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Introduction

Insomnia is defined as a problem with initiating sleep, maintaining sleep, waking up too early, or experiencing poor quality (nonrestorative) sleep, which interferes with daytime functioning. Symptoms include fatigue, impaired concentration, decreased initiative, daytime sleepiness, poor performance, low mood, and irritability. The prevalence of insomnia is about 10-15% in the general US population and close to 20% in medical patients.¹ It has been estimated to be as high as 44% among cardiac patients.^2,3

Evidence is mounting for prospective links between insomnia and hypertension, cardiovascular events, and death. A recent Taiwanese study followed 44,080 men and women diagnosed with insomnia over 10 years and found higher incidence of stroke and myocardial infarction (MI) compared to a sample of age-, sex-, and health-matched controls.⁴ Data from the NIH Women's Health Initiative revealed that self-reported insomnia was associated with higher risk of developing coronary heart disease(CHD) or cardiovascular disease over 10 years among 86,329 postmenopausal women.⁵ These self-report findings were recently confirmed in another prospective population-based study including 13,617 men and women with no previous cardiac events.⁶

Three recent meta-analyses have been published on prospective studies measuring insomnia and cardiac outcomes, with all three pointing towards strong associations between baseline insomnia and subsequent risk of MI, stroke, and death associated with CHD.^7-9 With more and more evidence for a connection between sleep and cardiovascular disease, some have argued for including sleep disturbances as the 10th potentially modifiable cardiovascular risk factor.¹⁰

Despite the evidence for an association between sleep and cardiac health, causal mechanisms remain unclear. There is good support for a connection between sleep and hypertension,^11-13 with both objective and self-report sleep data suggesting that short sleep duration (<6 hours) predicts higher blood pressure.¹⁴ Sleep loss has also been linked with elevated systemic circulating levels of inflammatory biomarkers such as C-reactive protein and Interleukin-6, which are associated with cardiovascular disease.^15,16 Finally, insomnia may influence heart health through its impact on lifestyle behaviors such as diet and exercise, which are known to affect cardiovascular outcomes.¹⁷

3P Model of Chronic Insomnia

Figure 1: 3P Model of Chronic Insomnia

The 3P model is a stress-diathesis model of chronic insomnia (see Figure 1).¹⁸ The 3P model holds that individuals may have predisposing factors (e.g., biological or psychological traits) that increase the likelihood that they will develop acute sleep problems when faced with precipitating factors (e.g., stressful life event, medical or psychiatric illness). In an attempt to compensate for poor sleep, individuals may unwittingly engage in behaviors that ultimately perpetuate their sleep problems, even after the precipitating factors resolve. It is these perpetuating factors that give rise to chronic insomnia.

Perpetuating factors may include, for example, spending more time in bed to compensate for poor sleep, which can have the unintended effect of disrupting sleep/wake cycles, decreasing sleep efficiency, and creating a conditioned response between being in bed and being awake. Others may compensate for poor sleep by taking daytime naps (which decreases homeostatic sleep drive the following night) or increasing caffeine intake. Over time, individuals may come to regard nighttime as a frustrating struggle, which increases physiological activation and further decreases the likelihood of entering a sleep state.

Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral interventions for sleep disturbance are highly effective, producing clinically significant improvements in sleep in 70-80% of adults and children.^19,20 A recent meta-analysis reviewed 37 randomized controlled trials of cognitive behavioral therapy for insomnia (CBTi) among patients with comorbid psychiatric and medical conditions, finding it efficacious for improving sleep quality and outcomes related to the comorbid conditions.²¹ While fewer studies of CBTi have been conducted in cardiac populations, two recent studies with heart failure patients found improvement in sleep quality, fatigue, and physical functioning among those randomized to receive CBTi.²²

CBTi focuses on modifying perpetuating factors that maintain chronic insomnia. CBTi treatment approaches include the following:

• Sleep Consolidation, which aims to restore homeostatic sleep drive by limiting the amount of time in bed based on current sleep efficiency (i.e., Total Sleep Time/Time in Bed). Once sleep becomes consolidated, the amount of time in bed can be incrementally increased.
• Stimulus Control, which aims to limit associations between being in bed and being awake and build associations between the bed and sleep (see below).
• Sleep Hygiene, which aims to modify the environment and pre-bedtime ritual to be conducive to sleep (see below).
• Cognitive Techniques, which involve education about the development and maintenance of chronic insomnia, and identifying and modifying maladaptive thoughts/beliefs about sleep (e.g., "If I don't fall asleep soon I will sleep through my alarm tomorrow and be late for work").
• Relaxation Training, which involves teaching relaxation exercises (e.g., breathing exercises, mindfulness meditation) that patients can use to help decrease physiological activation throughout the day and especially at nighttime.

Tips to Share with Patients

While some patients will require behavioral sleep treatment, many patients with sleep problems can benefit from implementing the following:

• Stimulus Control
  • Limit activities in bed to sleep and sex (no phones, laptops, or TV).
  • Get up at the same time every morning, even on weekends.
  • Go to bed only when sleepy.
  • If you have not fallen asleep in about 20 minutes, get out of bed and do something relaxing elsewhere under low light. Return to bed only when sleepy. Repeat.
  • Do not watch the clock.
• Sleep Hygiene
  • Avoid naps during the day.
  • Avoid caffeine after noon.
  • Avoid nicotine, alcohol or heavy meals within 2 to 3 hours of bedtime.
  • Consistently employ a relaxing bedtime ritual.
  • Exercise during the day so you are more tired at night.
  • Get light exposure during the day.
  • Make sure your room is dark, quiet, and a comfortable temperature. Use earplugs or eye mask if needed.

