Insomnia is defined as poor sleep despite adequate opportunity. Acute insomnia usually remits once the offending stressor is gone, however adaptations may occur leading to chronic insomnia. Insomnia must be present for at least 3 nights a week for at least 3 months to be considered chronic.
It is estimated that 10-15% of the population suffers from chronic insomnia. It can be disabling, with numerous consequences on daytime functioning including fatigue, sleepiness, mood disturbance, proneness to judgement errors such as motor vehicle accidents, tension headaches and increased pain. Chronic insomnia is also associated with considerable morbidity, including an increased risk of GI problems, headaches, muscle pain and mental health conditions along with a doubling of risk for hypertension. Getting less than 7 hours of sleep is correlated with obesity. After only 2 weeks of insomnia, there is a 4-fold increased risk for developing a first episode of depression. Dr. Colin Shapiro of Toronto, Canada has published a book on the sleep, pain and mood triangle.
Despite sleep being considered fundamental for health, few general practitioners or specialists routinely ask patients about their sleep. Rheumatologists are not in the practice of prescribing medication specifically for the purpose of enhancing sleep. The hope is that improvements in disease activity will lessen pain, and therefore sleep quality will improve. Yet this is often not the case, and pain, fatigue and poor sleep may continue despite achieving low disease activity.
Cognitive Behavioural Therapy for Insomnia (CBT-I) has demonstrated efficacy as a treatment for primary insomnia where no other co-morbid condition exists. In the presence of pain or depression, many practitioners assume that treatment of insomnia cannot be successful without the use of pharmacotherapy. But in fact, CBT-I is as effective for treating insomnia in the presence of pain as pharmacotherapy, and has a longer duration of benefit.
Treating co-morbid insomnia may improve the co-morbid condition itself. In patients with chronic pain, coping ability, quality of life and physical activity all improved with improved sleep following CBT-I treatment. It is expected that 70-80% of patients with insomnia could benefit from this approach.
CBT-I programs exist throughout Canada and some are government-funded. New online resources are being developed to reach communities that do not have a professional trained in CBT-I. The effectiveness of an online program for patients with background pain has yet to be determined, but it may be worth consideration.
Carolyn Whiskin, BSc. Phm is currently the director of pharmacy programs for the Charlton Centre for Specialized Treatments in Hamilton, Ontario. She also practices pharmacy at Brant Arts Dispensary in Burlington, Ontario and is the pharmacist representative to the Ontario Rheumatology Association’s Model of Care committee.View Full Bio