Gentry: UNR Grand Rounds Flashcards by Megan Foggia

Criteria for insomnia?

A. 1 or more of the following: difficulty falling asleep, staying asleep, or early waking with the inability to fall back asleep

B. Sleep disturbance causes clinically significant distress or impairment in functioning

C/D. Sleep difficulty occurs at least 3 nights a week for at least 3 months

E. Sleep difficulty occurs despite adequate opportunity to sleep

F. Insomnia is not better explained by another sleep-wake disorder (i.e. narcolepsy)

G. Insomia is not attributable to a substance abuse

H. Co-existing mental/medical disorders don’t explain the insomnia

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What percentage of primary care patients experience insomnia? How many mention the problem? How many seek treatment?

50%;
1/3;
5%

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Up to (blank)% of adults are impacted by insomnia on a chronic basis

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Increased rates of insomnia in these groups…

women
older adults
pts with chronic medical/psych problems

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T/F: Individuals with chronic insomnia compared to those without insomnia have more difficulty with intellectual, social, and/or vocational functioning.

True

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Poor sleep increases risk for development of widespread (blank)

pain

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Cost of insomnia annually?

100 billion dollars

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Patients with insomnia more likely to suffer from these conditions…

pain
GI distress
HTN
heart disease
diabetes
depression

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Depression disturbed sleep is associated with increased symptom severity, slower/lower rates of remission, higher treatment dropout rates, less stable response to treatment, and (blank)

increased suicide risk!

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Insomnia is predictive of (blank) thoughts and behaviors

suicidal

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What is the largest group of insomnia sufferers at sleep clinics?

major depression and insomnia

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(blank) is prevalent after treatment for depression

residual insomnia

**also the case for PTSD

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What are these?

Zolpidem (Ambien)
Sopidem ER
Zaleplon (Sonata)
Eszopiclone (Lunesta)

nonbenzpdiazepines

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Pros of non-benzos?

Cons?

pros: bind to sub-types of GABA receptors that specifically modulate sleep and therefore are thought to have less unwanted side effects
cons: drowsiness, dizziness, unsteady gait, rebound insomnia and memory impairment

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What are these?

Alprazolam (Xanaz)
Lorazepam (Ativan)
Clonazepam
Temazepam
Diazepam

benzos

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Pros of benzos?

Cons?

Pros: enhance sleep, decrease anxiety

Cons: daytime sedation, unsteady gait, higher risk of tolerance, dependence, withdrawal and risk of abuse

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What are these?

Doxepin (Sinequan)
Amitriptyline (Elavil)
Trazadone (Desyrel)
Mirtazapine (Remeron)

antidepressants

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Pros of antidepressants?

Cons?

can be used for insomnia and depression;

side effects

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What is Ramelteon (Rozerem)?

melatonin receptor agonist

What are diphenhydramine and hydroxine?

antihistimines

What are these?

Quetiapine
Chlorpromazine
Risperidone
Olanzapine
Ziprasidone

antipsychotics

recommended as the first line treatment by National Institute of Health (NIH) and American Academy of Sleep Medicine.

Cognitive Behavior Therapy for Insomnia

Goals of cognitive behavior therapy for insomnia?

improve sleep quality
decrease daytime impairment
decrease insomnia symptoms
form a clear association b/w bed and sleeping
decrease distress related to sleep deprivation

How many sessions are included in CBTI? What are some pros of CBTI?

4-6 sessions (30+ minutes);

inexpensive, effective, well sustained after treatment is ofer

T/F: CBTI is essentially sleep hygiene

False; it is NOT sleep hygiene, sleep hygiene by itself is not effective

What is Spielman's 3 P's model?

predisposing factors: biological traits or social factors precipitating factors: medical or psych illness, stressful life events perpetuating factors: excessive time in bed, napping, conditioning

Works through the extinction of a conditioned arousal- repeated experiences of anxiety, frustration and tension when unable to sleep.

stimulus control

What is sleep restriction therapy?

reduce time in bed to the patients current sleep time only; if unwanted wakefulness decreases, then you can expand time in bed

What is an example of hyper-attention to threats to sleep?

clock monitoring

How to reduce hyperarousal?

relaxation techniques create buffer time before bed cognitive therapy **educate patients on facts/myths about underlying sleep beliefs

What are some contradictions to treating sleep disorders?

active psychotic symptoms current alcohol/drug (*min of 30 days sobriety recommended before treatment) excessive daytime sleepiness bipolar disorder (*use caution)

How is CBTI better than hypnotics?

longer-lasting effects no drug side effects or drug-drug interactions cost effective efficacy equivalent to medications

What did Jacobs et al find when they evaluated zolpidem, CBTI, combo of zolpidem/CBTI and a placebo?

greatest effect on sleep latency for both groups involving CBTI

In patients with persistent insomnia, when did the addition of medication to CBTI help?

during acute therapy, it provided added benefits, but long-term outcome was optimized when medication was discontinued during maintenance CBTI

Which groups in the Jacobs study had the best outcomes with sleep?

CBTI and combined CBTI with medication

Sustained benefits of CBTI have been reported up to (blank) months after end of treatment

T/F: In larger randomized clinical trials, CBTI has been shown to be clinically effective for treating insomnia: Superior to relaxation training, medication placebo, and a no treatment wait-list control. Superior to usual “medication management strategies” (medications and sleep advice)

True

T/F: Patients prefer medication to CTBI

False; Patients express preference for CBTI versus medications: Patients rate behavioral interventions over sleep medications. (Morin, 1999) Patients state that they not only prefer CBTI over pharmacotherapy, but also expressed expectations that CBTI would produce greater improvements in daytime functioning, better long-term effects, and fewer negative side effects. (Morin, et al., 1992)

So what can sleep medications be used for effectively?

reduction of sleep-related anxiety | relief for acute/brief forms of insomnia (ex: jet lag)

What are some probs with sleep medications?

tolerance and decreased efficacy with continued use over time risk of psychological and physiological dependence unable to address the wide range of behaviors and cognitions

BZRAs and CBTI are effective in treatment of insomnia in the (blank), but CBTI has more durable effects when active treatment is discontinued.

short term

T/F: Depression and insomnia are linked, and treating insomnia helps treat depression.

True **sleep meds and CBTI are important for depression therapy, too

Could provide an alternative to CBTI; Shown to have the highest rates of treatment remission and response at 6 month follow-up

meditation based interventions

T/F: Insomnia and OSA frequently co-occur. Combination therapy, including both CBTI & OSA treatment resulted in greater improvements in insomnia than either treatment alone.

True

What is one of the biggest barriers to CBTI?

lack of access to therapists with training in sleep

T/F: Data suggests insomnia should not simply be understood as a symptom of other disorders. AND When it occurs in the context of medical and/or psychiatric illness may be better understood, and treated, as a comorbid condition.

True **think of insomnia as its own disorder