clinical management, adult Flashcards
Cognitive therapy indications and rationale
Primary or co-morbid insomnia, acute or chronic
Indication: those with dysfunctional beliefs about sleep
More helpful for those with psychophysiological or paradoxical insomnia, rather than idiopathic insomnia
Rationale: target sleep-related beliefs that are presumed to contribute to maintenance or exacerbation of insomnia
Appraisal of a situation (sleeplessness) can trigger negative emotions (fear, anxiety) that are incompatible with sleep
What are the Steps of Cognitive therapy?
Steps:
Identifying negative automatic thoughts
Connections between cognitions, emotions, thoughts
Examine evidence
Substitute more realistic interpretations
learn to identify and modify core beliefs
DBAS
Dysfunctional beliefs and attitudes about sleep
30 item scale
16 item short form
Pick strongly held beliefs
What are outcomes for cognitive therapy
Key component of multi-component therapy
Plays a role in positive outcomes and long term remission
What do we know about CPAP adherence?
Self report is unreliable
Use across studies averages ~5hrs/night mean of use
29-83% reported to be nonadherent
Half the patients are consistent users averaging ~6hrs/night
Patients decide early to be nonadherent (~4 nights in)
If you skip 1 night of CPAP, back to baseline on many variables
~25% patients d/c treatment within 1st year of use
How long do you need to use CPAP?
For Daytime sleepiness: ~4 hrs Objective sleepiness (commercial driver, ~6hrs). MSLT <7 to MSLT >7
What is not a strong determinant of CPAP adherence?
Age, gender, disease severity, BMI, symptom severity
Other aspects of CPAP adherence
Split night study: no difference in adherence form split night vs full night
ADX vs UDX study does matter
Best predictor is change in SE
The mask does not make a difference: no difference in nasal vs FFM
Better quality sleep and less pressure discomfort with AutoPAP
Better QOL with auto-titrating
Flexible pressure: pt can set pressure within a range
can work because it can build self-efficacy and control
Not a psychological abnormality
If it’s the the patient’s idea, then more likely to be active in treatment
Active but not passing coping (confrontive coping, planful problem solving)
Person’s perception and opinion matter
Maladaptive behavior (social isolation, emotional reactions)
Claustrophobic tendencies
What are predictors of adherence in 1st week?
3 main factors:
Race (Black less adherent, ?SES factors)
Residual events
Risk perception (if thought they were at risk, then would use CPAP)
Does the nose make a difference? Volume
Claustrophobia and adherence to PAP:
higher claustrophobia scored 2x likely poor adherence (avg use <2hrs/night)
claustrophobia scores decreased over time in some
Humidification: conflicting data
What domains make up the bio psychosocial model?
Psychological domain: person, illness, treatment
Social domain
Biomedical domain
Education alone does not work to improve adherence
Component you have to have, but won’t work on its own
What medication can you use for residual sleepiness and adherence
Modafanil can help
What are the critical elements of CPAP adherence?
Pretreatment: Who referred patient? Knowledge of OSA/perception of treatment degree and awareness symptoms How do they handle challenges? Assess claustrophobic tendencies Consult ENT Mask selection Early exposure to treatment spousal involvement
On-treatment: Humidification, if needed phone call/follow-up visit 1st week Assessment of use and outcome: use of apps/software perception of treatment Bed partner experience Troubleshoot problems immediately: telehealth Treat residual sleepiness
What is Motivational Enhancement Therapy?
MET is for motivating adherence to PAP therapy in OSA
Specific indication:
Recent dx of OSA
judged to be good responders to PAP: AHI<10 on PAP titration study, remission of snoring,
arousal index<10; PLM index <15
What are contraindications to MET?
Serious medical condition: (COPD, ESRD, severe COPD, severe asthma). These conditions cause increased EDS and no improvement with PAP therapy
Hx of or current Dx of major psychiatric illness (including current substance abuse) with exception of depression. Makes it hard to participate in Tx.
Cognitive impairment due to dementia
What is rationale for MET?
25% of patients d/c PAP within 1st year of use
Willingness and motivation fluctuate for Tx
Motivational interviewing, help to resolve ambivalence,
Focus on perceived importance of change and their confidence that they can maintain a new behavior
What is the “Elicit-Provide-Elicit” strategy in MET?
