Insomnia

About one in every seven Canadians have difficulty going to sleep or staying asleep. The Management of Chronic Insomnia tool was developed to guide primary care providers in assessing and managing insomnia using non-pharmacological and pharmacological options in the general adult population.

Question #1: Use of sedative hypnotics, such as benzodiazepines or Z-drugs, can increase total sleep time by 52 minutes (compared to placebo).

Question #2: Behaviours such as maintaining a regular sleep schedule; sleeping only when tired; limiting caffeine and alcohol; and avoiding light-emitting devices before bedtime are representative of:

Question #3: The five most commonly prescribed medications likely to disrupt sleep are:

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Management of Chronic Insomnia tool
Management of Chronic Insomnia tool

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 Chronic insomnia can impact both daily functioning and quality of life. The Management of Chronic Insomnia tool addresses  what providers should do when a patient is concerned about their lack of sleep.

The tool also discusses appropriate management options, such as Cognitive Behaviour Therapy for Insomnia (CBT-I) and pharmacotherapy regimens to support primary care providers in their practice.

Divided into six sections, the tool highlights the following:

  1. Addressing and optimizing the management of any underlying medical, psychiatric or environmental causes
  2. Considering pharmacological causes of insomnia
  3. Non pharmacological options
  4. Pharmacotherapy
  5. Benzodiazepine or Z-drug Tapering
  6. Special populations

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Project Overview

Approximately half of the people who report insomnia symptoms also have multiple health problems. We developed the Management of Chronic Insomnia tool to help primary care providers identify patients who report having chronic insomnia and those who do not as well.

Development Process

The Management of Chronic Insomnia tool was developed using the CEP’s integrated knowledge translation approach. This approach ensures that providers are engaged throughout the development processes through the application of user centred design methodology. Clinical leadership of the resource was provided by Dr. Jose Silveira and Dr. Deanna Telner. Clinical experts were also engaged to provide feedback on the tool.

The Management of Chronic Insomnia tool is one of several resources developed as part of the Knowledge Translation in Primary Care Initiative. This multi-year initiative is a collaboration between the Centre for Effective Practice (CEP), the Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, CEP conducted a Primary Care Needs Assessment to determine topics of interest to primary care providers. In this survey, providers identified the need for more effective resources to help manage chronic insomnia.

Meet the Team

 The need for a more effective approach to manage chronic insomnia was identified by Ontario primary care providers as part of the Knowledge Translation in Primary Care Initiative. The Centre for Effective Practice enlisted the collaboration of clinical leads and a clinical working group to create the tool.

Clinical Leads

Jose Silveira Head ShotJose Silveira B.Sc., M.D., FRCPC, Dip. ABAM
Dr. Jose Silveira is an Associate Professor in the Department of Psychiatry at the University of Toronto; Psychiatrist-in-Chief at St. Joseph’s Health Centre in Toronto as well as Medical Director of Mental Health and Addiction Programs. He works closely with primary care physicians and has been part of the Ontario College of Family Physician’s Collaborative Mental Health Network since 2000 as a clinical resource, chair and steering committee member. Dr. Silveira’s scholarship has focused on knowledge translation into primary mental health and addiction care with an emphasis on safety.

 

Deanna TelnerDeanna Telner, MD, MEd, CCFP, FCFP 
Dr. Deanna Telner is a family physician at the community-based, academic teaching site, South East Toronto Family Health Team. She is involved in teaching medical students, residents and colleagues. She is an Assistant Professor and part-time researcher in the Department of Family and Community Medicine, University of Toronto. Her area of research interest is in postgraduate and continuing education. Dr. Telner has been extensively involved in the development of online clinical modules for primary care providers.

Acknowledgements

A clinical working group comprised of a nurse practitioner and a family physician participated in the development of this tool. Members include:

  • Claudia Mariano, nurse practitioner
  • Dana Newman, family physician

Thank you to all providers involved for their time and expertise.

Supporting Material

Here are some additional resources and sources of information. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. CEP will make every effort to keep these links up to date.

