Sleep Disorders

Insomnia

Insomnia is a common sleep disorder, characterized by the inability to initiate or maintain sleep or early morning awakening despite the opportunity to sleep. At least one-third of the adult population reports having symptoms consistent with insomnia, and 10% to 15% meet the diagnostic criteria for chronic insomnia. Untreated insomnia is associated with many psychiatric and medical comorbidities, in addition to a significant economic burden related to increased healthcare utilization, decreased productivity, and absenteeism. Cognitive behavioral therapy for insomnia (CBT-I), which does not involve sedative-hypnotic medications, is one of the most effective treatments for insomnia.

Patients are evaluated and treated for insomnia with CBT-I by a behavioral sleep medicine expert at the Sleep Disorders Center, individually or in a group setting. CBT-I strategies include stimulus control, sleep restriction, and cognitive restructuring of negative thoughts about sleep. Meta-analyses have shown better and more durable outcomes in insomnia patients using CBT-I compared with using sedative-hypnotic medications alone.

Improvement in Insomnia-Related Symptoms Following Individual CBT-I

2018 – 2019

CBT-I = cognitive behavioral therapy for insomnia, ESS = Epworth Sleepiness Scale, FSS = Fatigue Severity Scale, ISI = Insomnia Severity Index, PHQ-9 = Patient Health Questionnaire, PROMIS = Patient-Reported Outcomes Measurement Information System, TST = total sleep time

Among 542 patients evaluated using the Epworth Sleepiness Scale (ESS) during at least 2 visits in 2018–2019, 232 had a baseline score ≥ 10. At follow-up, 49.6% showed improvement, 40.1% remained stable, and 10.3% worsened. Clinically meaningful change was defined as a 3 point change, based on one-half the standard deviation.¹ Median duration of follow-up was 154 days (range, 15-733).

Among 462 patients evaluated using the Fatigue Severity Scale (FSS) during at least 2 visits in 2018–2019, 320 had a baseline score ≥ 36. At follow-up, 29.1% showed improvement, 63.7% remained stable, and 7.2% worsened. Clinically meaningful change was defined as a 7 point change, based on one-half the standard deviation.¹ Median duration of follow-up was 156 days (range, 15-654).

Among 448 patients evaluated using the Insomnia Severity Scale (ISI) during at least 2 visits in 2018–2019, 355 had a baseline score ≥ 10 indicating significant insomnia symptoms. At follow-up, 54.9% showed improvement, 36.1% remained stable, and 9% worsened. Clinically meaningful change was defined as a 3 point change, based on one-half the standard deviation.¹ Median duration of follow-up was 157 days (range, 13-733).

Among 471 patients evaluated using the Patient Health Questionnaire (PHQ-9) during at least 2 visits in 2018–2019, 167 had a baseline score ≥ 10. At follow-up, 40.7% showed improvement, 52.1% remained stable, and 7.2% worsened. Clinically meaningful change was defined as a 6 point change, based on one-half the standard deviation.² Median duration of follow-up was 154 days (range, 15-733).

Among 271 patients with obstructive sleep apnea (OSA) evaluated using the Patient-Reported Outcomes Measurement Information System (PROMIS) during at least 2 visits in 2018–2019, 107 had a baseline Mental Health score ≤ 45 indicating impairment in mental health. At follow-up, 20.6% showed improvement, 66.4% remained stable, and 13.1% worsened. Clinically meaningful change was defined as a 5-point change in T-score, based on one-half the standard deviation.¹ Median duration of follow-up was 185 days (range, 14-695).

Among 270 patients with OSA evaluated using PROMIS during at least 2 visits in 2018–2019, 131 had a baseline Physical Health score ≤ 45 indicating impairment in physical health. At follow-up, 20.6% showed improvement, 69.5% remained stable, and 9.9% worsened. Clinically meaningful change was defined as a 5-point change in T-score, based on one-half the standard deviation.¹ Median duration of follow-up was 161 days (range, 14-695).

Among 487 patients with self-reported total sleep time (TST) during at least 2 visits in 2018–2019, 31.4% showed improvement, 50.9% remained stable, and 17.7% worsened. Clinically meaningful change was defined as a 1 point change, based on one-half the standard deviation.¹ Median duration of follow-up was 157 days (range, 7-654).

References
  1. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003 May;41(5):582-592.
  2. Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004 Dec;42(12):1194-1201.