Used during feedback
Designed to reduce likelihood of patient denial and defensiveness
Therapist asks an open-ended question (“elicit”), shares information (“Provide”), and follow up with another open-ended question (“Elicit”) to learn the patient’s reaction
Adopt curious, eliciting and non-judgemental tone, calibrating session to patient’s level of readiness to change, and exploring patient ambivalence about change.
Goal is to develop intrinsic motivation to use Tx, enhance long-term adherence
Session 1 for MET
Patient assessment of PAP during titration night
Patient assessment of PAP during titration night
Ask re: experience of using PAP in sleep study
Assessment of motivation to use PAP (1-10)
Info exchange (video clip of OSA pt)
Review pre-treatment PSG
Place AHI on graph, mild/mod/severe
graph of oxygen sat
Review of sx (primary sx that let to seek tx)
Mortality graph: cumulative survival rates according to categories of PAP compliance:
significantly higher cumulative survival rates for those who use PAP>6 hrs and those who use it 1-6 hrs, compared to those who use it <1 hr
Session 2
Patient’s subjective appraisal of adherence to PAP
Values assessment Decisional balance Review of reaction time on and off Tx PAP benefits for health and functioning Cognitive benefits of SA treatment Assess motivation and confidence Explore and identify experienced or anticipated barriers to PAP use Renegotiate plan based on readiness and confidence
Phone call in MET
Self-report PAP use
Building confidence to use PAP
Summary
Research MET
MET vs standard care vs education
ED and MET > SC at 3 mos
MET= best for ambivalence (used 2-5 hrs/night in 1st week
6 months only MET demonstrated significance
Exposure therapy for Claustrophobic reactions to PAP therapy
Claustrophobia = extreme anxiety/panic in situations such as tunnels, elevators, person feels trapped
Rachmaninov and Taylor 2 core fears: fear of restriction, fear of suffocation
Development of fears explained by 2 factor model by Mowrer (fear reactions initially developed by classical conditioning and maintained through operant conditioning
CPAP can elicit memories of original UCS or set of circumstances that elicit claustrophobic response (military vets, trauma, bad exp w/ pap)
Exposure breaks the link between anxiety and avoidance response
What is the Procedure for Exposure therapy
1-6 sessions over 1-3 months
Session 1: assessment, education, implement exposure therapy (Tx rationale, exposure hierarchy,
goal setting/homework
Sessions 2-6: assess adherence to homework, monitor progress, problem solve, in-session exposure trial (if indicated) provide feedback
Research: 1/3 of people report claustrophobic reactions to CPAP
Exposure yields large effect size
Sleep Apnea self-management program
Need referral to claustrophobia protocol if that is the presenting concern
Focus is on education, sleep testing, sleep apnea, CPAP therapy
How is chronic illness defined?
Gradual onset Lengthy or indefinite duration Multivariate causation (which may change over time) Focus on functional status rather than individual diagnoses OSA better characterized as chronic rather than acute disease
What is chronic disease self-management?
Systematic behavioral approach to help patients with chronic conditions participate actively in self-monitoring of systems or physiologic processes, decision making (i.e. managing the disease or its impact, based on self-monitoring), and problem-solving
disease, medication, and health management
Role management
emotional management
How is Self management program carried out?
Group size 3-6 patients
4 sessions 1-2 hrs each
CBT to increase adherence to CPAP
Psychoeducation in presentation format (discussion, emphasis questions)
Social cognitive therapy (how people learn by modeling)
self efficacy
outcome expectations
Stages of change
Video and discussion for modeling
Stages of Change from Transtheoretical Model
Precontemplation: no intention to change, i.e. snorer can’t see the problem, can’t see “what all the fuss is about”
Contemplation: “fence sitting”, some recognition there may be a problem with snoring/apneas, May need to do something about it. Change often triggered by bed partner moving out of shared bed.
Preparation: change in both intention and behavior. Consult w/ PCP re: snoring/apneas is example of patient showing that he understands the problem and is now prepared to take some action. Referral to sleep specialist, PSG, etc.
Action: relates to how patient modifies his behavior, experience, and/or environment to make the necessary change. Learning about OSA, learning about CPAP, what it does, undergoing titration study, being committed to Tx for specific time period, learning to seek help.
