New research now links sleep problems with Alzheimer’s disease. According to the Alzheimer’s Association, more than five million Americans live with Alzheimer’s.
Cleveland Clinic’s Stephen Rao (pronounced Ray-Oh) did not participate in the new study but says results suggest people who have trouble sleeping may be at an increased risk of developing Alzheimer’s later in life.
CG: Stephen Rao, PhD /Cleveland Clinic: “The basic finding is that the more disturbance of sleep that people reported, the more likely that they were going to have pathology in their spinal fluid that related to Alzheimer’s disease.” [:15]
RESEARCHERS SURVEYED JUST OVER ONE-HUNDRED PEOPLE AT HIGH RISK OF DEVELOPING ALZHEIMER’S WHO HAD NORMAL THINKING AND MEMORY ABILITIES.
PARTICIPANTS WERE ASKED ABOUT THEIR SLEEP QUALITY AND ALSO PROVIDED A
SPINAL FLUID SAMPLE.
RESULTS SHOW THAT PEOPLE WHO REPORTED HAVING SLEEP PROBLEMS HAD MORE
BIOLOGICAL MARKERS FOR ALZHEIMER’S DISEASE IN THEIR SPINAL FLUID THAN FOLKS WHO DID NOT REPORT SLEEP PROBLEMS.
DOCTOR RAO NOTES THAT WHILE THE STUDY SHOWS A LINK BETWEEN SLEEP
AND ALZHEIMER’S IT’S A BIT OF A CHICKEN AND EGG SCENARIO, IN THAT DOCTORS AREN’T SURE WHAT COMES FIRST. THE ALZHEIMER’S OR THE SLEEP PROBLEMS.
HE SAYS MORE RESEARCH NEEDS TO BE DONE TO BE SURE.
CG: Stephen Rao, PhD/Cleveland Clinic: “We don’t know what the chicken or egg cause is here, it may very well be that sleeping longer will help us to prevent us from developing or slow down the process of Alzheimer’s disease but we certainly don’t have the definitive answer as yet.”
Complete results of this study can be found online in the Journal NEUROLOGY. [:10]
“A multitude of factors may cause insomnia, but I bet the primary cause is your choice of food or beverage before turning in. Technology is a biggie, but if you’re sleepy you won’t want to look at your phone or computer.
Your brain requires healthy food and beverages to stay sharp and sleep well.
Numerous foods and beverages are already proven to disrupt sleep including high-fat foods, soda, chocolate, caffeine, heavy spicy foods, alcohol 4 to 6 hours before bedtime, meat and high protein intake. Even prescription and over-the-counter cold medications may contain caffeine. Let’s also not rule out tobacco usage.
Healthy foods that promote sleep include nuts, seeds, eggs, bananas and a few crackers & cheese. Water no later than 8 p.m. is a healthy go-to beverage.
Daily exercise also helps you sleep well.
I’d love to see “further studies” include two groups of people “at risk” for developing Alzheimer’s: 1. sedentary people who eat and drink disruptive foods and beverages, use tobacco and take prescription medications 2) compared to people that exercise daily, eat and drink healthy foods and beverages and do not take OTC or prescription medications or use tobacco.
Then, compare how well these two different groups sleep, along with their biological markers for Alzheimer’s disease.
Bottom line: Missing piece to this puzzle may be finding out what causes sleep problems. I posit people more at risk have unhealthy habits leading to sleeplessness.
Remember, you have the power to change your daily habits and choices.
It’s time to research and study causes, so people can practice prevention instead of seeking treatment for symptoms, or worse believing the symptom is a cause. ”
NATIONAL MEDIA: See Pathfire #: 10826 dated July 5, 2017 for soundbites/voiceover
SLEEP APNEA AFFECTS AT LEAST TWENTY-FIVE MILLION ADULTS IN THE U-S.
THE CONDITION CAUSES THE UPPER AIRWAY TO COLLAPSE FREQUENTLY WHILE SLEEPING, ROBBING SUFFERERS OF A GOOD NIGHT’S SLEEP AND LEADING TO DAYTIME SLEEPINESS AND DROWSY DRIVING.