Supporting Materials

  1. Sleep Disorders Questionnaire
    http://www.topalbertadoctors.org/download/1923/Sleep%20Disorders%20Questionnaire.pdf
  2. Sleep Diary (patient can fill out)
    http://www.topalbertadoctors.org/download/1922/Sleep%20Diary.pdf?_20160406091338
  3. Insomnia Severity Index (patient can fill out)*
    C. M. Morin, G. Belleville, L. Belanger, H. Ivers (2011). The Insomnia Severity
    Index: Psychometric indicators to detect insomnia cases and evaluate
    treatment response. Sleep, 34, 601-608. © Morin, C.M. (1993, 1996, 2000, 2006).
    https://eprovide.mapi-trust.org/instruments/insomnia-severity-index/rc_isi_lastmonth_eng-ca-us
  4. Epworth Sleepiness Scale*
    Murray W. Johns. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale, Sleep, 1991; 14 (6): 540-545. ESS © MW Johns 1990-1997. Used under License.
    https://eprovide.mapi-trust.org/instruments/epworth-sleepiness-scale
  5. STOPBANG
    http://www.thoracic.org/assemblies/srn/questionaires/stop-bang.php
  6. Sleep Clinic Map
    https://css-scs.ca/resources/clinic-map
  7. Choosing Wisely Canada
    Insomnia and anxiety in older people: Sleeping pills are usually not the best
    solution.
    http://www.choosingwiselycanada.org/materials/insomnia-and-anxiety-inolder-people-sleeping-pills-are-usually-not-the-best-solution/
  8. Centre de Recherche de l’Institut Universitaire de Gériatrie de Montréal
    Sedative-Hypnotic Medication Deprescribing Brochure
    http://www.criugm.qc.ca/fichier/pdf/BENZOeng.pdf
  9. Additional supporting materials and resources that may be useful for providers
  10. MySleep101 – animated educational modules on sleep disorders
    Johns Hopkins Mobile medicine. Cost $5.49 CAD for mobile application.
    https://itunes.apple.com/us/app/mysleep101-animated-educational/id963623959?mt=8
  11. Sleepio Clinic:
    sleep medicine resources for healthcare professionals and researchers.
    https://www.sleepio.com/clinic/
  12. Evidence-based desprescribing algorithm for benzodiazepine receptor
    agonists.

    Pottie K, Thompson W, Davies S, Grenier J, Sadowski C, Welch V, Holbrook A,
    Boyd C, Swenson JR, Ma A, Farrell B (2016). Evidence-based clinical practice
    guideline for deprescribing benzodiazepine receptor agonists. [Unpublished
    manuscript].
    http://www.open-pharmacy-research.ca/evidence-based-deprescribingalgorithm-for-benzodiazepines
  13. Insomnia in Adults and Children
    This booklet reviews the pathology, the psychological and physical treatments
    of insomnia in adults, children and teens
    https://css-scs.ca/files/resources/brochures/Insomnia_Adult_Child.pdf
  14. Canadian Sleep Society
    The Canadian Sleep Society provides resources for clinicians and patients to
    treat insomnia.
    http://css-scs.ca
  15. Top Ten Sleep Tips (patient handout)
    http://www.topalbertadoctors.org/download/1924/Top%20Ten%20Sleep%20Tips.pdf?_20160406091338
  16. National Sleep Foundation
    https://sleepfoundation.org/insomnia/home
  17. Canadian Books on Sleep
    The Canadian Sleep Society has a list of Canadian books and workbook(s)
    on sleep
    https://css-scs.ca/resources/books
  18. Toxnet
    Toxicology Data Network
    http://toxnet.nlm.nih.gov
  19. Motherisk
    www.motherisk.org
  20. Online CBT-I & Apps
  21. CBT for Insomnia
    This website offers 5-session on-line cognitive behavioural therapy (CBT)
    program for insomnia. Cost ranges from $24.95 US to $49.95 US.
    http://www.cbtforinsomnia.com
  22. CBT-i Coach
    CBT-i Coach provides a structured program that teaches strategies to improve
    sleep and help alleviate symptoms of insomnia.
    http://t2health.dcoe.mil/apps/CBT-i
  23. Sleepio
    An evidence-based CBT-I online and mobile app programme. Cost is $300 US
    for a 12-month subscription.
    https://www.sleepio.com/
  24. SlumberPRO
    A self-help program based out of Queensland Australia that requires about 30-
    60 minutes each day. The program lasts 4-8 weeks. Cost $39 AUS.
    http://www.sleeptherapy.com.au/index.php?page=6
  25. Go! To Sleep
    A 6-week CBT-I program available through Cleveland Clinic of Wellness.
    A mobile app is also available. Cost $3.99 US for app or $40 US for web.
    http://www.clevelandclinicwellness.com/Programs/Pages/Sleep.aspx
  26. SHUTi
    A 6-week CBT-I program that has been evaluated in 2 randomized trials
    involving adults with insomnia and cancer survivors. Cost $135 US for 16 weeks
    access or $156 US for 20 weeks access.
    http://www.myshuti.com/
  27. Restore CBT-I
    A 6-week CBT-I program evaluated in a randomized trial (developed by
    Canadian psychologist, Dr. Norah Vincent). Price varies from £99 to £199.
    http://restore.cbtprogram.com/
  28. Sleep Training System
    6-week on-line CBT-I program with money-back guarantee and personalized
    feedback. Cost $29.95 US.
    http://www.sleeptrainingsystem.com/index.php
  29. Meditation Oasis
    Relax & Rest Guided Mediation apps. Cost $2.79 US.
    http://www.meditationoasis.com/apps/