Maintenance: undertaking CPAP for at least 6 mos. Patient taking ownership of having OSA and the undertaking that this Tx intervention gives health and life choices. Continually update and seek help when there are mask/machine problems
Relapse: needs to be seen as normal, generally not possible to use mask/machine all the time. What is important is what the patient does during the relapse period, how can get back on track, for example cold/flu/traveling has been resolved. Relapse if the rule, not the exception
Avoid of supine posture during sleep for patients with supine-related sleep apnea
Positional therapy
Recommended for patients with any breathing abnormality during sleep:
obstructive apnea
mixed/central apnea
UARS, most of breathing issues while sleeping in supine position
Sleeping in other positions, the severity of events reduces to AHI <5-10
patients w/o OSA, but snore supine
patients who have not responded to other treatments and mainly struggle while supine
Rationale for Avoidance of supine posture during sleep
Supine problems are high (55.9% had at least twice as many breathing problems while supine)
Prevalence of supine disturbance is much higher (65-69%) in patients with mild/mod. OSA
Mild OSA is less likely to succeed with CPAP
What is the Procedure for positional supine therapy?
Any form of therapy with will help patients roll back onto their side at night
Tennis ball technique: Tennis ball in wide cloth band or belt attached to waist, when patient
rolls over onto back, pressure causes them to roll back over
An Alarm system: momentarily wake up when rolling onto back
The Sleep positioner: Device consists of foam block placed on back
The positioner
The BPOD unit: located on midline of chest and will detect position
Thoracic anti-supine board
The supine position prevention vest
Zoma positional sleeper
Vest-type design
What is Imagery Rehearsal Therapy (IRT) ?
Indicated for chronic nightmares, sometimes used in acute
Disturbing dreams and/or nightmares , regardless of nighttime awakening
Belief that chronic nightmares appear to be driven by a conditioning process-function as a learned behavior
Common co-morbidities in nightmares: anxiety, depression, PTSD
Contraindications:
caution with PTSD and daytime imagery concerns (e.g. flashbacks, daycares, trauma memories)
Inability to access imagery system
No evidence that IRT works w/parasomnias, RBD, hypnagogic hallucinations
consider whether PTSD needs to be the focus of therapy
What is the rationale for IRT
IRT views nightmares as a learned behavior (bad things= bad dreams)
Nightmares occur frequently in childhood and adolescence
6.8% of sample (mean age 17) w/nightmares
20% in 11-14 years old
Peak in early childhood (2.5 yrs, 42%), followed by progressive decline to adolescence with final prevalence of 7.3% (16 years)
Adults: 40% report onset before 15 years old
>50% of chronic nightmare sufferers developed nightmares before age 20
Other aspects of nightmares
nightmares may represent specific marker for hx of sexual trauma in abused children and teens
common for residual nightmares after successful PTSD treatment
What are the 3 steps to IRT?
Selecting a nightmare, facts about the nightmare
changing it as you wish
rehearsing the new set of images in a waking state
Facts about nightmares
link between nightmares and sleep problems
fear of nightmares provoking sleep onset insomnia
Fear of returning to sleep post-nightmare provoking sleep maintenance insomnia
Nightmares appear to fragment sleep and thus degrade sleep quality
Raise questions about cause of nightmares:
what is initial cause of cause of nightmares:?
why do nightmares persist in some people?
what might it mean is nightmares have not responded to tx w/meds or psychotherapy?
Is it possible to imagine we have more control over nightmares that we might have thought possible?
Practicing pleasant imagery in IRT
opportunity to assess visualization exercises that patient has ability to create images and monitor for unpleasant images
7 simple behavioral techniques are taught (thought stopping, breathing, grounding, talking, writing, acknowledging, and choosing)
what are the key points of imagery phase of IRT?
imagery is natural component of human brain
imagery is accessed repeatedly throughout the day to solve problems- for ex, remember where you put something, driving instructions
capacity to actively engage one’s imagery system: “active daydreaming” or “guided daydreaming”
imagery exercises are not meant to be intense efforts yielding meditative or hypnotic-like states; they may or may not be comfortable.
Best to evoke pleasant images when re-engaging the system.
Goal=imagery is naturally occurring form of thinking
with practice of pleasant imagery, it becomes clear that the mind can influence some of the images that emerge in the mind’s eye.
If images can be influenced in a waking state, might not such influence extend to sleep state?
3 step process of IRT
Write new dream for learning purposes
Practice rehearsing pleasant dream for 5-20 min per day for 1 month
No more than practicing 2 “new dreams” per week
f/u at 4 and 12 weeks to review process
Some additional notes re: IRT
discourage practicing more distressing dream first: learn process first.