Additional Referrals and Resources

CBT-i Coach is an evidence-based free phone app co-developed by the Veterans Health Administration and Department of Defense (http://t2health.dcoe.mil/apps/CBT-i). It guides users through the process of learning about sleep, developing positive sleep routines, and improving their sleep environments. It provides a structured program that teaches strategies proven to improve sleep and help alleviate symptoms of insomnia. CBT-i Coach is intended to augment face-to-face care with a healthcare professional. It can be used on its own, but it is not intended to replace therapy for those who need it.

Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach Workbook, by Jack Edinger and Colleen Carney, provides information about healthy sleep and the reasons for improving sleep habits. Sleep diary, assessment forms, and other assignments are included. It is designed to be used in conjunction with face-to-face therapy. It can be used on its own, but it is not intended to replace therapy for those who need it.

Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety or Chronic Pain, by Colleen Carney and Rachel Manber, guides patients to optimize their sleep pattern using methods to calm the mind and help identify sleep-interfering behaviors that contribute to insomnia. It offers the same techniques offered by experienced sleep specialists. It is a self-help book designed to be used on its own.

For patients with chronic or unremitting insomnia, refer to a behavioral sleep specialist. The Society of Behavioral Sleep Medicine (http://www.behavioralsleep.org) offers a list of member and non-member providers who have completed specialized training in this area.

References

1. Budhiraja R, Roth T, Hudgel DW, Budhiraja P, Drake CL. Prevalence and polysomnographic correlates of insomnia comorbid with medical disorders. Sleep 2011;34:859-67.
2. Bankier B, Januzzi JL, Littman AB. The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease. Psychosom Med 2004;66:645-50.
3. Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep 2007;30:213-8.
4. Hsu CY, Chen YT, Chen MH, et al. The association between insomnia and increased future cardiovascular events: a nationwide population-based study. Psychosom Med 2015;77:743-51.
5. Sands-Lincoln M, Loucks EB, Lu B, et al. Sleep duration, insomnia, and coronary heart disease among postmenopausal women in the Women's Health Initiative. J Womens Health 2013;22:477-86.
6. Canivet C, Nilsson PM, Lindeberg SI, Karasek R, Östergren PO. Insomnia increases risk for cardiovascular events in women and in men with low socioeconomic status: a longitudinal, register-based study. J Psychosom Res 2014;76:292-9.
7. Cappuccio FP, Cooper D, D'Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J 2011;32:1484-92.
8. Li M, Zhang XW, Hou WS, Tang ZY. Insomnia and risk of cardiovascular disease: a meta-analysis of cohort studies. Int J Cardiol 2014;176:1044-7.
9. Sofi F, Cesari F, Casini A, Macchi C, Abbate R, Gensini GF. Insomnia and risk of cardiovascular disease: a meta-analysis. Eur J Prev Cardiol 2014;21:57-64.
10. Redline S, Foody J. Sleep disturbances: time to join the top 10 potentially modifiable cardiovascular risk factors? Circulation 2011;124:2049-51.
11. Gangwisch JE. A review of evidence for the link between sleep duration and hypertension. Am J Hypertens 2014;27:1235-42.
12. Meng L, Zheng Y, Hui R. The relationship of sleep duration and insomnia to risk of hypertension incidence: a meta-analysis of prospective cohort studies. Hypertens Res 2013;36:985-95.
13. Bruno RM, Palagini L, Gemignani A, et al. Poor sleep quality and resistant hypertension. Sleep Med 2013;14:1157-63.
14. Bathgate CJ, Edinger JD, Wyatt JK, Krystal AD. Objective but not subjective short sleep duration associated with increased risk for hypertension in individuals with insomnia. Sleep 2016;39:1037-45.
15. Motivala SJ. Sleep and inflammation: psychoneuroimmunology in the context of cardiovascular disease. Ann Behav Med 2011;42:141-52.
16. Jackowska M, Steptoe A. Sleep and future cardiovascular risk: prospective analysis from the English Longitudinal Study of Ageing. Sleep Med 2015;16:768-74.
17. Spiegelhalder K, Scholtes C, Riemann D. The association between insomnia and cardiovascular diseases. Nat Sci Sleep 2010;2:71-8.
18. Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am 1987;10:541-53
19. Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia: an American Academy of Sleep Medicine review. Sleep 1999;22:134-56.
20. Mindell JA, Kuhn B, Lewin DS, et al. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006;29:1263-76.
21. Wu JQ, Appleman ER, Salazar RD, Ong JC. Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis. JAMA Intern Med 2015;175:1461-72.
22. Conley S, Redeker NS. Cognitive behavioral therapy for insomnia in the context of cardiovascular conditions. Curr Sleep Med Rep 2015;1:157-65.

Keywords: Anxiety, Biomarkers, Blood Pressure, Breathing Exercises, C-Reactive Protein, Caffeine, Chronic Pain, Cognition, Cognitive Behavioral Therapy, Coronary Disease, Depression, Diet, Disease Susceptibility, Heart Failure, Hypertension, Life Style, Meditation, Myocardial Infarction, Nicotine, Precipitating Factors, Risk Factors, Sleep, Sleep Initiation and Maintenance Disorders, Sleep Stages, Stroke, Primary Prevention

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