new paradigms in Comorbid Insomnia

Insomnia is a leading cause of absenteeism, presenteeism (lost productivity when employees are at work), accidents, and errors in the workplace. Overall direct and indirect costs exceed $30 billion annually. A significant portion of these costs are attributable to patients with comorbid insomnia, making these conditions a significant clinical public health issue. These comorbid conditions include mood and anxiety disorders; chronic pain; respiratory, urinary, and neurologic conditions; diabetes; and cardiovascular diseases. Traditional treatment for insomnia with comorbid conditions has focused on treating the comorbid condition with the expectation that the insomnia will resolve. Recent studies, however, suggest this approach is not the most appropriate. Instead, treating both conditions simultaneously may improve the outcomes for each. (Am J Manag Care. 2009;15:S6-S13) For author information and disclosures see end of text. Comorbid Insomnia: Current Directions and future Challenges VOL. 15, NO. 1 n THe aMerICaN JOurNaL Of MaNageD Care n S7 effect on daytime functioning as well as the status of their comorbid condition. for instance, various studies found that patients with chronic insomnia have significantly higher risks for falls and accidents.1,9 One study reported that 8% of workers with severe insomnia were involved in industrial accidents compared with 1% of good sleepers (P = .0150).10 Other studies have shown sleep-onset insomnia to be a statistically significant risk factor in being involved in a traffic accident11; in fact, those suffering from insomnia are more than twice as likely to have an automobile accident.12 In addition, adults with severe insomnia miss twice as many workdays as those without insomnia, even when matched for work type and schedule.10 In fact, insomnia may be the greatest predictor of absenteeism in the workplace.13 employees with severe insomnia have been shown to make significantly more errors at work (15% vs 6%; P <.001), and were more than twice as likely to exhibit presenteeism, or poor efficiency, as those without insomnia (18% vs 8%; P = .0004).10 People with chronic insomnia also use significantly more medical services than those without insomnia.4,10,14,15 Leger et al found twice as many individuals with severe insomnia were hospitalized in the year prior to an administered questionnaire (18% vs 9%; P = .0017) than those without insomnia. They also found this cohort used more medications than those without insomnia, particularly cardiovascular, CNS, urogenital, and gastrointestinal drugs.10 There is also data indicating patients with depressive disorders suffering from insomnia have a greater suicide risk than those without insomnia. This translates into higher costs.16,17 even controlling for age, sex, and chronic disease score, average total health services are approximately 60% higher in those with insomnia than in those without insomnia.18 Ozminkowski et al found that average direct (inpatient, outpatient, pharmacy, and emergency department costs) and indirect costs (absenteeism and the use of short-term disability programs) for adults in the 6 months before a diagnosis for insomnia or beginning prescription treatment for the condition were approximately $1253 greater than for those without insomnia (ages 18-64), whereas average direct costs among adults aged 65 and older were $1143 greater.19 although the economic and social costs of comorbid insomnia compared with primary insomnia have yet to be investigated, it is likely that they account for the majority of the annual $30 billion to $35 billion in costs for chronic insomnia simply because comorbid insomnia is so much more prevalent.17,20 Comorbid Insomnias: Untangling the