New advances in insomnia

What’s the latest thinking in insomnia?

It’s been a busy time in insomnia research. New drugs under development, and active research in to psychology-based strategies. Basic science research looking at how the brain behaves in insomnia, which gives insights in to future treatment approaches. There is also increasing recognition of the interaction between insomnia, sleep and how people live across the day.

Emerging concepts in insomnia

One of the important concepts in insomnia is an increasing understanding and research showing that improving sleep takes a very broad approach, not just focussing on sleep itself.

Whilst cognitive behavioural therapy (CBTi) is an effective treatment for insomnia, it has traditionally focussed on thinking and behaviour around sleep. However, research we have done and are in the process of preparing for publication, together with other studies published in the last 12 months, have shown that techniques such as mindfulness have a significant role to play in the treatment of insomnia. We found with our research, which focussed predominantly on training people in mindfulness-based meditation, that people were feeling much better through the day, and changed the way they thought about sleep, or their relationship with sleep, rather than changing sleep itself. The changes to sleep seemed to come later, over time.

Biology of insomnia

New imaging techniques have been used to look at how different areas in the brain behave during sleep in people with insomnia. Techniques such as PET scanning can look at brain activity in areas such as:

• Default mode network – underlies functions such as self-awareness, mind wandering, autobiographical thought
• Executive control network – engaged with cognitively demanding tasks
• Salience network – involved with cognitive, homeostatic and emotional salience

In people with insomnia, the default mode network (DMN) and executive control network (ECN) don’t turn off as well during sleep. This fits with what people with insomnia describe, feeling as if they are more aware of their environment, have more of a wandering mind, and engaged in thinking during sleep. Recent research has also shown that cognitive behavioural therapy the DMN switches off more normally during sleep.

Measurement of sleep in insomnia

An example of a technology that uses HRV data and incorporates that in to a sleep management program is SleepRate. Their system combines measuring sleep and stress using HRV, then using that information to tailor an online cognitive behavioural therapy program for individuals.

Although all these wearable technologies provide a ready way to measure sleep, one concern expressed by experts in the field, is that this may make people overly focussed on their sleep and increase anxiety about sleep. In this same way, when we use paper sleep diaries, some people can find it increases their concern about sleep. It is a matter of balance, as measuring sleep can give good insights in to sleep and help with motivation and engagement. I’m usually in favour of measuring sleep, but like people to take an unemotional, scientific approach to the measurement rather than getting too emotionally involved.

Non-drug treatments

In June 2015, our research showing that cognitive behavioural therapy for insomnia (CBTi) is an effective treatment was published. In that research we showed that on average people went to sleep 19 minutes faster and stayed asleep 26 minutes longer after CBTi. This is similar to the effects of sleeping tablets, but without the negative effects and the effects persisted long after treatment finished.

Complementing our research, a paper in JAMA showed that CBTi also improves insomnia symptoms in people with insomnia co-morbid with other medical or mental health conditions. Interestingly the effects were greater in mental health conditions than medical conditions and CBTi also had positive effects on co-morbid conditions. For example, depression scores improved by 29% in those treated with CBTi.

With these 2 papers showing CBTi is effective, further research will look at how CBTi can be delivered effectively to more people such as using apps. One of the best apps around at the moment is CBT-i Coach. It was developed by the US Department of Veterans Affairs and is designed for people who are already working with a health professional on CBTi, and helps to support that treatment by providing information and instructions about sleep timing.

I think use of apps to support treatment, or even provide treatment is the way of the future, but more research is needed in to how to best do this.

Drug treatments

There are a number of new medications for insomnia currently in development.

Lorediplon, looks promising, with results of the 1 preliminary study published so far showing effects at least as good as Stilnox (zolpidem). Given these preliminary results development of lorediplon is continuing with a phase II trial comparing it to placebo and zolpidem in people with insomnia. Lorediplon is a pyrazolopyrimadine, similar in structure to other GABA-A agonists such as zaleplon (not available in Australia).

Suvorexant is a new class of drug for insomnia that blocks the effect of orexin. This class is called dual orexin receptor antagonists (DORAs), and are of interest as orexin is involved in activating wakefulness, and these drugs theoretically block wake drive. Suvorexant is now licensed for use in the US and Japan, and it may be available in Australia over the next 12 months. There are other DORAs in development such as lemborexant.

Related posts & links:

• Medications for insomnia – blog post on insomnia medication
• Cognitive behavioural therapy for insomnia
• Sleep health – sleeping well is more than treating sleep disorders
• Good sleep, It’s not about the night
• Advances in the management of insomnia – article from F1000 Prime reports

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