New Guidelines Issued for Insomnia and Other Sleep Disorders

From Medscape Medical News
Laurie Barclay, MD

September 2, 2010 — The British Association for Psychopharmacology (BAP) has issued a consensus statement on evidence-based treatment of insomnia, parasomnias, and circadian rhythm disorders. The new recommendations, intended to guide psychiatrists and physicians caring for those with sleep problems, are published online September 2 in the Journal of Psychopharmacology.

"Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners," write Sue J. Wilson, from the Psychopharmacology Unit, University of Bristol, Bristol, United Kingdom, and colleagues.
"These ...BAP guidelines are designed to address this problem by providing an accessible yet up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment.
We limited ourselves to discussion of sleep problems that are not regarded as being secondary to respiratory problems (e.g. sleep apnoea – see NICE Guidance TA139), as these fall outside the remit of the BAP."

These guidelines also do not cover neuropsychiatric disorders, such as narcolepsy and restless legs, for which recent sets of guidelines already exist. The new recommendations were developed after a consensus meeting in London in May 2009 of BAP members, as well as clinicians, experts, and advocates in sleep disorders, based on literature reviews and a description of standard of evidence.

Recommendations for Diagnosis and Treatment

Specific evidence-based recommendations for diagnosis and treatment of insomnia and other sleep disorders, and their accompanying level of evidence rating, are as follows:

The diagnosis of insomnia is primarily based on complaints provided in the clinical interview by the patient, family, and/or caregiver, ideally corroborated by a patient diary.
Referral to a specialist sleep center may be indicated for other tests in some cases, such as actigraphy for differential diagnosis of circadian rhythm disorder, polysomnography for suspected parasomnia or other primary sleep disorder, or in the case of treatment failure.
Insomnia should be treated because it impairs quality of life and many areas of functioning and is associated with an increased risk for depression, anxiety, and possibly cardiovascular disorders. Treatment goals are to reduce distress and to improve daytime function. Choice of treatment modality is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
For chronic insomnia, cognitive behavioral therapy (CBT)-based treatment packages are effective and should be offered to patients as a first-line treatment. CBT, which may include sleep restriction and stimulus control, should be made available in more settings.
When prescribing hypnotic drug treatment, clinicians need to consider efficacy, safety, and duration of action. Other issues to consider may include previous efficacy or adverse effects of the drug and history of substance abuse or dependence.
Recommendations for long-term hypnotic drug treatment are to use it as clinically indicated. To discontinue long-term hypnotic drug therapy, intermittent use should first be attempted if feasible. Depending on ongoing life circumstances and patient consent, discontinuation should be attempted every 3 to 6 months or at regular intervals. During taper of long-term hypnotic drug treatment, CBT improves outcome.
When using antidepressants, clinicians should apply their knowledge of pharmacology. When there is a comorbid mood disorder, antidepressants should be used at therapeutic dose. However, clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed.
Because of frequent adverse effects of antipsychotic drugs, as well as a few reports of abuse, there is no indication for use as first-line treatment of insomnia or other sleep disorders.
Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia.

Recommendations for Certain Populations

Specific evidence-based recommendations for management of insomnia and other sleep disorders in special populations and conditions are as follows:

After menopause, the incidence of sleep-disordered breathing increases, and the clinical presentation is different in women vs men and often includes insomnia. Informed, individualized treatment of symptoms is needed for use of hormone therapy, considering risks and benefits clarified in recent studies.

Behavioral strategies are recommended for children with disturbed sleep.
In children with attention-deficit/hyperactive disorder not treated with stimulant drugs, melatonin administration may help advance sleep onset to normal values.
For children and adults with learning disabilities, clinical evaluation should describe the sleep disturbance and triggering and exacerbating factors

Recommended first-line therapy includes environmental, behavioral, and educational strategies.
Melatonin is effective in improving sleep. The treatment plan should be based on a capacity/best-interests framework.
For management of circadian rhythm disorders, clinical evaluation is essential in delayed sleep-phase syndrome and free-running disorder.
In delayed sleep-phase syndrome, free-running disorder, and jet lag, melatonin may be useful, but other strategies such as behavioral regimens and scheduled light exposure (in sighted individuals) can also be used .

J Psychopharmacol. Published online September 2, 2010.