No longer mentioning a precipitating life stressor and talking about insomnia as “the problem” may mark the transition from short-term to chronic insomnia. 9 Short-term and chronic insomnia may be inferred from a patient’s language. It may end when the stressor resolves or the patient learns to cope, or it may evolve into chronic insomnia. Insomnia is often precipitated by a significant life stressor (eg, acute pain, traumatic event). 8 It is short-term if symptoms occur for less than 3 months and chronic if symptoms occur 3 or more times per week for 3 months or longer. 8ĭiagnostic criteria for insomnia include difficulty getting to sleep or staying asleep and results in daytime dysfunction in a patient who has an adequate opportunity to sleep. To the contrary, the maladaptive cognitions and behaviors that perpetuate insomnia must be addressed regardless of coexisting medical or psychiatric disorders. The underlying rationale for removal was that calling insomnia comorbid may misleadingly imply that it is a secondary concern that will resolve with adequate treatment of the comorbid condition. The previous subclassification of chronic insomnia as primary or comorbid was eliminated because it did not improve diagnostic accuracy or differentiate treatment options. 8 It now subclassifies insomnia as short-term, chronic, or other. In 2014, the third edition of the International Classification of Sleep Disorders ( ICSD-3), the most widely used classification system for sleep disorders, revised how insomnia is defined. Insomnia: Classification, Diagnosis, and Monitoring In a recent study of a managed care population, an 80% increase in healthcare costs after a diagnosis of insomnia was attributed to management of insomnia and coexisting conditions. 4 Further, insomnia is linked to higher healthcare utilization and costs, especially in patients with coexisting medical or psychiatric disorders, 5,6 illustrating why it is an important managed care issue. 3 Between 19, the diagnosis of insomnia during office visits in the United States increased 11-fold, from 800,000 to 9.4 million. 2 Because it is so common, the annual loss of quality-adjusted life-years from insomnia appears to be greater than the loss from other medical and psychiatric conditions, including arthritis, depression, and hypertension. 1 Combined direct and indirect costs for insomnia in the United States exceed $100 billion annually. Insomnia, the most common sleep disorder, is a substantial burden for the US healthcare system and vulnerable patient groups. The underlying concepts and supporting evidence for CBTI and dCBTI are presented, including their utility in vulnerable patient groups. The second part explores the rapidly evolving landscape of nondrug therapy for insomnia. The first part of this article reviews the epidemiology and pathophysiology of insomnia with a focus on vulnerable patient groups. Now, digital CBTI (dCBTI) is emerging as a scalable option with the potential to overcome these barriers in managed care. Although cognitive behavioral therapy for insomnia (CBTI) is first-line treatment for insomnia, its high cost and a lack of trained providers has prevented widespread uptake. It has a negative impact on vulnerable patient groups, including active military personnel and veterans, patients with coexisting psychiatric and medical disorders, those in life transitions such as menopause, and elderly persons. Insomnia, whether short-term or chronic, is a common condition.
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