Abstract
Objective
To measure the frequency of pharmacotherapeutic failure and its association with the
diagnosis of sleep-disordered breathing among patients with chronic insomnia disorder.
Patients and Methods
In a retrospective review of medical records from January 1, 2005, through December
31, 2012, we identified an inclusive, consecutive series of 1210 patients with insomnia
disorder, 899 (74.3%) of whom used sleep aids either occasionally (168 [18.7%]) or
regularly (731 [81.3%]). Patients presented to a community-based sleep medicine center
in Albuquerque, New Mexico, with typical referral patterns: 743 (61.4%) were referred
by primary care physicians, 211 (17.4%) by specialists, 117 (9.7%) by mental health
professionals, and 139 (11.5%) by self-referral. Pharmacotherapeutic failure was assessed
from subjective insomnia reports and a validated insomnia severity scale. Polysomnography
with pressure transducer (an advanced respiratory technology not previously used in
a large cohort of patients with insomnia) measured sleep-disordered breathing. Objective
data yielded accuracy rates for 3 pretest screening tools used to measure risk for
sleep-disordered breathing.
Results
Of the total sample of 1210 patients, all 899 (74.3%) who were taking over-the-counter
or prescription sleep aids had pharmacotherapeutic failure. The 710 patients taking
prescription drugs (79.0%) reported the most severe insomnia, the fewest sleep-associated
breathing symptoms, and the most medical and psychiatric comorbidity. Of the 942 patients
objectively tested (77.9%), 860 (91.3%) met standard criteria, on average, for a moderate
to severe sleep-associated breathing disorder, yet pretest screening sensitivity for
sleep-disordered breathing varied widely from 63.7% to 100%. Positive predictive values
were high (about 90%) for all screens, but a tool commonly used in primary care misclassified
301 patients (32.0% false-negative results).
Conclusion
Pharmacotherapeutic failure and sleep-disordered breathing were extremely common among
treatment-seeking patients with chronic insomnia disorder. Screening techniques designed
from the field of sleep medicine predicted high rates for sleep-disordered breathing,
whereas a survey common to primary care yielded many false-negative results. Although
the relationship between insomnia and sleep-disordered breathing remains undefined,
this research raises salient clinical questions about the management of insomnia in
primary care before sleep center encounters.
Abbreviations and Acronyms:
AASM (American Academy of Sleep Medicine), AHI (apnea-hypopnea index), ISI (Insomnia Severity Index), MSAS (Maimonides Sleep Arts & Sciences, Ltd), NCPT (nasal cannula pressure transducer), NPV (negative predictive value), OSA (obstructive sleep apnea), OTC (over-the-counter), PAP (positive airway pressure), PPV (positive predictive value), PSG (polysomnography), RDI (respiratory disturbance index), RERA (respiratory effort–related arousal), SDB (sleep-disordered breathing), UARS (upper airway resistance syndrome)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: September 15, 2014
Footnotes
For editorial comment, see page 1591
Potential Competing Interests: Mr Ulibarri and Ms McIver report no conflicts of interest. Dr Krakow owns and operates 6 websites that provide education and offer products and services for patients with sleep disorders; is the medical director of Classic SleepCare, for which his sole functions are consultation/quality assurance with no patient encounters or benefit from the sale of any equipment; markets and sells 3 books for patients with sleep disorders; owns and operates Maimonides Sleep Arts & Sciences, Ltd; conducts educational programs on sleep disorders for medical and mental health professionals, some of which involve the attendee paying a fee directly and others that may be paid for by vendors such as Respironics, Inc, and ResMed or other institutions such as the US Army Medical Education Department Center and School, US Department of Veterans Affairs medical centers, and regional sleep centers; and is president of the Sleep & Human Health Institute that occasionally provides consultation services or receives grants for pilot studies from companies including Con Alma, Respironics, Inc, GlaxoSmithKline, Covidien, the Simon Charitable Foundation, and the Oxnard Foundation.
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