NOW, NEW CLEVELAND CLINIC RESEARCH SUPPORTS A GROWING BODY OF EVIDENCE THAT SHOWS TREATING SLEEP APNEA WITH A C-PAP (SEE-PAP) MACHINE REDUCES SLEEPINESS BEHIND THE WHEEL.
CG: Dr. Harneet Walia /Cleveland Clinic “There was a significant reduction in the drowsy driving episodes and this reduction was more pronounced in patients who were CPAP adherent. This is a very important finding because drowsy driving poses a very important public health risk.” [:14]
RESEARCHERS ANALYZED SELF-REPORTED QUESTIONNAIRES FROM NEARLY TWO THOUSAND PEOPLE WITH SLEEP APNEA. THEY ASSESSED DROWSY DRIVING INCIDENTS BEFORE AND AFTER PARTICIPANTS USED A C-PAP MACHINE.
C-PAP STANDS FOR CONTINUOUS POSITIVE AIRWAY PRESSURE AND IS WORN AT NIGHT WHEN SOMEONE IS SLEEPING.
IT’S DESIGNED TO INCREASE AIR PRESSURE IN THE THROAT TO PREVENT THE AIRWAY FROM COLLAPSING AND THEREFORE RESULT IN A BETTER NIGHT’S SLEEP.
RESULTS SHOW A SIGNIFICANT IMPROVEMENT IN REPORTED ACCIDENTS AND NEAR-MISS-ACCIDENTS AFTER USING A C-PAP MACHINE. FOLKS WHO USED IT REGULARLY AND COMPLIED WITH TREATMENT GUIDELINES SAW THE GREATEST IMPROVEMENT.
IN ADDITION TO DROWSY DRIVING AND DAYTIME SLEEPINESS, DOCTOR WALIA (WALL-EE-UH) SAYS SLEEP APNEA CAN ALSO HAVE CARDIOVASCULAR CONSEQUENCES, SO IT’S IMPORTANT TO BE PROPERLY DIAGNOSED AND TREATED.
CG: Dr. Harneed Walia /Cleveland Clinic “If you think you have obstructive sleep apnea, or you have signs of obstructive sleep apnea such as loud snoring, having pauses in breathing, or you feel excessively tired throughout the day please seek medical attention.” [:14]
DOCTOR WALIA SAYS SLEEP APNEA CAN BE EASILY DETECTED DURING AN OVERNIGHT SLEEP STUDY AND THAT USING A C-PAP MACHINE IS OFTEN THE FIRST LINE OF TREATMENT. COMPLETE RESULTS WERE PRESENTED AT THE AMERICAN ACADEMY OF SLEEP MEDICINE IN BOSTON.
For more information please visit: firstname.lastname@example.org
See June 6, 2017 Sound Bites/Voice Over Pathfire#: 10803
He tried lots of gadgets, but nothing worked. He couldn’t remember to use them.
That’s when he created something he wouldn’t have to remember to wear or charge.
It’s a mattress pad called EIGHT, after recommended hours of sleep.
Eight personalizes sleep tracking for each user.
HOW IT WORKS: The mattress pad tracks your usual bedtime, time you fall asleep, normally wake, movement, heart rate, breathing rate, hours slept, and get out of bed. It also tracks room temperature, humidity, light levels, noise levels, and local weather.
Based on the info it collects, a companion app provides you with a sleep score, data on number of hours slept, sleep debt trends, and data on how much deep sleep you received.
The mattress cover also offers ten different temperature settings that can be adjusted on either side of the bed if you are sleeping with a partner.
The system costs between $249 and $289 depending on bed size, is available for preorder for $99 on its website. Use code SLEEPWEEK to get $35. off. According to the website, there is a one-year limited warranty and 30-day free return.
Last year, Eight launched a crowdfunding campaign for its mattress cover, which ended up raising $1.2 million, significantly more than its $400,000 goal.
Though the campaign ended in March 2015, none of the orders have been fulfilled yet, but Franceschetti said they plan to start shipping the device in the spring of this year.
