American Academy of Sleep Medicine review

Insomnia is a condition which affects millions of individuals, giving rise to emotional distress, daytime fatigue, and loss of productivity. Despite its prevalence, it has received scant clinical attention. An adequate evaluation of persistent insomnia requires detailed historical information as well as medical, psychological and psychiatric assessment. Use of a classification system for sleep disorders and familiarity with major diagnostic groups will facilitate the clinician's evaluation and treatment. Thorough assessment also requires attention to the unique aspects of presentation and specific set of etiologies which are associated with particular age groups.     

Practice parameters for the treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Report. Standards of Practice Committee of the American Academy of Sleep Medicine

These are the first clinical guidelines published for the treatment of Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) providing evidence-based practice parameters. They were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The guidelines provide recommendations for the practice of sleep medicine in North America regarding the treatment of RLS and PLMD. Recommendations are based on the accompanying comprehensive review of the medical literature regarding treatment of RLS and PLMD which was developed by a task force commissioned by the American Academy of Sleep Medicine. Recommendations are identified as standards, guidelines, or options, based on the strength of evidence from published studies that meet criteria for inclusion. Dopaminergic agents are the best studied and most successful agents for treatment of RLS and PLMD. Specific recommendations are also given for the use of opioid, benzodiazepine, anticonvulsant, and adrenergic medications, and for iron supplementation. In general, pharmacological treatment should be limited to individuals who meet diagnostic criteria and especially who experience insomnia and/or excessive sleepiness that is thought to occur secondary to RLS or PLMD. Individuals treated with medication should be followed by a physician and monitored for clinical response and adverse effects. It would be desirable for future investigations to employ multicenter clinical trials, with expanded numbers of subjects using double-blind, placebo-controlled designs, and an assessment of long-term response, side effects, and impact of treatment on quality of life. Evaluation of special groups such as children, pregnant women, and the elderly is warranted.     

Manifestations of Insomnia in Sleep Apnea: Implications for Screening and Treatment

The aims of this study were to examine the presence, type, and severity of insomnia complaints in obstructive sleep apnea (OSA) patients and to assess the utility of the Sleep Symptom Checklist (SSC) for case identification in primary care. Participants were 88 OSA patients, 57 cognitive-behavioral therapy for insomnia (CBT-I) patients, and 14 healthy controls (Ctrl). Each completed a sleep questionnaire as well as the SSC, which includes insomnia, daytime functioning, psychological, and sleep disorder subscales. Results showed that OSA patients could be grouped according to 3 insomnia patterns: no insomnia (OSA), n = 21; insomnia (OSA-I), n = 30, with a subjective complaint and disrupted sleep; and noncomplaining poor sleepers (OSA-I-NC), n = 37. Comparisons among the OSA, CBT-I, and Ctrl groups demonstrate distinct profiles on the SSC subscales, indicating its potential utility for both case identification and treatment planning.     

Sleep problems in Chinese elderly in Hong Kong.

BACKGROUND: To examine the sleep habits and one-year prevalence of sleep disturbance (difficulty in falling asleep, broken sleep and early morning wakening) as well as insomnia (subjectively inadequate or poor sleep) in an elderly Chinese population in Hong Kong. METHOD: In Phase 1, a representative sample of elderly aged 70 years or above were interviewed with a sleep questionnaire, and Cantonese versions of the Mini-Mental State Examination (CMMSE) and Geriatric Depression Scale(CGDS). In Phase 2, those with scores suggestive of cognitive impairment on CMMSE or depression on CGDS were interviewed by psychiatrists for making clinical diagnoses according to DSM IV. RESULTS: 1,034 elderly were interviewed in Phase 1. Occasional or persistent sleep disturbance were reported by 75% and insomnia in 38.2% of elderly. Slightly less than half of elderly with sleep disturbance complained of insomnia. Advancing age was associated with a higher rate of sleep disturbance while females had a higher rate of insomnia. Factors associated with sleep disturbance and insomnia included poor perceived health, past history of smoking, current depressive disorders, more chronic physical illness, more life events and more somatic complaints. Only 2.8% of the sample had taken sleeping pills within a one-year period. CONCLUSIONS: Sleep disturbance and insomnia are two separate but overlapping constructs and should be differentiated. Sleep disturbance is very common in the elderly and may be due to physiological changes with ageing. In contrast, those with a concommitant complaint of insomnia have impaired physical and mental health and may merit more medical attention.     