*If you would like to use the ISI or ESS questionnaires in your practice, please contact Mapi Research Trust for permission to use: Mapi Research Trust, Lyon, France – Internet: https://eprovide.mapi-trust.org

References

  1. Statistics Canada. The Daily – Study: Insomnia. 2005. [cited 2016 October 16]. Available from http://www.statcan.gc.ca/daily-quotidien/051116/dq051116a-eng.htm
  2. Toward Optimized Practice. Assessment to management of adult insomnia. Clinical Practice Guideline. December 2015.
  3. Qaseem A, Kansagara D, Forciea M, Cooke M, Denberg T. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016. www.annals.org
  4. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):487-504.
  5. Jungquist C, O’Brien C, Matteson-Rusby S, Smith M, Pigeon W, Xia Y, et al. The Efficacy of Cognitive Behavioral Therapy for Insomnia in Patients with Chronic Pain. Sleep Med. 2010;11(3):302-9.
  6. Sidani S, Epstein D. Effects of a multi-component behavioral intervention (MCI) for insomnia on depressive and insomnia symptoms in individuals with high and low depression. J Evid Info Soc Work. 2015;12(5):451-61.
  7. Doufas A, Panagiotou O, Panousis P, Wong S, Ioannidis P. Insomnia from drug treatments: evidence from meta-analyses of randomized trials and concordance with prescribing information. Mayo Clin Proc. 2016;92(1):72-87.
  8. Winkelman J. Insomnia Disorder. N Engl J Med. 2015;373:1437-44.
  9. Allessi C, Vitiello M. Insomnia (primary) in older people: non-drug treatments. Clinical Evidence. 2015.
  10. Montgomey P, Dennis J. Physical exercise for sleep problems in adults aged 60+. Cochrane Database of Systemic Reviews. 2002;(4):CD003404.
  11. Chang A, Aeschbach D, Duffy J, et al. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. PNAS. 2015;112(4):1232-7.
  12. Morin CM, Beaulieu-Bonneau S, Ivers H, Vallières A, Guay B, Savard J, et al. Speed and trajectory of changes of insomnia symptoms during acute treatment with cognitive-behavioral therapy, singly and combined with medication. Sleep Med. 2014;15(6):701-7.
  13. Tenni P, Dunbabin D. A guide to deprescribing benzodiazepines. Consultant Pharmacy Services. Australia. 2016. [cited 2016 September 16] Available from http://www.primaryhealthtas.com.au/sites/default/files/A%20Guide%20to%20Deprescribing%20Benzodiazepines.pdf
  14. PL Detail-Document, Insomnia Treatments. Pharmacist’s Letter/Prescriber’s Letter. May 2013.
  15. Canadian Pharmacists Association. Therapeutic Choices for Minor Ailments. First Edition. 2013. Chapter 5: Insomnia, p. 33-42.
  16. Ferracioli-Oda E, Qawasmi A, Bloch MH. Meta-analysis: melatonin for the treatment of primary sleep disorders. PLOS ONE 2013; 8(5):e63773.
  17. Wright A, Diebold J, Otal J, et al. The effect of melatonin on benzodiazepine discontinuation and sleep quality in adults attempting to discontinue benzodiazepines: A systematic review and meta-analysis. Drugs Aging. 2015;32(12):1009-18.
  18. Fernández-San-Martín MI, Masa-Font R, Palacios-Soler L, Sancho-Gómez P, Calbó-Caldentey C, Flores-Mateo G. Effectiveness of valerian on insomnia: A meta-analysis of randomized placebo-controlled trials. Sleep Med. 2010;11(6):505-11.
  19. Glass J, Lanctot K, Hermann N, Sproule B, Busto U. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005.
  20. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007;22:1335
  21. Hansen R, Boudreau D, Ebel B, Grossman D, Sullivan S. Sedative hypnotic medication use and the risk of motor vehicle crash. Am J Public Health. 2015;105(8):e64-e69
  22. Barbone F, McMahon AD, Davey PG, Morris AD, Reid IC, McDevitt DG, MacDonald TM. Association of road-traffic accidents with benzodiazepine use. Lancet. 1998; 352:1331–36.
  23. Gustavsen I, Bramness JG, Skurtveit S, Engeland A, Neutel I, Mørland J. Road traffic accident risk related to prescriptions of the hypnotics zopiclone, zolpidem, flunitrazepam and nitrazepam. Sleep Medicine. 2008;9(8):818–822.