Avoid giving suggestions for the new dream
Never offer examples of a changed dream until they try for themselves.
what are modifications/variants of IRT?
Group vs indiv- more RCT using groups
longer vs shorter treatment time: 7-10hrs for goups, less for individual
more vs less exposure de-emphasizes exposure, but some aspects of talking about nightmares is inherently exposure
More info about the SCN
located behind eyes
light information communicated from IPRGCs
IPRGCs contain melanopsin
melanopsin is a photopigment sensitive to short-wave (blue-green) light
IPRGCs send excitatory input to SCN via Retino-hypothalamic tract (RHT)
SCN neurons generate circadian rhythms through transcription-translation molecular feedback loops
self sustaining every 24.12 hrs
circadian clock gene feedback loops present in virtually all cells in body.
How do we leverage the SCN?
Bright light for advanced sleep phase
DSWPD, Dx criteria?
Significant delay in phase of major sleep period (> 2 hrs relative to socially acceptable time)
Sx present 3 months
Ad lib sleep improves sleep quality, quantity, consistency
associated features: sleep initiation insomnia, alcohol and hypnotic use at BT
delay during teen years
7% of population
longer tau
what is Tx for DSWPD?
Align sleep schedule to natural delayed phase
Dim light 2 hrs prior to BT
Bright light only after CBTmin
0.3-0.5 mg melatonin 2-6 hrs prior to bedtime
Advanced Sleep Wake disorder (ASWPD)
Dx criteria
Significant advance in phase of major sleep period (> 2 hrs relative to socially acceptable time)
Sx present x at least 3 mos
Ad lib sleep improves sleep quality, quantity, consistency
associated features: early am awakening, Est. 1% of population likely low (less likely to be seen as problem)
Tau <24 hrs
What is treatment for ASWPD?
Bright light in evening
Avoid bright light in morning
Irregular sleep wake rhythm disorder (ISWRD)
Dx criteria
Associated features
Absence of well-defined circadian pattern to sleep-wake cycle
TST comparable to healthy same-aged peer but lacks major sleep period across 24 hr day
3 or more sleep episodes (1-4 hr each) w/ longest period typically occurring between 2-6 am
Sx present for at least 3 months
Associated features:
Most commonly associated w/ AD, other neurodegenerative d/o
Env disruptions: ICU, hospital, rehab units
Hypnotics contraindicated
ISWRD
Treatment
Increase circadian amplitude: sleep hygiene, meal timing, social activities, AM bright light
Melatonin as a mono therapy may have negative effects on mood
Hypnotics contraindicated
Non-24 hour Sleep-wake disorder (N24SWD)
Diagnostic criteria
Associated features
Diagnostic criteria:
Pattern of circadian misalignment will typically present as relatively steady, continual delay in sleep-wake timing
Sx present x 3 months
Associated features:
Can present as periods of insomnia, EDS, or asx depending upon when individual is trying to sleep relative to his/her circadian period
N24SWD most commonly found in individual who are blind (13-50%)
Rare/controversial in sighted individuals (DSWPD with long tau?)
What is treatment for N24SWD?
Sighted individuals w/ N24SWD: same as for DSWPD
Melatonin receptor agonist (ramelteon, tasimelteon) or melatonin (<0.3mg)
Administer 1-2 hrs before desired bedtime
Once entrainment is established over the course of a month, can switch to melatonin (<0.5mg)
2-6 hrs before bedtime to maintain entrainment
Jet lag Disorder
Dx criteria
Associated features
Dx criteria:
Complaints of insomnia or EDS and decreased TST assoc w/ jet travel across at least 2 time zones
Assoc daytime impairment (fatigue, malaise, decision-making, reaction times, athletic performance)
And/or Somatic complaints (GI disruptions)
Occurs within one to two dats after travel
Associated features:
Limited data suggests increased difficulties for middle to older adults (>50 yo) vs younger (<30)
Limited data suggests that jet lag could precipitate a relapse of depressive episode (for westward travel) or a hypo manic episode (for eastward travel)
What is treatment for Jet lag disorder?
As a general rule for infrequent travelers: maximize daytime light!