Practice parameters for the indications for polysomnography and related procedures: an update for 2005

These practice parameters are an update of the previously-published recommendations regarding the indications for polysomnography and related procedures in the diagnosis of sleep disorders. Diagnostic categories include the following: sleep related breathing disorders, other respiratory disorders, narcolepsy, parasomnias, sleep related seizure disorders, restless legs syndrome, periodic limb movement sleep disorder, depression with insomnia, and circadian rhythm sleep disorders. Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders; for continuous positive airway pressure (CPAP) titration in patients with sleep related breathing disorders; for the assessment of treatment results in some cases; with a multiple sleep latency test in the evaluation of suspected narcolepsy; in evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; and in certain atypical or unusual parasomnias. Polysomnography may be indicated in patients with neuromuscular disorders and sleep related symptoms; to assist in the diagnosis of paroxysmal arousals or other sleep disruptions thought to be seizure related; in a presumed parasomnia or sleep related seizure disorder that does not respond to conventional therapy; or when there is a strong clinical suspicion of periodic limb movement sleep disorder. Polysomnography is not routinely indicated to diagnose chronic lung disease; in cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated; for patients with seizures who have no specific complaints consistent with a sleep disorder; to diagnose or treat restless legs syndrome; for the diagnosis of circadian rhythm sleep disorders; or to establish a diagnosis of depression.     

Manual der American Academy of Sleep Medicine

In the 2007 manual of the American Academy of Sleep Medicine (AASM), all parameters for a cardiorespiratory polysomnography (PSG) were published for the first time in an evidence-based manner including technical specifications and rules for derivations and scoring. After the regularly planned review and revision, the current version 2.0 was published. The significant modifications and their possible impact on clinical routine in Germany are discussed. The most important changes are related to the measurement and scoring of the parameters of breathing. Only one definition remains for the scoring of hypopneas with a flow decrease of 30?% over at least 10 s associated with either a desaturation of at least 3?% or an arousal. In addition, apneas should be rated if they start or end in an epoch scored as wake whenever the patient showed sleep before or afterwards. The revised version allows the measurement of both apneas and hypopneas using an oronasal thermistor or a nasal pressure transducer in the case the other method is not possible due to technical reasons. Furthermore, the definitions and scoring of hypoventilation and Cheyne–Stokes breathing have changed. Concerning sleep scoring, it should be noted that stage N3 can also be determined using C4-M1 depending on the use of recommended or alternative electroencephalogram (EEG) and electrooculogram (EOG) combinations. Although the now unified rule for the rating hypopneas and the possibility to detect apneas or hypopneas using one method seem to be a great simplification for clinical routine, other recommendations must be proven in practice. With the publication of version 2.0 of the AASM manual, it must be asked whether the procedures of the manual should be mandatory for use in Germany or if at least specific basic principles could also be used with older PSG equipment. From the scientific position, the use of the AASM manual version 2.0 for sleep research is indespensible.     

Familial incidence of insomnia

This study evaluated the familial incidence of sleep disturbances among individuals with insomnia complaints. The sample consisted of 285 patients evaluated for insomnia at a sleep disorders clinic. All patients completed a sleep survey and underwent a semistructured clinical interview as part of their initial evaluation of insomnia. Information on the presence and nature of sleep disturbances among their family members (first- and second-degree relatives) was obtained from a sleep survey. The findings indicate that 35% of patients consulting for insomnia had a positive family history of sleep disturbances. Insomnia was the most common type of sleep disturbance identified (76%) and the mother was the most frequently afflicted family member. Reports of sleep disturbances among a family member were more prevalent when the onset of insomnia was before 40-years-old than when it was later in life. A positive family history was slightly higher when the insomnia complaint involved sleep-onset difficulties relative to sleep-maintenance or mixed insomnias. Although the present findings suggest that a positive family history of insomnia may be a potential risk factor for insomnia, it is unclear whether this reflects a genetic predisposition or a social learning phenomenon.     

Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007

BACKGROUND: Actigraphy is increasingly used in sleep research and the clinical care of patients with sleep and circadian rhythm abnormalities. The following practice parameters update the previous practice parameters published in 2003 for the use of actigraphy in the study of sleep and circadian rhythms. METHODS: Based upon a systematic grading of evidence, members of the Standards of Practice Committee, including those with expertise in the use of actigraphy, developed these practice parameters as a guide to the appropriate use of actigraphy, both as a diagnostic tool in the evaluation of sleep disorders and as an outcome measure of treatment efficacy in clinical settings with appropriate patient populations. RECOMMENDATIONS: Actigraphy provides an acceptably accurate estimate of sleep patterns in normal, healthy adult populations and inpatients suspected of certain sleep disorders. More specifically, actigraphy is indicated to assist in the evaluation of patients with advanced sleep phase syndrome (ASPS), delayed sleep phase syndrome (DSPS), and shift work disorder. Additionally, there is some evidence to support the use of actigraphy in the evaluation of patients suspected of jet lag disorder and non-24hr sleep/wake syndrome (including that associated with blindness). When polysomnography is not available, actigraphy is indicated to estimate total sleep time in patients with obstructive sleep apnea. In patients with insomnia and hypersomnia, there is evidence to support the use of actigraphy in the characterization of circadian rhythms and sleep patterns/disturbances. In assessing response to therapy, actigraphy has proven useful as an outcome measure in patients with circadian rhythm disorders and insomnia. In older adults (including older nursing home residents), in whom traditional sleep monitoring can be difficult, actigraphy is indicated for characterizing sleep and circadian patterns and to document treatment responses. Similarly, in normal infants and children, as well as special pediatric populations, actigraphy has proven useful for delineating sleep patterns and documenting treatment responses. CONCLUSIONS: Recent research utilizing actigraphy in the assessment and management of sleep disorders has allowed the development of evidence-based recommendations for the use of actigraphy in the clinical setting. Additional research is warranted to further refine and broaden its clinical value.     

Sleep fragmentation and daytime sleepiness

It has been noted that clinical populations complaining of excessive daytime sleepiness (EDS) frequently have disrupted or fragmented nocturnal sleep. The relation between sleep fragmentation and daytime sleepiness has not been systematically studied. This study was designed to use correlational techniques evaluating the relation between these variables in patients complaining of EDS, patients complaining of insomnia, and asymptomatic controls. The four groups studied included patients complaining of EDS with sleep apnea (n = 15) or with periodic leg movements (n = 15), patients complaining of insomnia (n = 15), and healthy volunteers with no sleep complaint (n = 10). One night of polysomnography followed by a Multiple Sleep Latency Test was obtained for each subject. Each recording was evaluated using standard criteria and also by a four-level arousal scoring system. Across all subjects, the total number of arousals correlated significantly with sleepiness index (r = 0.48, p less than 0.001). Closer analysis of the data shows that, depending upon the sleep complaint, different types of arousals are predictive of degree of daytime sleepiness. It is concluded that the number and type of nocturnal arousals play an important role in subsequent daytime sleepiness.     

Medical therapy for obstructive sleep apnea: a review by the Medical Therapy for Obstructive Sleep Apnea Task Force of the Standards of Practice Committee of the American Academy of Sleep Medicine

A significant number of patients with obstructive sleep apnea neither tolerate positive airway pressure (PAP) therapy nor achieve successful outcomes from either upper airway surgeries or use of an oral appliance. The purpose of this paper, therefore, was to systematically evaluate available peer-reviewed data on the effectiveness of adjunctive medical therapies and summarize findings from these studies. A review from 1985 to 2005 of the English literature reveals several practical findings. Weight loss has additional health benefits and should be routinely recommended to most overweight patients. Presently, there are no widely effective pharmacotherapies for individuals with sleep apnea, with the important exceptions of individuals with hypothyroidism or with acromegaly. Treating the underlying medical condition can have pronounced effects on the apnea/hypopnea index. Stimulant therapy leads to a small but statistically significant improvement in objective sleepiness. Nonetheless, residual sleepiness remains a significant health concern. Supplemental oxygen and positional therapy may benefit subsets of patients, but whether these therapies reduce morbidities as PAP therapy does will require rigorous randomized trials. PAP therapy has set the bar high for successful treatment of sleep apnea and its associated morbidities. Nonetheless, we should strive towards the development of universally effective pharmacotherapies for sleep apnea. To accomplish this, we require a greater knowledge of the neurochemical mechanisms underlying sleep apnea, and we must use this infrastructure of knowledge to design well-controlled, adequately powered studies that examine, not only effects on the apnea/hypopnea index, but also the effects of pharmacotherapies on all health related outcomes shown beneficial with PAP therapy.     

