Management Strategies for Insomnia

Approximately 30% of the general population experiences insomnia symptoms, and 6% to 10% have symptoms associated with daytime functional impairment. During a presentation at NAMCP 2020 Virtual Spring Managed Care Forum, David N. Neubauer, MD, of Johns Hopkins University School of Medicine, discussed treatment goals for treating patients with insomnia and addressed barriers to care.

Risk factors for insomnia include comorbid mental and physical disorders, temperamental factors (e.g., anxiety, repression of emotions), environmental issues (e.g., noise, light, temperature), advancing age, and genetic components. Patients with insomnia have an increased risk of other conditions, such as major depression, hypertension, alcohol use, reduced quality of life, etc.

Insomnia can also pose a societal burden, resulting in decreased productivity, lost income, vehicular crashes, and other accidents. A study published in 2019 in Sleep found that untreated insomnia increased all-cause health care utilization and costs among Medicare beneficiaries across all point of service locations (inpatient, emergency department, outpatient, prescriptions). A 2014 study published in the American Journal of Managed Care found that following an insomnia diagnosis, health appears to decline relatively more than in members without this diagnosis. Untreated insomnia was also associated with 26% higher costs.

Treatment approaches for insomnia can include healthy sleeping habits, education about sleep, optimization of comorbid conditions, psychotherapeutic techniques, behavioral strategies, cognitive behavioral therapy, and pharmacotherapy.

Dr. Neubauer then discussed pharmacotherapy options in detail. He noted that there are a number of dietary supplement sleep aids on the market, none of which are regulated by the U.S. Food and Drug Administration (FDA) and most of which have limited efficacy data to support their claims. There are also a number of over-the-counter sleep aids, which are regulated by the FDA. Often, medications are used off-label for insomnia, including antidepressants, antipsychotics, anxiolytics, antihistamines, anticonvulsants/mood stabilizers, and antihypertensives.

He then highlighted some current FDA-approved insomnia therapies, such as benzodiazepine receptor agonists, ramelteon, low-dose doxepin, suvorexant, and lemborexant. The FDA has added boxed warnings for serious injuries caused by sleep walking with certain insomnia medicines.

Despite various treatment options, there are a number of barriers to effective treatment. For example, patients may not view sleep as a health issue, and they may have misinformation about insomnia treatment options. Physicians may not screen for sleep disorders and may not consider insomnia a serious problem. Poor treatment adherence, therapy costs, and insurance and formulary limitations can also hamper efforts to manage insomnia. Treatment should be personalized to optimize efficacy and safety, Dr. Neubauer concluded.

Presentation: Effective Ways to Manage Insomnia: Improving Outcomes through Optimal Treatment Strategies. NAMCP 2020 Virtual Spring Managed Care Forum, April 16-17.