Insomnia patients often denied sleep treatment when they have mental health conditions

Patients with insomnia who are diagnosed with accompanying mental health ailments often are not prescribed medication that will help them sleep - which could then make related anxiety or depression worse, new research suggests.

Scientists examining treatment patterns for insomniacs say that their findings suggest that many doctors appear to be reluctant to prescribe sleep aids, even those that pose no risk of dependence, if patients also have depression, anxiety or mood disorders. An exception is psychiatrists, who were found to be twice as likely as primary care physicians to prescribe medication for insomnia.

'Insomnia can cause you to have anxiety and depression, and depression and anxiety can cause you to have insomnia. It's a chicken-and-egg type of story. But research has shown that if one of the conditions is left untreated it can exacerbate the other condition,' said senior study author Rajesh Balkrishnan, the Merrell Dow professor of pharmacy at Ohio State University.

'What this calls for is specific guidelines related to the treatment of insomnia that takes into consideration these different types of patients, because insomnia has become such a big public health problem.'

An estimated 20 percent of Americans have occasional sleep problems, with about one in 10 suffering from chronic insomnia.

Balkrishnan acknowledges concerns that physicians might have about prescribing certain medications that can cause dependence, especially to patients with mental health disorders. Older sleep aids, a class of drugs called benzodiazepines, are muscle relaxants with addictive properties and high potential for abuse. However, since the early 1990s, a new class of drugs for insomnia called non-benzodiazepines has been on the market. They are effective sleep aids that don't carry the risk of addiction, Balkrishnan said, and for that reason, patients should have ready access to these medications.

'This research highlights the need to take into account that many patients who see their doctors with complaints of insomnia also have a psychiatric condition. But the presence of those mental conditions should not preclude them from being appropriately treated for their insomnia,' he said.

The study is published in the January issue of the Journal of Medical Economics.

Balkrishnan and colleagues collected data from the National Ambulatory Medical Care Survey, which tracks Americans' annual outpatient medical visits. The researchers identified 5,487 physician visits by patients with insomnia between 1995 and 2004, which was calculated to represent about 161 million U.S. patients over that 10-year period.

According to the analysis, an estimated 6.5 million Americans who saw a doctor for insomnia also were diagnosed with a mental health disorder. Of the visits examined, 38 percent of patients with insomnia were diagnosed with at least one other condition, and at least four of every 10 of those accompanying conditions related to mental health. The most common additional condition was anxiety (15.6 percent), followed by episodic mood disorders (14.9 percent), high blood pressure (10.1 percent), depression (7 percent) and diabetes (3.5 percent).

The study showed that insomnia patients with mental health disorders were 36 percent less likely to receive medication for their sleeping problems than were patients without the mental health diagnosis. Those with anxiety were the least likely to receive a sleep aid, with a 45 percent decreased likelihood of receiving medication for insomnia compared to patients without anxiety.

Balkrishnan said that with generic forms of nonaddictive insomnia medication available by prescription, even patients taking antidepressants and anti-anxiety drugs can safely - and affordably - add a sleep aid to their regimen. The most common forms of antidepressants prescribed in the United States are a class of drugs called selective serotonin reuptake inhibitors (SSRIs).

'Physicians might perceive that drowsiness is induced by medications such as SSRIs so there might be a general fear about combining them with insomnia medications,' Balkrishnan said. 'But I think those fears are somewhat unfounded because we found that psychiatrists don't have any problems prescribing sleep medications in patients who have accompanying mental conditions; they know there is no danger of a drug-to-drug interaction.'

According to the analysis, patients visiting psychiatrists had two times higher odds of receiving medication for insomnia than patients visiting family practice or internal medicine physicians. The study showed that 33 percent of patients with insomnia saw family practice or internal medicine physicians, 30 percent visited psychiatrists and 9 percent went to neurologists.

The study identified other factors associated with insomnia medication prescribing patterns - for example, older and established patients were more likely to receive insomnia medications than were younger patients or those seeing the doctor for the first time. But Balkrishnan said a clear theme emerged from the analysis.

'There is a divide in who gets appropriate medication and who is not appropriately medicated,' he said. 'It might not be happening willfully, but it points to a knowledge gap between different types of physicians and the need to develop widely accepted treatment guidelines. And the guidelines should be ratified by essentially all physicians treating the condition.'

This research was funded by a grant from Sanofi-Aventis, a sleep-aid manufacturer based in Bridgewater, N.J. The study does not discuss any specific products of the sponsor company. Balkrishnan is a paid consultant for the company.

Co-authors on the study were Manjiri Pawaskar of Ohio State's College of Pharmacy, Vijay Joish of Sanofi-Aventis, Fabian Camacho of Wake Forest University School of Medicine, and Rafia Rasu of the University of Missouri-Kansas City.