All that tracking would keep me up. I do like the temperature feature, but I remember sleeping with heated blankets ended up being a health hazard. I recall learning years later that electric blankets create a magnetic field that has been linked to childhood leukemia, miscarriages, breast cancer and endometrial cancer. A study was published on it 9 years ago in the European Journal of Cancer Prevention. This mattress cover also runs on electricity. It’s radiating a constant low level magnetic field. You have no idea what it will do to you ten or twenty years from now. Further, whoever invested in it doesn’t want you to think them dumb for investing in everything called “smart” so fake blogs, articles and sites will pop up saying how wonderful it is without mentioning this hazard at all. Then, they buy quotes from physicians or experts to say it’s safe. The only one who suffers the long-term consequences is the healthcare consumer who bought it. You’ll be up worrying. Ah, the irony. The founders may add software with sleep coaches (again keeping you up). I’m thinking its because they already know this electric mattress will not improve your sleep. Smart people will not fall for slick presentations. The only person sleeping soundly will be the founder with millions of dollars from investors. They fell for the line: “Changing sleep forever, for better.”
Here’s a reminder of why sleep is so important to good health followed by what may be the underlying cause of insomnia.
Medical Causes of Insomnia from Sleep Foundation
Examples of medical conditions that can cause insomnia are:
Gastrointestinal problems such as reflux
Endocrine problems such as hyperthyroidism
Neurological conditions such as Parkinson’s disease
Low back pain
Medications such as those taken for the common cold and nasal allergies, high blood pressure, heart disease, thyroid disease, birth control, asthma, and depression can also cause insomnia.
In addition, insomnia may be a symptom of underlying sleep disorders. For example, restless legs syndrome—a neurological condition in which a person has an uncomfortable sensation of needing to move his or her legs—can lead to insomnia.
Patients with restless legs syndrome typically experience worse symptoms in the later part of the day, during periods of inactivity, and in the transition from wake to sleep, which means that falling asleep and staying asleep can be difficult. An estimated 10 percent of the population has restless legs syndrome.
Sleep apnea is another sleep disorder linked to insomnia. With sleep apnea, a person’s airway becomes partially or completely obstructed during sleep, leading to pauses in breathing and a drop in oxygen levels. This causes a person to wake up briefly but repeatedly throughout the night. People with sleep apnea sometimes report experiencing insomnia.
If you have trouble sleeping on a regular basis, it’s a good idea to review your health and think about whether any underlying medical issues or sleep disorders could be contributing to your sleep problems.
In some cases, there are simple steps that can be taken to improve sleep (such as avoiding bright lighting while winding down and trying to limit possible distractions, such as a TV, computer, or pets).
While in other cases, it’s important to talk to your doctor to figure out a course of action. You should not simply accept poor sleep as a way of life—talk to your doctor or a sleep specialist for help.
Insomnia & Depression
Sleep problems may represent a symptom of depression, and the risk of severe insomnia is much higher in patients with major depressive disorders. Studies show that insomnia can also trigger or worsen depression.
Insomnia, Depression, Anxiety
Insomnia can come from feeling excited, worried, nervous or anxious. It’s natural for most adults. If it becomes a regular pattern it could lead to:
Getting caught up in thoughts about past events
Excessive worrying about future events
Feeling overwhelmed by responsibilities
A general feeling of being revved up or overstimulated
There are 2 types of insomnia:
Onset insomnia (trouble falling asleep)
Maintenance insomnia (waking up during the night and not being able to return to sleep).
According to the Sleep Foundation, when this happens for many nights (or many months), you might start to feel anxiousness, dread, or panic at just the prospect of not sleeping. This is how anxiety and insomnia can feed each other and become a cycle that should be interrupted through treatment.
Examples of how specific lifestyles and sleep habits can lead to insomnia are:
You work at home in the evenings. This can make it hard to unwind, and it can also make you feel preoccupied when it comes time to sleep. The light from your computer could also make your brain more alert.
You take naps (even if they are short) in the afternoon. Short naps can be helpful for some people, but for others they make it difficult to fall asleep at night.
You sometimes sleep in later to make up for lost sleep. This can confuse your body’s clock and make it difficult to fall asleep again the following night.
