New Canadian consensus recommendations for managing chronic insomnia

Insomnia affects one in seven Canadians. The optimal management of insomnia is challenging due to the lack of sufficient Canadian guidance for healthcare providers. To address this issue, a multidisciplinary panel of 16 Canadian experts in sleep medicine and insomnia developed up-to-date consensus recommendations to improve the diagnosis and management of chronic insomnia in Canada. Based on high-quality evidence, the panel strongly recommends to not underestimate the burden of chronic insomnia, as it increases the risk of depression, anxiety, substance use disorder, suicidality, weight gain, cardiovascular issues, all-cause death and fatigue-related accidents.Diagnosis of insomnia should include a thorough history to identify the nature of insomnia complaints and comorbid sleep, mental and physical health conditions. Patients should be screened for comorbid obstructive sleep apnea (OSA), because of the high prevalence of insomnia symptoms (40%–60%) in patients with OSA. Few patients with insomnia seek medical attention; therefore, healthcare providers should proactively ask simple sleep-related screening questions about difficulties falling or staying asleep and whether symptoms contribute to difficulties in daytime functioning. Measurement-based care with short patient-rated scales (e.g., PHQ-9, GAD-7, STOP-Bang) can assist in defining the nature and severity of insomnia as well as major comorbidities. Data from sleep trackers should be used with caution when estimating sleep amount and quality, as they have not been well validated in individuals with sleep disorders.TreatmentCognitive behavioural therapy for insomnia (CBT-I) is the first-line treatment for insomnia for all individuals, even those with comorbid conditions. Various modalities (in-person, virtual, self-help, group) are available, although efficacy and adherence may vary. CBT-I provides sustained improvements in sleep-onset latency, wake-after-sleep onset, total sleep time and sleep efficiency. It can also alleviate associated psychological symptoms, such as depression and anxiety disorders. However, more resources are needed to overcome barriers to CBT-I accessibility, such as the scarcity of trained specialists. About 30%-to-35% of individuals do not respond to CBT-I; this may result from limited compliance, suboptimal delivery, and the time consuming nature of CBT-I. Four to six biweekly CBT-I sessions are likely needed to produce long-term improvements. Abbreviated versions of CBT-I or single behavioural therapy components involving stimulus control or sleep restriction may help when multicomponent CBT-I is not available or feasible. However, sleep hygiene education alone is insufficient to treat insomnia disorder. CBT-I can sometimes be combined with pharmacotherapy, although optimal ways of combining and sequencing, and considerations for deprescribing, should be established.Medications with different safety and efficacy are used to treat insomnia disorder, including benzodiazepines (e.g., flurazepam, temazepam), zdrugs (e.g., eszopiclone, zolpidem, zopiclone), dual orexin antagonists (e.g., daridorexant, lemborexant), antidepressants and antihistaminergic drugs such as doxepin.Benzodiazepines and z-drugs improve sleep duration and quality, but are associated with potentially concerning adverse effects such as daytime drowsiness, risk of falls and motor vehicle accidents, risk of addiction and abuse, and rebound insomnia after discontinuation. Dual orexin antagonists Emerging evidence suggests that dual orexin antagonists may have benefits that outweigh their risks. They improve various sleep outcomes in individuals with insomnia, including wake time after sleep onset, latency to persistent sleep, and total sleep time. No marked rebound or withdrawal signs or symptoms have been seen when treatment is discontinued, suggesting an improved safety profile compared to other commonly prescribed insomnia medications. Access to daridorexant and Lemborexant, however, may be limited due to coverage issues.Other prescription medications Low-dose doxepin, the only antidepressant approved for insomnia, has been shown to effectively improve sleep maintenance and total sleep duration. Other antidepressants (e.g., amitriptyline, mirtazapine, trazodone), as well as antipsychotics (e.g., quetiapine) and anticonvulsants (gabapentin, pregabalin) are commonly used as off-label medications for insomnia. However, evidence supporting their efficacy is inconsistent and their unclear or hazardous safety profiles (e.g., fall risk, daytime drowsiness) may outweigh their benefits. Antidepressants or antipsychotics should be considered only in the context of treating comorbid psychiatric conditions.Over-the-counter medications (e.g., antihistamines such as dimenhydrinate and diphenhydramine), although commonly used in Canada for the treatment of insomnia, have unclear or hazardous safety and efficacy profiles that may outweigh their benefits.Natural health products Despite evidence of improvements in certain populations treated with exogenous melatonin (e.g., older adults, individuals with ADHD, neurodevelopmental disorders), no strong evidence supports the use of melatonin for the treatment of insomnia. If melatonin or other natural health products are chosen to manage insomnia, advise patients to select products with an eight-digit NPN (natural product number) to ensure that safety and quality have been assessed by Health Canada.Cannabis Some evidence suggests that cannabis may improve sleep in individuals with certain chronic diseases (e.g., chronic pain); however, more research is needed to assess its effects and guide its use in insomnia management.SummaryThe consensus statement includes 37 recommendations pertaining to the epidemiology, diagnosis and treatment of chronic insomnia. It also provides an algorithm summarizing the diagnosis and treatment principles for managing chronic insomnia in Canada.Overall, the consensus recommendations highlight the need to: increase awareness, capacity for, and access to CBT-I; integrate newly approved pharmacotherapy, such as daridorexant and lemborexant; and reduce use of self-medication for insomnia and medications with limited evidence or low risk/benefit ratio.Reference:Morin CM, Khullar A, Robillard R, et al. Delphi consensus recommendations for the management of chronic insomnia in Canada. Sleep Medicine 2024;124:598-605. (accessed November 7, 2024).

New Canadian consensus recommendations for managing chronic insomnia

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