Will I Ever Get a Good Night's Sleep?
Will I Ever Get a Good Night's Sleep?
Abstract & commentary
By Allan J. Wilke, MD, Associate Professor of Family Medicine, University of Alabama at Birmingham School of MedicineHuntsville Regional Medical Campus, Huntsville. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Insomnia persists.
Source: Morin CM, et al. The natural history of insomnia: A population-based 3-year longitudinal study. Arch Intern Med 2009;169:447-453.
These investigators from Quebec study insomnia and set about to discover what happens to people with it over time. They divided insomnia into two categories: insomnia syndrome (I-SYN) and insomnia symptoms (I-SYMP). The definitions were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DMS-IV), and the International Classification of Diseases, Tenth Edition (ICD-10), criteria for insomnia, use of an OTC or prescribed insomnia medication, subjective dissatisfaction with sleep, and frequency of symptoms. Subjects with I-SYN met all the diagnostic criteria, used medication at least three times a week, were dissatisfied or very dissatisfied with their sleep patterns, and had symptoms at least 3 times a week for at least 1 month. Subjects with I-SYMP had the same frequency of symptoms, but did not meet all the diagnostic criteria (including less than a month's duration), and used medication less frequently. Everyone else was a "good sleeper." Re-evaluation occurred yearly. For insomnia progression the options were: it gets better (remission), it gets worse, or it stays the same (persistence). For example, a subject with I-SYMP could become a good sleeper (remission) or stay the same (persistence) or become I-SYN (get worse). At the second and third re-evaluations, there was an additional option: relapse, which indicated going from good sleeper to I-SYN or I-SYMP.
A total of 2001 subjects were surveyed by phone, and 1427 agreed to participate in the 3-year longitudinal study. After multiple exclusions, 388 subjects with insomnia were enrolled, 119 with I-SYN and 269 with I-SYMP. They were on average 45 years old and predominantly female (61%). Not all of them completed the whole 3 years. At the end of the study 260 were left and only 244 had data for all four assessments. Of those, 74 had I-SYN and 170 had I-SYMP. At the 3-year mark, 46% of subjects had persistence. Those with I-SYN fared worse than those with I-SYMP (66% vs 37%). During that period, 54% had at least one remission, and again, it was better to have I-SYMP at baseline than I-SYN (63% vs 34%). The relapse rate was 27%. Older women (≥ 55 years) had the highest persistence rate (95%) compared to middle aged (77%) and young women (68%). Age was not a significant factor for men, who ranged from 59% to 69%.
Looking at the data from a different angle, Morin et al determined for each subject his/her "insomnia trajectory," which is the pattern he/she took from baseline to the end of the study. They then grouped the subjects by baseline status. The most common trajectory for both I-SYN and I-SYMP was no change from one assessment to the next (30% and 21%, respectively). The second most common was remission for I-SYMP (12%) and I-SYMP for I-SYN (11%).
Commentary
The DSM-IV criteria for insomnia are "a complaint of difficulty initiating or maintaining sleep or of nonrestorative sleep that lasts for at least a month (Criterion A) and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B). The disturbance in sleep does not occur exclusively during the course of another sleep disorder (Criterion C) or mental disorder (Criterion D) and is not due to the direct physiological effects of a substance or a general medical condition (Criterion E)." Insomnia is commonly seen in primary care. The list of secondary causes is long. Good sleep hygiene is first-line therapy. Short-term symptoms can be treated with benzodiazepines and sedative-hypnotics, but they should not be used longer than a few weeks. (Only eszopiclone and ramelteon are FDA-approved for long-term use.) And there's the rub. There is no good way to know a priori whether a patient's insomnia will be short- or long-term, and prolonged medication use can have adverse effects, especially in the elderly. This study provides some preliminary indication of insomnia's natural history, and the prognosis isn't good. Whether one has insomnia symptoms or syndrome, chances are good that the status quo will be maintained. This study has some shortcomings. The initial telephone recruitment relied on self-identification of insomnia. Many people were excluded initially, and the dropout rate over the course of 3 years was more than a third. The frequency of assessments was relatively long; a lot can happen in a year. The duration of the study, although longer than previous ones, was only 3 years. I suspect that if there are additional follow-up reports, the news will not be good. In the meantime, when a patient presents with a complaint of insomnia, be scrupulous in searching for secondary causes and parsimonious in the use of your prescription pad.
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