You are a shift worker (meaning that you work irregular hours). Non-traditional hours can confuse your body’s clock, especially if you are trying to sleep during the day, or if your schedule changes periodically.
If you can’t sleep, review the following lifestyle factors:
Alcohol is a sedative. It can make you fall asleep initially, but may disrupt your sleep later in the night.
Caffeine is a stimulant. Most people understand the alerting power of caffeine and use it in the morning to help them start the day and feel productive. Caffeine in moderation is fine for most people, but excessive caffeine can cause insomnia.
A National Sleep Foundation poll found that people who drank four or more cups/cans of caffeinated drinks a day were more likely than those who drank zero to one cups/cans daily to experience at least one symptom of insomnia at least a few nights each week.
Caffeine can stay in your system for as long as eight hours, so the effects are long lasting. If you have insomnia, do not consume food or drinks with caffeine too close to bedtime.
Nicotine is also a stimulant and can cause insomnia. Smoking cigarettes or tobacco products close to bedtime can make it hard to fall asleep and to sleep well through the night. Smoking is damaging to your health. If you smoke, you should stop.
Heavy meals close to bedtime can disrupt your sleep. The best practice is to eat lightly before bedtime. When you eat too much in the evening, it can cause discomfort and make it hard for your body to settle and relax. Spicy foods can also cause heartburn and interfere with your sleep.
Insomnia & The Brain
In some cases, insomnia may be caused by certain neurotransmitters in the brain that are known to be involved with sleep and wakefulness.
There are many possible chemical interactions in the brain that could interfere with sleep and may explain why some people are biologically prone to insomnia and seem to struggle with sleep for many years without any identifiable cause—even when they follow healthy sleep advice.
The Sleep Foundation reviewed Eight, which used to be called Luna, along with other monitors that slide under your sheets to keep an eye on your sleep habits without disrupting your slumber.
While most high-tech sleep trackers involve a wristband, some people prefer to sleep without anything on their arms. That’s where these three new products come in.
This system is made up of a mattress pad that goes under your mattress (above your box spring), a smart phone app, and a bedside device that produces light and sound. The pad tracks your sleep patterns and the light and sound programs help you transition to sleep at night and wake up in the morning. You can also use the Smart WakeUP function so that your alarm goes off when you’re in a light sleep cycle so you’ll feel less groggy. Another fun feature: The bedside device monitors light and noise in the room, in case there’s a connection between, say, a routine garbage truck on your street and your waking up at 5:00am every day. ($299.95)
This mattress cover learns your sleep habits and cycles by tracking your heart rate and breathing rate. It also changes the temperature of your bed, warming it up around your normal bedtime and cooling down throughout the night. If you and your partner have different preferences, you can each set your half of the bed to separate temperatures. Think of this as turning your mattress into a smart bed, since Luna can communicate with other devices. For instance, Luna can connect with activity trackers (and figure out if your exercise or eating habits are affecting your sleep). It can “talk” to other smart home devices like your alarm clock (Luna will make sure that it’s set). And it can even work directly with your thermostat (Luna will lower it when you go to sleep). (Starts at $249)
Take any mattress—foam, memory foam, waterbed, pillow top, or spring—and place the RestOn sensor on top of it, under your fitted sheet. Hit start on the RestOn app on your smart phone, get into bed, and it will start recording heart rate, respiratory rate, movement, and sleep cycles. The RestOn goes one step further and suggests habits that will result in better sleep, like making your room cooler, cutting out late-in-the-day coffee, or eating a lighter lunch. You’ll also get weekly and monthly reports that detail your sleep trends so you can make adjustments to improve your slumber. ($149)
Stanford sleep research and treatment focuses on all types of sleep disorders including, but not limited to, the following:
INSOMNIA debilitates no fewer than 14 percent of Americans. It has been shown to be one of the strongest predictors of depression later in life. But new therapies, including some that do not require medication—such as sleep restriction, light therapy, better sleep habits, and cognitive therapy—bring 80 percent to 90 percent satisfaction even in severe cases.
