Sleep Medicine 16 (2015) 555–556

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Sleep Medicine j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / s l e e p

Editorial

Why is the prevalence of insomnia skyrocketing? And what can be done about it?

Complaints of insomnia (difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and/or non-restorative sleep) are prevalent and getting more so. If trends in sleeping pill prescription are any indication, there was at least a three-fold increase in insomnia diagnoses in the past decade [1]. What is going on? Probably several things. For starters, insomnia is well-known to be associated with psychiatric conditions [2,3], and increased recognition and treatment of mental illness may be contributing to increased diagnosis and treatment of insomnia. However, a second cause of the increased prevalence of insomnia diagnoses is likely to be the increased chronic disease burden resulting from an older, heavier population. There is a growing awareness that insomnia is robustly associated with chronic medical conditions as well as psychiatric ones. Insomnia symptoms have been reported in many chronic conditions, including cardiopulmonary diseases, arthritis, chronic renal failure, diabetes, and neurologic disorders [4–10]. As sleep clinicians, we know that insomnia is also a presenting complaint of obstructive sleep apnea (OSA) [11,12]. The study of sleep quality in sarcoidosis patients by BosseHenck et al. in this edition of Sleep Medicine [13] further substantiates the strong association of insomnia with chronic medical disorders. This report results from the administration of four different questionnaires to a large number of German patients with sarcoidosis. The authors found that poor subjective sleep quality is more common in sarcoidosis patients than it is in the general population, and that there is an inverse relationship between subjective sleep satisfaction and dyspnea. This supports earlier findings correlating disease severity with insomnia symptom severity; for example, the severity of chronic obstructive pulmonary disease (COPD) directly predicts the burden of insomnia symptoms [8,9]. In a somewhat related finding, the prevalence of insomnia goes up linearly with the number of medical conditions that a person has [10]. In other words, the sicker you are, the worse you sleep. Thus, the increasing prevalence of chronic medical conditions may be a factor driving the increased diagnosis of insomnia. While we don’t necessarily agree with the author’s assertion in the abstract that “Questions about sleep complaints should be included in the management of sarcoidosis,” [13] we suspect that this notion reflects a possible third factor that may be contributing to the increasing prevalence of insomnia: misattribution (or hype, for lack of a better word). Simply put, there is nothing that will keep you awake at night like believing that being awake at night will worsen your disease, whatever it is. This may be the implicit message that well-intended practitioners transmit with intense focus on sleep symptoms and aggressive efforts to increase satisfaction with sleep. http://dx.doi.org/10.1016/j.sleep.2015.01.013 1389-9457/© 2015 Elsevier B.V. All rights reserved.

To understand why this might be counterproductive, let’s remember that the cognitive part of Cognitive Behavioral Therapy (CBT) focuses on challenging cognitive hyperarousal by addressing “. . .maladaptive thoughts and . . ..unrealistic expectations. . .” [14] (In other words, try not to worry about it). When we anxiously query patients about sleep complaints and undertake aggressive efforts to improve these symptoms by whatever means necessary, we may be inadvertently doing the opposite of reducing the cognitive hyperarousal that perpetuates and exacerbates insomnia. We suspect that this approach is yet another reason that the numbers of prescriptions for sleeping pills are skyrocketing. Given the lack of safe and robustly effective treatments for insomnia (even CBT, the best thing we have to offer, has modest success and high attrition rates), we don’t think this is a good idea. On the other hand, since chronic medical conditions can be associated with increased sleep complaints, and since treating chronic medical conditions may improve sleep quality, perhaps we should evaluate patients who complain of chronic insomnia for chronic illnesses. For example, Continuous Positive Airway Pressure (CPAP) treatment improves insomnia complaints in some patients with OSA [12,15]. Surgery may improve sleep quality in some people with arthritis [16]. And pulmonary rehabilitation can improve sleep in patients with COPD [17]. Maybe we could slow down the insomnia epidemic by evaluating patients who report sleep complaints for chronic medical illnesses, instead of the other way around. If there is good news here, it is probably that the association of insomnia with bad outcomes is likely to be mediated by the underlying multiple medical and mental illnesses that predispose to insomnia, and not the insomnia itself. (And this may also be true of the association of adverse outcomes associated with chronic use of sleeping pills). With so many complexities and unknown variables, should we screen patients with chronic illness for insomnia? In our opinion, it should be an individual and symptom-driven process. The focus should be on controlling underlying disease, sleep hygiene, and CBT if necessary. In the end, the value of reassurance and redirecting focus on improving overall health can never be overstated.

Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2015.01.013.

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Editorial/Sleep Medicine 16 (2015) 555–556

References [1] Ford ES, Wheaton AG, Cunningham TJ, et al. Trends in outpatient visits for insomnia, sleep apnea, and prescriptions for sleep medications among US adults: findings from the National Ambulatory Medical Care Survey 1999–2010. Sleep 2014;37:1283–93. doi:10.5665/sleep.3914. [2] Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA 1989;262:1479–84. [3] Goldman-Mellor S, Gregory AM, Caspi A, et al. Mental health antecedents of early midlife insomnia: evidence from a four-decade longitudinal study. Sleep 2014;37:1767–75. doi:10.5665/sleep.4168. [4] Taylor DJ, Mallory LJ, Lichstein KL, et al. Comorbidity of chronic insomnia with medical problems. Sleep 2007;30:213–18. [5] Sivertsen B, Lallukka T, Salo P, et al. Insomnia as a risk factor for ill health: results from the large population-based prospective HUNT Study in Norway. J Sleep Res 2014;23:124–32. [6] Li Y, Zhang X, Winkelman JW, et al. Association between insomnia symptoms and mortality: a prospective study of U.S. men. Circulation 2014;129:737–46. doi:10.1161/CIRCULATIONAHA.113.004500. [7] Abbasi M, Yazdi Z, Rezaie N. Sleep disturbances in patients with rheumatoid arthritis. Niger J Med 2013;22:181–6. [8] Phillips B, Mannino DM. Does insomnia kill? Sleep 2005;28:965–71. [9] Hynninen MJ, Pallesen S, Hardie J, et al. Insomnia symptoms, objectively measured sleep, and disease severity in chronic obstructive pulmonary disease outpatients. Sleep Med 2013;14:1328–33. doi:10.1016/j.sleep.2013.08.785. [10] Budhiraja R, Roth T, Hudgel DW, et al. Prevalence and polysomnographic correlates of insomnia comorbid with medical disorders. Sleep 2011;34:859–67. doi:10.5665/SLEEP.1114. [11] Vozoris NT. Sleep apnea-plus: prevalence, risk factors, and association with cardiovascular diseases using United States population-level data. Sleep Med 2012;13:637–44. doi:10.1016/j.sleep.2012.01.004.

[12] Björnsdóttir E, Janson C, Sigurdsson JF, et al. Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep 2013;36:1901–9. doi:10.5665/sleep .3226. [13] Bosse-Henck A, Wirtz H, Hinz A, et al. Subjective sleep quality in sarcoidosis. Sleep Med 2015. [14] Schwartz DR, Carney CE. Mediators of cognitive-behavioral therapy for insomnia: a review of randomized controlled trials and secondary analysis studies. Clin Psychol Rev 2012;32:664–75. doi:10.1016/j.cpr.2012.06 .006. [15] Bjorvatn B, Pallesen S, Grønli J, et al. Prevalence and correlates of insomnia and excessive sleepiness in adults with obstructive sleep apnea symptoms. Percept Mot Skills 2014;118:571–86. [16] Fielden JM, Gander PH, Horne JG, et al. An assessment of sleep disturbance in patients before and after total hip arthroplasty. J Arthroplasty 2003;18:371–6. [17] Soler X, Diaz-Piedra C, Ries AL. Pulmonary rehabilitation improves sleep quality in chronic lung disease. COPD 2013;10:156–63. doi:10.3109/15412555 .2012.72962.

Subodh Pandey, Barbara A. Phillips * Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, United States * Corresponding author. Tel.: +1 859 226 7008. E-mail address: [email protected] (B.A. Phillips). Available online 26 January 2015

Why is the prevalence of insomnia skyrocketing? And what can be done about it?

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