1. What is Chronic Insomnia? Scope of the problem 1,2 –52%–64% of primary care patients have sleep complaints –10%–14% experience severe insomnia that interferes with daytime functioning Essential components of insomnia 3,4 –Difficulty initiating or maintaining sleep –Nonrestorative sleep despite adequate opportunity for sleep –Distress or impairment of daytime functioning Insomnia is chronic if it has lasted for at least 1 month 3 1.Simon GE, VonKorff M. Am J Psychiatry. 1997;154(10):1417-1423. 2.Terzano MG et al. Sleep Med. 2004;5(1):67-75. 3.American Academy of Sleep Medicine. ICSD-2; Diagnostic and coding manual. 2005. 4.American Psychiatric Association. DSM-5 Development.

2. Diagnosing Chronic Insomnia Ask about sleep Identify insomnia Recognize comorbid insomnia

3. Treating Chronic Insomnia Cognitive behavioural therapy for insomnia (CBT-I) -Recommended first-line therapy 1-3 -Strategies allow biological sleep processes to operate without interference -Effective for adults, including elderly and patients with comorbidities 4 -Benefit up to 2 years 5 1.Canadian Medical Association. Guideline for Adult Primary Insomnia: Diagnosis to Management. 2.Schutte-Rodin S et al. J Clin Sleep Med. 2008;4(5):487-504. 3.Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600. 4.Morin CM et al. Sleep. 2006;29(11):1398-1414. 5.Morin CM et al. JAMA. 1999;281(11):991-999.

4. CBT-I Strategies and Rationale –.–. StrategyRationale Don’t go to bed too early. Stay up late.Helps build up the homeostatic sleep drive, and counters the unproductive strategy of going to bed early in an attempt to gain more sleep Keep a constant rise time 7 days a week, regardless of how little sleep you have had. Strengthens the circadian rhythm of sleep regulation Your bed is for sleep. Get out of bed when not sleeping. Go to another room. Return when sleepy. Strengthens the association of the bed and bedroom with sleep and sleepiness Do something with racing thoughts. Use relaxation techniques or visual imagery. Reduces hyperarousal and makes it easier for sleep to arrive Relaxation exercises should be done in the early evening, not in bed Visual imagery can be used in bed to take the mind away from worry or racing thoughts

5. Adjusting Time in Bed Based on Sleep Efficiency Sleep EfficiencyAdjustment to Bedtime < 85%15 minutes later 85%–89%No change 90%–94%15 minutes earlier ≥95%30 minutes earlier After the patient has restricted his/her time in bed to his/her initial sleep window for 1 week, the bedtime is adjusted based on the sleep efficiency attained.

6. Pharmacotherapy Benzodiazepine (BDZ) receptor agonists -Traditional BDZs -Z-drugs: zopiclone, zolpidem, zaleplon*, and eszopiclone* Debate about duration of therapy Safety Potential for abuse and dependence -Lower with Z-drugs than with BDZs 1-3 -However, use same precautions for both classes * Not available in Canada 1.Roth T, Roehrs T. Sleep Med Clin. 2010;5:529-539. 2.Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600. 3.Hajak G et al, Addiction. 2003;98(10):1371-1378.

7. Pharmacotherapy (cont) Sedating antidepressants –Paucity of research on use in nondepressed patients –Generally riskier than BDZ receptor agonists 1 –Higher drop-out rates 2 Over-the-counter sleep aids –Little evidence of benefit in chronic insomnia 3 Melatonin –Prolonged use may be safe and effective; however, few long-term studies, and not available in Canada –Immediate-release generally not useful for chronic insomnia –Ramelteon shows promise, 4 but not available in Canada 1.National Institutes of Health. Sleep. 2005;28(9):1049-1057. 2.Wilson SJ et al. J Psychopharmacol. 2010;24(11):1577-1600. 3.Mendelson WB et al. Sleep Med Rev. 2004;8(1):7-17. 4.Mayer G et al. Sleep. 2009;32(3):351-360.

8. Tapering Medications Taper BDZ receptor agonists slowly to prevent rebound insomnia Tapering is most successful when done in combination with CBT-I 1 1.Morin CM et al. Am J Psychiatry. 2004;161(2):332-342.