OBSTRUCTIVE SLEEP APNEA afflicts 30 million Americans, or 10 percent of the population. Soft tissue in the airway stops breathing repeatedly during sleep, preventing deep sleep, causing low oxygenation, and resulting in sleep deprivation. Apnea is now accepted as the leading treatable cause of hypertension and is a strong predictor of stroke and heart disease. Difficulty with memory, intimacy, and attention are common.
CENTRAL SLEEP APNEA, a less common type of sleep apnea, affects several million Americans. Although people with central sleep apnea seldom snore, symptoms and results are much the same as the obstructive type—a deprivation of oxygen and poor sleep. About 40 percent to 60 percent of persons with heart failure have central sleep apnea.
RESTLESS LEGS SYNDROME (RLS) afflicts 12 million Americans. An uncontrollable urge to move the legs, often associated with painful sensations, seriously disrupts sleep. The genetic basis of RLS has just been discovered. RLS is also associated with depression, anxiety, and heart disease.
NARCOLEPSY AND IDIOPATHIC HYPERSOMNIA (disabling daytime sleepiness) shatter more than 200,000 lives in the United States. In addition to sudden, unpredictable sleeping, they can cause cataplexy, a muscular collapse brought on by emotional excitement. Lifelong treatment with stimulants or powerful sedatives is often required but brings only partial relief. Although the cause of narcolepsy is now established, almost nothing is known regarding idiopathic hypersomnia and its treatment.
Learn more about the Stanford Center for Sleep Sciences and Medicine by clicking on one of the links below.
MARIA DORFNER, the founder NewsMD connects medical & media.
“When We Tell Stories…People Listen”
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We have zero tolerance for scams when it comes to health. If anything ever doesn’t work as hyped let us know. When it comes to investing in health make sure today’s solution isn’t tomorrow’s bigger problem. -M. Dorfner
by Gregory M. Asnis, MD, Elishka Caneva, MD, and Margaret A. Henderson, MD
Insomnia is highly prevalent in psychiatric disorders, and it has significant implications.
This review focuses on insomnia in the context of anxiety disorders. The prevalence of comorbid insomnia in anxiety disorders is addressed and the clinical implications associated with insomnia are discussed as well as when and how to treat this important comorbidity.
Just how specifically insomnia relates to and possibly affects anxiety disorders is highlighted by the fact that insomnia is one of the defining criteria in a number of the DSM-IV-TR anxiety disorders.
For example, difficulty in falling or staying asleep is a criterion for PTSD, acute stress disorder, and generalized anxiety disorder (GAD).
The relationship of insomnia to anxiety disorders is also influenced by comorbid major depression. The severity of insomnia is increased when an anxiety disorder is comorbid with a major depressive disorder (MDD).1 This is highly relevant because 58% of MDD patients have a lifetime anxiety disorder.2
The presence of insomnia has a deleterious effect on daytime functioning and negative effects on quality of life, including social and work relationships.3
Also, there is clear evidence that the presence of insomnia in anxiety disorders is associated with increased morbidity.
For example, in patients with PTSD, insomnia is associated with an increased likelihood of suicidal behavior, depression, and substance abuse as well as nonresponsiveness to treatment.4-6
In addition, insomnia as an early symptom in traumatized patients increases the risk of the development of PTSD 1 year later.7
It is important to carefully assess for insomnia early in the evaluation of patients with anxiety disorders and to aggressively treat this complicating comorbidity.
Insomnia is an underrecognized and undertreated problem. Patients rarely report their symptoms of insomnia spontaneously to their doctor. Adding to the problem of detecting insomnia is the finding that doctors rarely inquire about insomnia in their patients.3,8,9
Thus, a carefully taken history is an important first step in the assessment of insomnia.
Self-rating sleep questionnaires and direct clinical interviews are used to obtain a history of potential sleep disorders (eg, insomnia). A number of well-validated sleep questionnaires have been widely used.
The most widely used and validated questionnaire is the 19-question Pittsburg Sleep Quality Index. The questions cover sleep quality, sleep problems, sleep medications, and so on, within the past month.10
Another widely used questionnaire is the Leeds Sleep Evaluation Questionnaire (LSEQ). The LSEQ consists of 10 self-rating questions that cover sleep and aberrant sleep behaviors.11
Besides self-rating questionnaires that depend on memory of sleep disturbances, a sleep log or diary can confirm questionable sleep disturbances prospectively.