Westward travel: strategies for delaying sleep (clock needs to shift later)
evening light approaching CBTmin to provide the greatest delaying effects (seek light 4 hrs
before CBTmin, avoid light 4 hrs after CBTmin
Avoid bright light in the morning for the first few days
Eastward travel: strategies for advancing sleep (clock need to shift earlier in time)
Avoid bright light in the evening, seek bright light in the morning
Avoid light 4 hrs before CBTmin and seek light 4 hrs after CBTmin
When eastward travel exceeds 9 time zones, it becomes more advantageous to make any adjustments as if the trip were a 14 hr westward journey
Shift work disorder (SWD)
Diagnostic criteria
Diagnostic criteria:
Complaints of insomnia and/or EDS along with insufficient TST
Difficulties caused by a work schedule that routinely occurs during habitual sleep time
Sx present for at least 3 months
Most harmful to least:
night shift, rotating, early morning, afternoon/evening, daytime
Duration shift work: hours per shift (>12 hrs/shift), no. Of years engaged in regular shift work
Direction of rotation (counterclockwise worse Than clockwise)
Speed of rotating shift work: faster rotation (i.e. multiple rotations within 1 week), may be worse that slower rotation
What are associated features of Shift work Disorder?
2004: 13.5% US engages in shift work
22 million shift workers in US alone (2018)
Increased risk for metabolic, CV, reproduction, GI, mood, substance use and other sleep d/o
Known probable carcinogen (WHO, IARC)
What is treatment for Shift work disorder?
Best treatment= stop shift work if possible!
Stimulants (modafanil) approved to increase alertness during shift work
Match work shift with circadian profile of employees
Use of sedatives not recommended
Align as close to natural sleep-wake rhythm as possible
Increase amplitude of circadian signals
Estimate CBTmin for strategic light therapy
FEO support entrainment
Scheduled naps
Paradoxical intention
Good for: intense preoccupation w/sleep, sleep-related anxiety too much effort
Contraindications: Those w/ concrete approach, need more seasoned behavioral sleep therapist
Rationale: Because sleep is a voluntary process, attempts to put it under voluntary control will likely make it worse.
Contemporary understanding of PI fits w/ psychobiological inhibition/attention-intention-effort model where mental and behavioral focus on sleep process is regarded as inhibitory to sleep engagement
What is process for Paradoxical intention?
Consider sleep “normalcy”
Measure sleep normalcy (can use sleep effort scale)
Develop formulation of insomnia as sleep effort syndrome
Draw helpful parallels
Give up trying to sleep:
Method 1: turn the tables and be carefree about insomnia
Method 2: try to stay awake as long as possible
Use of humor
PI is embedded in all aspects of CBT
PI has evidence as standalone therapy
Sig reductions in SOL and WASO
PI often included in CBT
Relaxation strategies
Use w/ heightened somatic and/or cognitive arousal
More effective for sleep onset arousal
What is Benson’s Relaxation response technique?
4 procedural elements to focus on: Quiet environment Object to dwell on Passive attitude Comfortable position
PMR and Dr. Edmund Jacobson
Dr. Edmund Jacobson invented PMR in 1920’s as way to help his patients delay w/ anxiety
He felt that relaxing the muscles could relax the mind as well
PMR involves tightening one muscle group while keeping the rest of the body relaxed and then releasing the tension
PMR often combined with breathing exercises or mental imagery
Other aspects of Relaxation strategies
Prescribe 2 relaxation exercises per day: one at night and one during the day
Allow for few weeks of daytime practice before nighttime
Relaxation should not be done while waiting to fall asleep
What is Premack principle?
Making more preferred activities contingent on less preferred activities (e.g. do relaxation before watching TV)
What are possible Relaxation activities?
PMR Autogenic training (imagine peaceful scene, repeats phrases to self) Meditation (yoga, mindfulness) Imagery Biofeedback
What data supports Relaxation strategies?
There is support for mono therapy, CBTI, and other multi component therapies
AASM supports as primary treatment for insomnia
Sleep Restriction Therapy (SRT)
Gross indication: Insomnia, including beginning, middle and end of time spent in bed
EBT for older adults
Specific indication: For sleep difficulties in which subjective SE based on 1-2 wk sleep log is <85%
Or <80% in older adults
Contraindications: individuals that need to maintain optimal vigilance to avoid serious accidents (long haul truck drivers, air traffic controllers)
Conditions that are exacerbated by sleepiness or deep sleep (epilepsy, parasomnias, SDB)
One of the most reliable ways to strengthen homeostatic sleep drive and increase propensity for sleep during upcoming nights
SRT, rationale for intervention
Rapid sleep onset and well-consolidated night of quality sleep (core goals or insomnia tx) are achieved rapidly and reliably at start of SRT
According to 3P model of insomnia, behavioral principles and cognitive tendencies that perpetuate sleep disturbance are often the most promising targets for intervention (many perpetuating factors: spending too much TIB, anticipatory anxiety about prospects for sleep, inordinate concern re: daytime performance deficits, are addressed by SRT)
SRT tightens regulatory control of sleep by endogenous circadian pacemaker
What are the procedures for SRT?
