Unmet Needs in Treating Insomnia - Episode 3
A panel of experts break down the myriad of insomnia causes, discussing prevalence amid different patient populations.
Michael J. Thorpy, MD: There are many causes for insomnia. Nate, perhaps you could tell us a little about how disturbed sleep patterns contribute to medical psychiatric disorders, which contribute to insomnia. How do everyday lifestyle events, the psychosocial aspects, contribute to insomnia?
Nathaniel Fletcher Watson, MD: Thanks, Michael. Sleep is something that happens given the right circumstances, it’s not something that you do. In today’s day and age, it can be a challenge for people to clear the mind and allow sleep to happen. In many ways, we live in a toxic environment for sleep. When we look at psychosocial factors and environmental factors—ambient lighting, temperature, noises—the sleep environment might not be conducive to sleep. The sleep of a bed partner or other people in the home can also disturb an individual’s sleep. A lot of things out there can be problematic. We talk about comorbidities. As sleep physicians, we’ve got to think about obstructive sleep apnea, restless leg syndrome, and circadian rhythm sleep disorders, like the wake-sleep phase syndrome. These can have an insomnia component that may or may not get better when you treat the primary problem.
Let’s move on to psychiatric illness, which has such a tight association with insomnia, particularly depression and anxiety, bipolar disorder, and schizophrenia. Then we have neurological and medical illnesses, multiple sclerosis, Parkinson disease. Pain, chronic pain, cancer—sleep is something that affects nearly every aspect of our physiology, so it’s not surprising that when our physiology breaks down, when we have disease processes, that’s going to impact our sleep and cause insomnia problems.
Michael J. Thorpy, MD: We’ve talked about the symptoms of insomnia. We’ve talked about the causes of insomnia. How common is this? Karl, I’ll bet there are certain groups where insomnia is more common. What is a general prevalence of insomnia?
Karl Doghramji, MD: Insomnia is 1 of the most prevalent complaints known to man. Some international studies have estimated it’s the second most common complaint, with the first being upper-airway symptoms. We also know that an insomnia disorder, as Erinn described, occurs for 3 months or longer, causing distress, functioning issues, and so on. It occurs in 5% to 10% of the population at any time, so it’s a very common problem.
The prevalence of insomnia seems to increase in certain settings—for example, medical settings. In physicians’ offices, psychiatric settings, 30% or 25% of primary care patients had insomnia. Around 80% of psychiatric patients have insomnia, depending on whether it’s inpatient or outpatient. What’s interesting about these prevalent data in medical settings is that the recognition of insomnia is extraordinarily low from both patients and physicians. We conducted a chart study of inpatients at my institution [Jefferson Medical College]. Of 100 inpatients, 80 had significant insomnia, which put them at a diagnostic categorization of insomnia disorder. Guess how many patients had a diagnosis of insomnia on the chart? Zero. The recognition of insomnia as a problem worthy of clinical consideration unfortunately isn’t common in medical settings.
One final thing I’d like to mention is the comorbidities of insomnia. There seems to be a bidirectional relationship between the comorbidities of insomnia and insomnia itself. This is particularly apparent in depression and psychiatric disease, where we see that the problems with insomnia often predict the onset of depressive disorders. And fomenting insomnia seems to foment underlying psychiatric disease. What’s also interesting is that we have some studies suggesting that the management of these insomnia complaints may impart some benefit in terms of psychiatric disease.
Michael J. Thorpy, MD: What about age-related factors, Karl? How often do we see insomnia in children? We know that insomnia is a little more common in older adults, but how common is it in the childhood age range?
Karl Doghramji, MD: In children, it’s more common than we used to think. We used to discard it as being an unimportant problem in children. But adolescents have difficulty with delayed sleep phase disturbances, which tend to delay the circadian rhythms. Even in younger children—2- or 3-year-olds who have difficulty with phobias, fear of ghouls and monsters that emerge from the closet—these seem to have a strong influence on nightmares and causing insomnia and difficulties with sleep. They’re much more common than we think.
Michael J. Thorpy, MD: Do you see this in your practice, Erinn? Do you see parents bringing in their children and complaining that they have trouble sleeping?
Erinn E. Beagin, MD: Thank goodness I don’t do pediatrics. My husband does, and it’s common. They’re not falling asleep, or they’re waking up. “They’re trotting into my room in the middle of the night, waking us up.” It’s definitely a complaint, and a lot of times it’s more behavioral than treating it. As you said, it has its own entity.
Michael J. Thorpy, MD: How about in the older adults you see? Do they tend to have more insomnia? Do they bring it up to you and mention it to you?
Erinn E. Beagin, MD: The key is asking. Some will definitely bring it up if they’re functioning well during the day. A lot of times they think it’s a normal part of aging, but it isn’t. Plenty in my older population sleep well during the night, and they always have. Interestingly enough though for the patients who do come in, my older patients, there is a long history of it. It may have been episodic, at different parts or times of their lives, but it’s definitely a common complaint in the older population.
Nathaniel Fletcher Watson, MD: Healthy aging doesn’t necessarily mean sleep problems are going to be present. In other words, as we age if we don’t have a lot of comorbidities or other issues, our sleep should remain healthy, and we should not have insomnia. That’s something to think about. In regard to adolescent sleep, 1 reason the American Academy of Sleep Medicine and other organizations are fighting so hard to delay school start times to 8:30 AM or later for middle and high schools is because when schools start much earlier, adolescents—who can’t fall asleep before 11 PM—haveto go to bed earlier to get the recommended amount of sleep. As a result, they’re going to bed when their circadian rhythms are not telling them to sleep. Thus, they can begin to develop insomnia that can then perpetuate over time. This insomnia is another issue arguing for delaying school start times.
Michael J. Thorpy, MD: We all agree that insomnia is very common. Everybody at some stage in their life experiences sleep disruption—100% of people are going to have some sleep disturbances at some point.
Transcript edited for clarity.