The use of a sleep log allows for an analysis of day-to-day sleep patterns, such as the time that the patient went to bed, sleep latency, and nighttime awakenings.8,9 The log is filled out by the patient shortly after awakening in the morning (see Morin9(p38) for an example of a sleep log). If at all possible, monitoring for up to 2 weeks is highly recommended because it allows for sleep abnormalities that might show marked day-to-day variability and would more likely be detected by extensive monitoring.12,13
What is already known about insomnia
in patients with anxiety disorder?
■ Anxiety disorders frequently coexist with insomnia. The latter is believed to be part and parcel of various anxiety disorders and is one of the defining criteria of a number of them.
What new information does this article provide?
■ Our article clarifies new approaches to considering insomnia in anxiety disorders. The presence of insomnia should be considered a comorbid illness and treated on its own. Pharmacotherapy, cognitive-behavioral therapy, and a combination of both are discussed.
Insomnia is an added pathology that brings increased morbidity to patients with anxiety disorders. Our review suggests that successful treatment of insomnia actually increases the responsiveness of anxiety disorders to many antianxiety treatments.
What are the implications for psychiatric practice?
■ When evaluating patients with anxiety disorders, psychiatrists should carefully evaluate for the presence of insomnia. Patients infrequently bring up this symptom on their own. If insomnia is present, aggressive treatment early in the course of therapy is highly suggested.
If the presence of insomnia is suspected, interviewing a spouse, a significant other, or a caregiver is helpful. Some patients who believe they have insomnia symptoms appear to have “sleep state misperception,” where their partners clearly state that their sleep is normal.14
These “others” can also report problems that are likely not obvious to the patient:
• Apnea spells or excessive snoring as seen in obstructive apnea
• Excessive body movements as seen in periodic leg movement disorder and restless legs syndrome
• Various sleep-related behaviors (sometimes violent and aggressive) as seen in rapid eye movement behavior disorder (RBD)
Referral to a sleep specialist and sleep polysomnography has been recommended if pharmacological or nonpharmacological options are not working. Referral is also warranted for patients with insomnia in whom a specific sleep disorder, such as obstructive sleep apnea, periodic limb movements, narcolepsy, or RBD, is suspected.12,15
Even when a visit to a sleep laboratory is suggested, the cost of an overnight visit is often prohibitive—more than $1000 per night; usually 2 nights are required with the first being an adaptation night for the patient. Insurance frequently does not cover these costs.16
If it is found that the patient has sleep apnea, a sleep movement disorder, RBD, or a number of other sleep disorders, specific nonhypnotic treatments may be required (eg, continuous positive airway pressure for sleep apnea is the treatment of choice).
Before beginning treatment of anxiety disorder–associated insomnia symptoms, rule out any concurrent medical illness, medication treatment, or substance use that might be inducing or worsening insomnia. Many medical illnesses, such as cardiovascular disorders (eg, congestive heart failure), pulmonary disorders (eg, emphysema), endocrinopathies (eg, thyroid disorders), GI disorders (eg, acid reflux), and neurological disorders (eg, pain syndromes), are associated with insomnia.12
Before providing any significant intervention for insomnia, a careful evaluation regarding behaviors that might contribute to insomnia should be made.
Daytime naps, late nighttime snacks or meals, watching television in bed, nighttime exercise, or excessive light or loudness in the bedroom should be identified and modified. Eliminating these behaviors can lead to significant sleep improvements. A 13-item self-rating questionnaire by Mastin and colleagues17 can help elicit sleep hygiene information.
The treatment of insomnia in patients with anxiety disorders is, for the most part, the same as the treatment of insomnia per se: pharmacological, nonpharmacological, or a combination of the two.