Sleep Quality and Psychological Adjustment in Chronic Fatigue Syndrome

Without specific etiology or effective treatment, chronic fatigue syndrome (CFS) remains a contentious diagnosis. Individuals with CFS complain of fatigue and poor sleep—symptoms that are often attributed to psychological disturbance. To assess the nature and prevalence of sleep disturbance in CFS and to investigate the widely presumed presence of psychological maladjustment we examined sleep quality, sleep disorders, physical health, daytime sleepiness, fatigue, and psychological adjustment in three samples: individuals with CFS; a healthy control group; and individuals with a definite medical diagnosis: narcolepsy. Outcome measures included physiological evaluation (polysomnography), medical diagnosis, structured interview, and self-report measures. Results indicate that the CFS sample had a very high incidence (58%) of previously undiagnosed primary sleep disorder such as sleep apnea/hypopnea syndrome and restless legs/periodic limb movement disorder. They also had very high rates of self-reported insomnia and nonrestorative sleep. Narcolepsy and CFS participants were very similar on psychological adjustment: both these groups had more psychological maladjustment than did control group participants. Our data suggest that primary sleep disorders in individuals with CFS are underdiagnosed in primary care settings and that the psychological disturbances seen in CFS may well be the result of living with a chronic illness that is poorly recognized or understood.     

Sleep and health: research and clinical perspectives

Overall, the Workshop covered most of the principal areas which will be the focus of the Worldwide Project on Sleep and Health. Presentations ranged from the basic science of melatonin receptors to the epidemiology of untreated insomnia, and finally, to the education of primary care physicians. It was emphasized that there is a need for more data, and new experimental paradigms are necessary for successful public health initiatives dealing with sleep disorders.     

Wrist actigraphy in insomnia.

To assess the use of actigraphy in evaluating insomnia, 36 patients with a serious complaint of insomnia slept 3 nights each in the laboratory, where the usual polysomnograms (PSGs) were obtained as well as actigraphic assessments of their sleep. Patients also wore actigraphs for 7 days at home, were extensively interviewed and filled out psychometric tests. Based on all this information, the patients were then diagnosed according to the International Classification of Sleep Disorders. Averaged over the 3 nights for each insomniac, the mean discrepancy between actigram and PSG was 49 minutes per night. In three-fourths of the cases, actigram and PSG agreed to within 1 hour on the total amount of sleep per night. Discrepancies, however, were not random: In patients with psychophysiologic insomnia and in insomnia associated with psychiatric disease, the actigram typically overestimated sleep when compared with the PSG. In patients with sleep-state misperception, the actigram was either quite accurate or it underestimated sleep when compared with the PSG. Comparing laboratory with home sleep, one-third of all insomniacs slept better in the laboratory and two-thirds slept better at home. In addition, night-by-night variability was higher at home than in the laboratory. Based on our study, we now recommend actigraphy as an additional tool in the clinical evaluation of insomnia, but we believe that in complex cases it should be combined with 1 PSG night in the sleep disorders center.     

Predictors of Interest in Psychological Treatment for Insomnia Among Older Primary Care Patients With Disturbed Sleep

In this study, we examined whether the common sense model of illness representation (CSMIR) could be successfully used to predict interest in cognitive-behavioral treatment for insomnia (CBT-I) among older primary care patients with disturbed sleep. The Sleep Impairment Index (C. M. Morin, 1993) was used to assess sleep disturbance and the constructs of the CSMIR in primary care patients ages 55 and older. Statistical analyses showed that the CSMIR constructs of consequences (perceived adverse consequences of sleep disturbance to functioning), causes (attributing one's insomnia to bad sleeping habits), and emotion (concern about one's sleep problem) predicted interest in CBT-I. These data provided encouraging support for the ability of the CSMIR to accurately predict patient interest in treatment for insomnia. Implications for assessment and treatment of insomnia in primary care are discussed.