The American Journal Of Managed Care made available (for free) two excellent articles on co-morbid insomnia. “Comorbid Insomnia: Current Directions and Future Challenges” provides an excellent background and overview of this complicated sleep disorder, while “Current and New Thinking in the Management of Comorbid Insomnia” reviews current medications along with a short explanation of behavioral approaches to treatment. Check the end of this review for links to download both articles in PDF format.
“Comorbid Insomnia: Current Directions and Future Challenges” (Roth, 2009) covers the epidemiology/impact, complexities, evaluation, medical and psychiatric co-morbidities, and treatment. The abstract reads,
“Insomnia is a leading cause of absenteeism, presenteeism (lost productivity when employees are at work), accidents, and errors in the workplace. Overall direct and indirect costs exceed $30 billion annually. A significant portion of these costs are attributable to patients with comorbid insomnia, making these conditions a significant clinical public health issue. These comorbid conditions include mood and anxiety disorders; chronic pain; respiratory, urinary, and neurologic conditions; diabetes; and cardiovascular diseases. Traditional treatment for insomnia with comorbid conditions has focused on treating the comorbid condition with the expectation that the insomnia will resolve. Recent studies, however, suggest this approach is not the most appropriate. Instead, treating both conditions simultaneously may improve the outcomes for each.”
“Current and New Thinking in the Management of Comorbid Insomnia” (Neubauer, 2009) details a mostly medical approach to treatment. However, non-medical practitioners may find this to be a valuable overview of the pharmacological treatment of comorbid insomnia. Topics include general considerations in treatment, specific pharmacologic treatments, including benzodiazepine hypnotics, non-benzodiazepine hypnotics, melatonin receptor agonists, future directions in pharmacologic treatments, and non-pharmacologic/behavioral treatments, such as sleep hygiene, relaxation training, stimulus control, and sleep restriction. The abstract states that,
“Insomnia occurs predominantly in conjunction with a medical or psychiatric illness. New thinking regarding the treatment of comorbid insomnia has moved the field away from practices that called for treating the comorbid condition to resolve the coexisting insomnia to one in which the insomnia is treated as a separate condition. Although 10 medications currently are approved by the US Food and Drug Administration for the treatment of insomnia, only 2, eszopiclone and zolpidem, have been evaluated for efficacy in patients with chronic comorbid insomnia. Studies suggest clear benefits in comorbid insomnia. Nonpharmacologic treatments, such as cognitive behavioral therapy, sleep hygiene, and relaxation training, have also been investigated for comorbid insomnia, with studies suggesting these approaches may be effective either alone or in conjunction with medications. While behavioral issues should be optimized, clinicians need to customize treatments for patients with comorbid insomnia based on coexisting medical and psychiatric morbidities, age, medical history, current medications, and lifestyle issues.”
Neubauer, D. (2009). Current and New Thinking in the Management of Comorbid Insomnia. American Journal of Managed Care, 15, S24-S32.
Roth, T. Comorbid Insomnia: Current directions and future challenges (2009). American Journal of Managed Care, 15, S6-S13.