The primary treatment of insomnia is pharmacological because of the rapid onset of action (eg, hypnotics are usually effective within days to 1 week of use). The most common nonpharmacotherapy, cognitive-behavioral therapy for insomnia (CBT-I) takes considerably longer.3,8,12 Currently, the FDA has 11 approved drugs for the treatment of insomnia:
In recent years, nonbenzodiazepines have become the most recommended of the approved hypnotics. (There has been less and less reliance on benzodiazepines.) Not only are nonbenzodiazepines effective in treating insomnia (equivalent to the benzodiazepines), but there is a notion that they are safer than benzodiazepines.3,12
Both nonbenzodiazepines and benzodiazepines are associated with adverse effects that include fatigue, dizziness, ataxia, and the development of dependence and tolerance with long-term use. Although head-to-head studies comparing these classes of hypnotics have been minimal, a recent meta-analysis supports the finding of reduced adverse effects for the nonbenzodiazepines.18 The nonbenzodiazepines typically have a shorter half-life and are more selective at the γ-aminobutyric acid receptor, factors that are partially responsible for less residual daytime sedation and other adverse effects.
In the treatment of anxiety disorders with comorbid insomnia, the latter should be treated concurrently with, but independently of, the anxiety disorder per se. The idea that one should wait to see whether the insomnia resolves with only the treatment of the anxiety disorder is no longer valid. Clinical experience has shown that without targeted insomnia treatment, insomnia frequently persists.3,19
When adding a hypnotic to an antidepressant in the treatment of anxiety, the risk to benefit ratio must be considered. Pollack and colleagues20 looked at a large group of patients with GAD comorbid with insomnia (N = 595). The patients received either 10 mg of escitalopram(Drug information on escitalopram) coadministered with 3 mg of eszopiclone or the escitalopram with placebo. Those in the active hypnotic treatment group had a significant response in their insomnia by the first week. The combination of medications was well tolerated with no significant increase in adverse effects.
Most surprisingly, the anxiety scores for those patients who received the hypnotic significantly improved starting at week 4 even after removing insomnia symptoms from the anxiety assessment. The time to onset of the anxiolytic response was also reduced. In addition, the combination treatment led to a slightly better symptom response and remission rate for the anxiety disorder.
Similar results were reported in a 12-week open-label study (N = 27) undertaken by Gross and colleagues.21 The researchers evaluated ramelteon (8 mg/d), a melatonin agonist, in patients who had GAD comorbid with insomnia and whose condition was partially responsive to an SSRI or a serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitor. The hypnotic was well tolerated, effective for insomnia, and appeared to facilitate the treatment of GAD.
A double-blind placebo-controlled study by Fava and colleagues22 evaluated the efficacy and safety of zolpidem(Drug information on zolpidem) extended-release (12.5 mg/d) versus placebo in patients with comorbid GAD and insomnia who were being treated with escitalopram (10 mg/d). Sleep measures improved significantly by the end of week 1, and there was no added burden of adverse effects. Zolpidem did not show a beneficial anxiolytic effect.
Approximately 50% of patients with insomnia continue to have insomnia 3 years after initial diagnosis, and many patients require months to years of treatment. Nonbenzodiazepines for primary insomnia were found to have continued efficacy and to be well tolerated with no evidence of abuse or withdrawal symptoms on discontinuation of use after 12 months.23,24 Ramelteon was also found to be efficacious with no significant issues of abuse or tolerance in a 24-week open-label study.25 The literature for longer use of hypnotics is scarce.
Anxiety disorders are frequently comorbid with alcohol(Drug information on alcohol) or substance use disorders.4,26 Consider ramelteon or low-dose sinequan to avoid potential issues of abuse and addiction. Nonbenzodiazepines are preferred over benzodiazepines; there is evidence that the former have decreased potential for abuse and a better adverse-effect profile.
In some patients with insomnia, benzodiazepines are clearly necessary. The other hypnotics may not be as effective for some patients, and the anxiolytic properties of benzodiazepines may be helpful.
When hypnotics are used (particularly, benzodiazepines and nonbenzodiazepines), their use should be reassessed—every 3 to 4 weeks.3,12 Many patients with insomnia do not experience sleep disturbances nightly. Therefore, the use of hypnotics on an as-needed basis or a few times a week helps cut down on the amount and exposure to medication.27
Trazodone and mirtazapine(Drug information on mirtazapine) are also widely used for insomnia, as are atypical antipsychotics and herbal preparations. Unfortunately, these agents have not been rigorously studied for insomnia and thus their effectiveness and safety remain unclear.3
CBT-I is an important, widely accepted, multimodal treatment for insomnia and the best-studied of the nonpharmacological approaches for this disorder.
