Review
Sleep America: Managing the crisis of adult chronic insomnia and associated conditions

https://doi.org/10.1016/j.jad.2011.05.014Get rights and content

Abstract

Introduction

Chronic insomnia, a public health crisis affecting 10–15% of the U.S. population and costing billions of dollars annually, typically presents with one or more comorbid psychiatric or organic conditions. Historical classification of chronic insomnia as “secondary” to a presenting comorbid condition has resulted in under-recognition and under-treatment of both the insomnia and comorbid condition(s). Though critical in any model of comorbid disease management, chronic insomnia receives little, if any, public policy attention.

Method

We conducted a systematic review of recent empirical studies, review papers, books, government documents, press releases, advertisements, and articles pertaining to the classification, epidemiology, treatment, and physiology of sleep, insomnia, and comorbid conditions. Data were located primarily through MEDLINE, PsycINFO, SCOPUS, and PUBMED databases.

Objective and results

Our goal was to provide an overview of the systems for classifying insomnia and available epidemiological data, and to review theoretical models regarding the etiology and maintaining factors of chronic insomnia along with research on the complex, bidirectional associations between chronic insomnia and various affective (and other) conditions.

Conclusions

After thorough review of the literature, we propose several public policy measures as an initial step in managing chronic insomnia in the United States. These include introducing a nation-wide multi-modal educational and awareness campaign titled “Sleep America;” increasing the availability and demand for behavioral sleep medicine — the initially preferred treatment approach; and increasing the use of monitoring and enforcement activities by regulatory authorities to curtail false and misleading claims by sponsors of supplements or treatments for insomnia. Through the adoption of such measures, we hope to galvanize a national interest in healthy sleep and the evidence-based treatment of chronic insomnia.

Section snippets

Insomnia: prevalence, nosology, co-morbidities, and costs

Despite the overwhelming evidence associating insomnia with serious organic and psychiatric illnesses, public health bodies have largely overlooked the importance of sleep in maintaining physical and mental health (IMNA, 2006). For years, classification of insomnia as a symptom of, or secondary to, a comorbid condition has left millions of Americans with undiagnosed and untreated sleep disorders. Scientific research, however, has belied the assumption of causality, demonstrating instead a

Theoretical models

Several theoretical models have attempted to explain the etiology and/or maintenance of insomnia by describing the contributions of various cognitive, behavioral, physiological, and affective factors (Jansson and Linton, 2007). Identifying a precise trigger, cause, or even directionality of the multiple components underlying chronic insomnia, however, has proven difficult, if not impossible (Reimann, et al., 2010). Chronic insomnia was historically viewed as a psychological problem stemming

Treatments for insomnia

Individuals with insomnia use several forms of treatment including cognitive/behavioral therapy, pharmacotherapy, over-the-counter drugs, and herbal or dietary supplements. Those with insomnia typically choose treatments that are quick, easy, and many times self-administered, such as drugs and supplements. This is not surprising given the prevalence of advertisements for pharmaceuticals, over-the-counter drugs, and supplements to manage insomnia with conversely none for cognitive and behavioral

Public policy initiatives

In this paper we have shown that chronic insomnia is a public health crisis placing substantial economic, health, and social burdens on society. Though separate attention to, and treatment of, chronic insomnia is a necessary component in any model of comorbid disease management, it is routinely overlooked and undertreated. How we shape public health policies to manage this crisis remains largely unexplored. Chronic insomnia, moreover, is not the only sleep crisis in the United States. Chronic

Conclusion

In this paper, we have demonstrated that although chronic insomnia is a crisis placing substantial economic and social burdens on society, it receives comparatively little, if any, public health or clinician attention. Disparate systems of classifying, diagnosing, and sub-typing insomnia have confounded efforts to define affected populations. Moreover, insomnia has been idiosyncratically defined and non-uniformly measured in epidemiological research resulting in potential exclusion of those in

Role of the funding source

There are no funding sources to report.

Conflict of interest

There are no conflicts of interest to report.

Acknowledgments

There are no acknowledgements to report.

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