  24. Movig KL, Mathijssen MP, Nagel PH, van Egmond T, de Gier JJ, Leufkens HG, Egberts AC. Psychoactive Substance Use and the Risk of Motor Vehicle Accidents. Accident Analysis and Prevention. 2004;36(4):631–636.
  25. Engeland A, Skurtveit S, Mørland J. Risk of Road Traffic Accidents Associated With the Prescription of Drugs: A Registry-Based Cohort Study. Ann Epidemiol 2007;17(8):597–602.
  26. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934-1943.
  27. Canadian Geriatrics Society. Insomnia and anxiety in older people. Choosing Wisely Canada. 2014. [cited 2016 September 22] Available from http://www.choosingwiselycanada.org/wp-content/uploads/2014/09/Sleeping-pills-EN.pdf.
  28. Pollman AS, Murphy AL, Berman JC, Gardner DM. Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review. BMC Pharmacology and Toxicology. 2015;16:19.nb
  29. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. 2015. Appendix B-6. Benzodiazepine Tapering. [cited 2016 December 30] Available from http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b06.html
  30. Paquin A, Zimmerman K, Rudolph J. Risk versus risk: a review of benzodiazepine reduction in older adults. Expert Opin Drug Saf. 2014;13(7):919-34.
  31. Gould R, Coulson M, Patel N, Highton-Williamson E, Howard R. Interventions for reducing benzodiazepines in older people: meta-analysis of randomized controlled trials. Br J Psych. 2014;204:98-107.
  32. Otto M, McHugh R, Simon N, Farach F, Worthington J, Pollack M. Efficacy of CBT for benzodiazepine discontinuation in patients with panic disorder: Further evaluation. Behav Res Ther. 2010;48:720-7.
  33. Bostwick, JR, Casher MI, Yasugi S. Benzodiazepines: A versatile clinical tool. Current Psych. 2012;11(4):55-63
  34. Benzodiazepine. e-cps. 2015. [cited December 31, 2015]
  35. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized controlled trial. JAMA. 2006 Jun 28;295(24):2851-8.
  36. Krystal AD, Lankford A, Durrence HH, Ludington E, JochelsonP, Rogowski R, Roth T. Efficacy and safety of doxepin 3 and 6 mg in a 35-day sleep laboratory trial in adults with chronic primary insomnia. Sleep. 2011 Oct 1;34(10):1433-42.
  37. By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-46.
  38. Wilson SJ, Nutt DJ, Alford C, Argyropoulos SV, Baldwin DS, Bateson AN, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol Oxf Engl. 2010 Nov;24(11):1577-601.
  39. Driver H, Gottschalk R, Hussain M, Morin C, Shapiro C, Van Zyl L. Insomnia in Adults and Children. Joli Joco Publications Inc., 2012. [cited 2016 May 16] Available from http://css-scs.ca/images/brochures/Insomnia_Adult_Child.pdf

Copyright & Disclaimer

CEP fully supports the use of the Management of Chronic Insomnia tool by providers, educators, decision-makers and others. Please read the following information prior to use of the tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative CommonsThe Management of Chronic Insomnia tool is a product of the Centre for Effective Practice.  Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citation.  Use of the Management of Chronic Insomnia tool for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: [email protected])

For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the tool.

Please use this citation when referencing the tool: Reprinted with Permission from Centre for Effective Practice (January 2017). Management of Chronic Insomnia tool. Toronto: Centre for Effective Practice.

Disclaimer

The Management of Chronic Insomnia tool (the “Tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations.  These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Their Party Resource(s).

This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice.  Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool.

Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.