What Should Be the Focus of Treatment When Insomnia Disorder Is Comorbid with Depression or Anxiety Disorder?

Charles M Morin; Suzanne M Bertisch; Rafael Pelayo; Nathaniel F Watson; John W Winkelman; Phyllis C Zee; Andrew D Krystal

doi:10.3390/jcm12051975

What Should Be the Focus of Treatment When Insomnia Disorder Is Comorbid with Depression or Anxiety Disorder?

J Clin Med. 2023 Mar 2;12(5):1975. doi: 10.3390/jcm12051975.

Authors

Charles M Morin¹, Suzanne M Bertisch², Rafael Pelayo³, Nathaniel F Watson⁴, John W Winkelman⁵, Phyllis C Zee⁶, Andrew D Krystal⁷

Affiliations

¹ Department of Psychology, Brain Research Centre, Laval University, Quebec, QC G1V 0A6, Canada.
² Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
³ Department of Psychiatry and Behavioral Sciences, Stanford University Sleep Medicine Center, Redwood City, CA 94305, USA.
⁴ Department of Neurology, University of Washington School of Medicine, Seattle, WA 98195, USA.
⁵ Department of Psychiatry and Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
⁶ Department of Neurology, Center for Circadian and Sleep Medicine, Northwestern University, Evanston, IL 60611, USA.
⁷ Departments of Psychiatry and Neurology, UCSF Weill Institute for Neurosciences, San Francisco, CA 94158, USA.

Abstract

Insomnia is a significant, highly prevalent, persistent public health problem but often remains undiagnosed and untreated. Current treatment practices are not always evidence-based. When insomnia is comorbid with anxiety or depression, treatment often targets that comorbid condition with the expectation that improvement of the mental health condition will generalize to sleep symptoms. An expert panel of seven members conducted a clinical appraisal of the literature regarding the treatment of insomnia when comorbid anxiety or depression are also present. The clinical appraisal consisted of the review, presentation, and assessment of current published evidence as it relates to the panel's predetermined clinical focus statement, "Whenever chronic insomnia is associated with another condition, such as anxiety or depression, that psychiatric condition should be the only focus of treatment as the insomnia is most likely a symptom of the condition". The results from an electronic national survey of US-based practicing physicians, psychiatrists, and sleep (N = 508) revealed that >40% of physicians agree "at least somewhat" that treatment of comorbid insomnia should focus solely on the psychiatric condition. Whereas 100% of the expert panel disagreed with the statement. Thus, an important gap exists between current clinical practices and evidence-based guidelines and more awareness is needed so that insomnia is treated distinctly from comorbid anxiety and depression.

Keywords: anxiety; clinical appraisal; cognitive-behavioral therapy comorbidity; depression; pharmacological; psychiatric; sleep disturbances; treatment.

Publication types

Review

Grants and funding

Publication of this open access online article is the result of a survey assessment conducted by the publisher. The Insomnia Clinical Appraisal December 2021 project was initiated and funded by Idorsia Pharmaceuticals Ltd. (Idorsia). Management of the meeting and survey, and medical writing and editorial support, was funded by Idorsia and was provided by LAS Communications, Inc. Idorsia identified the chairperson and faculty members and was consulted in the development and review of the practice statements. All seven authors were members of the Alliance for Sleep funded by Idorsia. Idorsia conducted a medical review of the final draft publication. Authors received financial reimbursement by Idorsia for time spent on the literature review and analysis but received no compensation toward the development and writing of this manuscript.