It is a manualized treatment that focuses on various components of CBT (ie, cognitive restructuring and the use of psychological interventions, such as the practice of good sleep hygiene, stimulus control, sleep restriction, and relaxation therapy).
These methods address negative and distorted cognitions and behaviors that initiate and perpetuate insomnia.9,28 Treatment duration is relatively short. It is administered for 5 hours divided over 4 to 6 weeks and can subsequently be used as a maintenance treatment in monthly sessions. There are approximately 12 well-designed CBT-I trials that have clearly demonstrated that it is a highly effective intervention for insomnia for 1 year or longer.29,30
Studies that compared CBT-I with pharmacotherapy found equivalent efficacy.31 This has led the NIH Consensus and State of the Science Statement to conclude that CBT-I is “as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment.”3 In contrast to hypnotics, learned CBT-I skills may persist even when active treatment ends.9 Furthermore, some patients may prefer CBT-I over hypnotic drugs because of their possible adverse effects or because of concerns about drug interactions or taking a drug during pregnancy.9
In general, CBT-I is underutilized—only about 1% of patients with chronic insomnia receive this therapy.32 To increase the availability of CBT, it can be administered via self-help strategies (eg, educational books and materials) and in group formats. In addition, the use of the Internet to provide CBT has been shown to be effective. Nonetheless, patients frequently prefer face-to-face contact.33
Besides CBT-I, a number of other nonpharmacological therapies, such as bright light, physical exercise, acupuncture, tai chi, and yoga, have been used to treat insomnia. Unfortunately, the results have been inconsistent.32,34
Is a combination of pharmacotherapy and nonpharmacotherapy more effective than either alone in the treatment of anxiety disorders with insomnia? Combination therapy has not been addressed in studies of this particular patient population. Furthermore, the question has been minimally addressed even in the treatment of insomnia per se.
Study findings suggest only modest differences in outcomes with a combination of therapies. Similar results were seen in a study that compared CBT with CBT pluszolpidem(Drug information on zolpidem). The 6-week acute study demonstrated a 60% response rate and a 40% remission rate; the group with the combination treatment did have a significant increase in sleep time of 15 minutes, but the researchers question the clinical significance of this isolated finding.29
Anxiety disorders with comorbid insomnia are highly prevalent with potential negative consequences. Therefore, assess for insomnia with self-rating scales and careful clinical interviews. When appropriate, refer patients for polysomnography.
Insomnia should be treated aggressively with pharmacotherapy, nonpharmacotherapy (particularly CBT-I), or a combination. Some of the hypnotic treatments actually appear to facilitate successful therapy for the anxiety disorder.
Benzodiazepines and nonbenzodiazepines have a number of adverse effects and can lead to abuse and dependence. Patients with an anxiety disorder may be particularly vulnerable, especially those with a history of alcohol(Drug information on alcohol) and drug abuse. Treatment with benzodiazepine and nonbenzodiazepine hypnotics needs to be reassessed monthly. Alternatively, ramelteon, low-dose sinequan, and CBT-I should be considered because they have minimal adverse effects and no risk of abuse.
Successful treatment of insomnia is an important goal in patients with anxiety disorders. Both pharmacological and nonpharmacological interventions have response rates of approximately 60%.
ABOUT THE AUTHORS: Dr Asnis is Professor in the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine and Director of the Anxiety and Depression Clinic of Montefiore Medical Center, Bronx, NY; Dr Caneva is a Psychiatry Fellow at the Anxiety and Depression Clinic of Montefiore Medical Center; Dr Henderson is Research Coordina-tor at the Anxiety and Depression Clinic of Montefiore Medical Center. Dr Asnis is Consultant for Bristol-Myers Squibb and has received grants in the past year from Forest Pharmaceuticals, Lilly, Otsuka, and Pfizer. Drs Caneva and Henderson report no conflicts of interest concerning the subject matter of this article.