Early phase:
2 week sleep log
Initial TIB = Avg TST (no < than 5 hrs sleep)
If SE>90% (85% in seniors), TIB increased by 15 min
If SE< 85% (80% in seniors), TIB decreased to avg TST
If SE 85-90%, no changes made
Middle phase:
Follow above SE guidelines for extending or decreasing sleep
Completing SRT:
Satisfying nocturnal sleep
Good daytime functioning
Endpoint should be max TIB w/o compromising SE
Modifications:
TIB +30 min initially
Sleep compression
Approach that avoids the shock of radically reduced TIB
Goal: decrease TIB-TST discrepancy by cutting back TIB in incremental parts over the next several weeks (~6 weeks)
What are the steps of Sleep compression?
2 week sleep diary
Starts w/modest decrease of TIB
Start with 1/2 the difference between baseline TIB and baseline TST (e.g. 2 hr discrepancy, can cut 120 min by 20 min. For 6 weeks)
Adherence generally better
Prescribed bedtime rather than “go to bed when sleepy”
If goal is reached early, “hold the course” for a few weeks to ensure
Effective as mono therapy and multi component
Stimulus control
What is the rationale?
Cues are associated emotional reactions
The bed and bedroom has become cues for distress and frustration of trying to fall asleep
Internal cues: mind racing, anticipatory anxiety, physiological arousal
External cues: bed, etc.
Stimulus control
What is the goal?
What are the rules?
Goal is to re-associate the bed and bedroom with sleep
- Get out of bed after 15-20 min if unable to fall or return to sleep and go to another room
- Engage in quiet activities outside of bedroom (e.g. TV, reading) until you feel very sleepy. Do not exercise, eat, smoke or take showers or baths. Do not lie down or fall asleep when not in bed
- If you return to bed and still cannot fall asleep within 15 min., repeat step 2. Do this as often as necessary throughout the night
- Set your alarm and get up at same time every morning
Sleep hygiene
Maintain regular mealtimes Wind-down for the hour before bed Limit liquids in evening Avoid caffeine witching 6-8 hrs of bedtime Do not consume ETOH too close to bed Do not smoke before bed or during the night Avoid napping Exercise regularly Create a sleep-friendly environment Stay in bright light in the morning Limit bright light in the evening
Systematic desensitization
Develop a hierarchy of fear-invoking activities or thoughts from least to most frightening with the child
These activities or thoughts are paired with a relaxing activity
What are strategies for Treatment compliance?
Motivational interviewing
AASM clinical practice guidelines for Drug Tx chronic insomnia in adults
Weak recommendation for: suvorexant lunesta zalpelon zolpidem triazolam temazepam ramelteon doxepin
Recommendation to not use: trazodone tiagabine diphenhydramine melatonin tryptophan valerian
AASM guidelines for TX of chronic insomnia
CBT-I is standard of Tx
carries favorable benefit : risk ratio
all patients w/chronic insomnia should receive CBT-I as primary intervention
Meds for chronic insomnia should be considered mainly in the following patients:
1. unable to participate in CBT-I
2.Still have symptoms despite participation in CBT-I
3. In select cases, temporary adjunct to CBT-I
May 2016, the American College of Physicians published its own clinical practice guideline for the management of chronic insomnia.
This guideline makes two major recommendations
The first is that all patients with chronic insomnia
receive CBT-I as the initial treatment intervention. This is a strong recommendation based on moderate quality evidence.
The second is that a shared decision-making approach be employed by clinicians in determining whether pharmacotherapy should be employed for those patients who did not achieve
adequate response with CBT-I (weak recommendation based
on low quality evidence).
What is the incidence of Insomnia?
Occasional, short-term insomnia affects 30% to 50% of the population.
The prevalence of chronic insomnia disorder in
industrialized nations is estimated to be at least 5% to 10%.
