New guidelines to ease sleepless nights

BAP members, representative clinicians with a strong interest in sleep disorders and experts from the US and Europe got together in May 2009 in London, England to share their knowledge of insomnia, parasomnias and circadian rhythm disorders. As well as a chance to share literature reviews and clinical trial data, the event gave experts the opportunity to reach a consensus on the best current treatments for sleep disorders. The BAP then used this and further rounds of consultation with the event participants to create its guidelines, BAP consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders, which the organisation hopes will present a comprehensive guide to clinicians, who are managing patients in primary or secondary medical care.

Sleep experts agree that insomnia is a condition of unsatisfactory sleep, either in terms of sleep onset, sleep maintenance or early waking. They also agree that insomnia is a disorder that impairs daytime well-being and subjective abilities and functioning, and so can be considered a '24-hour' disorder. Insomnia can also be viewed as a syndrome similar to pain, because it is subjective and its diagnosis is through clinical observations rather than measurements. In some cases physicians will be unable to pinpoint a cause, although this doesn't prevent diagnosis.

Stress, life changes, a new baby, or shift work are typical factors that can trigger insomnia, but for some people this acute insomnia persists into a chronic state. Anxiety about sleep, maladaptive sleep habits and the possibility of an underlying vulnerability in sleep regulating mechanisms are all likely causes, as are other co-morbid disorders such as anxiety and depression, and diseases including cancer or arthritis. The recommendations address issues such as pregnancy, menopause, ageing, childhood disorders and other specific factors with suggestions for treatment, and an indication of the degree of agreement among experts in each case.

The good news is that insomnia can often be improved with specialist cognitive behavioral therapy (CBT) targeted at insomnia, which is as effective as prescription medications for short-term treatments for chronic insomnia. In addition, CBT is more likely to have a longer-lasting effect than drug treatment. However access to this type of treatment for insomnia sufferers is not always easy to access in the UK.

Women have a higher incidence of insomnia than men, and the older we get the more likely we are to suffer from poor sleep. Around a third of adults in Western countries will experience some difficulty getting to sleep or staying asleep at least once a week, and between six and 15 percent are thought to have full-blown insomnia.

Circadian rhythm disorders occur when our internal clocks don't match our daily lives. Caused most often by shift work and jet lag, some people also routinely have difficulty going to bed before two or three AM and waking up in the morning on time (delayed sleep phase syndrome). Others get cumulatively later as time goes, a condition known as free running sleep disorder.

Night terrors, sleep walking and violent behaviour at night are known as 'parasomnias.' Physicians may need to refer patients experiencing these distressing episodes to a specialist sleep centre for polysomnography and video recording for a correct diagnosis, and to discover whether the attacks occur during REM (rapid eye movement) or non-REM sleep, which can mean differing treatments.

Finding sleep inducing drugs that are readily absorbed by the body, work fast enough to be useful but clear out of the system by the morning to avoid a 'hangover' can be a challenge. In addition, stopping treatment can lead to problems in some cases, although this is not inevitable and is not an issue with several drugs that researchers have now studied. Long term drug use for insomnia is controversial and has been discouraged in the past -- although in fact this was due to the fact no longer term clinical trials had been conducted rather than due to a known risk of continued use. Despite the recommendation for treatment with hypnotic drugs being only two to four weeks, many millions of patients worldwide remain on long-term treatment. Researchers have recently carried out placebo-controlled trials which suggest that the risk/benefit for many drugs offered for insomnia does not change after three or four weeks' use. Taking drugs only 'as needed' rather than every night is one solution. However, the longer-term safety and efficacy of many other commonly used hypnotics remains uncertain.

Insomnia and other sleep disorders can decrease patients' quality of life, impair functioning, and increase the chances of depression, anxiety, and possibly cardiovascular disorders. Thankfully, a choice of treatments guided by professionals armed with the BAP guidelines mean a good night's rest could finally be within reach.