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Patients With Treatment-Resistant Insomnia Taking Nightly Prescription Medications for Sleep: A Retrospective Assessment of Diagnostic and Treatment Variables

Prim Care Companion J Clin Psychiatry 2010;12(4):e1-e10
10.4088/PCC.09m00873bro

Background: Some chronic insomnia patients who take nightly prescription medication achieve less than optimal results. The US Food and Drug Administration (FDA) and the American Academy of Sleep Medicine (AASM) recommend reevaluation of this type of patient to assess for potential psychiatric or medical causes to explain this “failure for insomnia to remit.”

Method: A retrospective chart review examined a consecutive series of chronic insomnia patients with persistent insomnia complaints despite current nightly use of prescription medication from May 2005 to February 2008. To assess the role of psychiatric influences on insomnia symptoms, our sample (N = 218) was divided into 2 subgroups: a group with a history of psychiatric complaints (psychiatric insomnia, n = 189) and a control group of no psychiatric complaints (insomnia, n = 29).

Results: The average patient reported insomnia for a decade and took prescription medication for sleep for a mean of 4.5 years. Although 100% of the sample used nightly sleep drugs, only 20% believed medication was the best solution for their condition. As evaluated by self-report and polysomnography, these patients exhibited moderately severe insomnia across most measures. Only a few differences were noted between groups. Subjective perception of insomnia severity was worse in the psychiatric insomnia group, which also reported significantly more insomnia-related interference in daily functioning, symptoms of sleep maintenance insomnia, and a trend toward greater daytime fatigue. The mean Apnea-Hypopnea Index score was 19.5 events/hour, yielding an obstructive sleep apnea diagnosis in 75% of patients per conservative AASM nosology (79% in the insomnia group and 74% in the psychiatric insomnia group, P = .22).

Conclusions: In this treatment-seeking sample of patients regularly taking sleep medications, residual insomnia was widespread, and patients with psychiatric insomnia may have perceived their condition as more problematic than a control group of insomnia patients without mental health complaints. Both groups exhibited high rates of objectively diagnosed obstructive sleep apnea, a medical condition associated with pervasive sleep fragmentation. These findings support FDA and AASM guidelines to reassess chronic insomnia patients who manifest residual symptoms despite nightly use of prescription medication for sleep.

Prim Care Companion J Clin Psychiatry 2010;12(4):e1–e10

Submitted: August 20, 2009; accepted November 24, 2009.

Published online: August 12, 2010 (doi:10.4088/PCC.09m00873bro).

Corresponding author: Barry Krakow, MD, Sleep & Human Health Institute, 6739 Academy NE, Ste 380, Albuquerque, NM 87109 (bkrakow@sleeptreatment.com).