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sleep:2-insomnia-disorder [on April 5, 2020]
sleep:2-insomnia-disorder [on February 1, 2024] (current)
psychdb
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 {{INLINETOC}} {{INLINETOC}}
 ===== Primer ===== ===== Primer =====
-**Insomnia Disorder** is the dissatisfaction with sleep quantity or quality, with complaints of difficulty initiating or maintaining sleep. ​These sleep complaints cause clinically significant distress and/or impairment in social, occupational,​ or other areas of functioning. ​The sleep disturbance ​can occur during the course of an other mental disorder or medical condition, or it may occur independently. +**Insomnia Disorder** is the dissatisfaction with sleep quantity or quality, with complaints of difficulty initiating or maintaining sleep. ​Put simply, insomnia is defined as difficulty falling asleep or staying asleep, //even when a person has the chance to do so//. Insomnia also involves daytime impairments (fatigue and daytime sleepiness). Other changes include cognitive impairment (impacts on attention, concentration,​ and memory), and mood changes (irritability,​ mood lability). Insomnia disorder often causes ​clinically significant distress and/or impairment in social, occupational,​ or other areas of functioning. ​It can occur during the course of another ​mental disorder or medical condition, or it may occur independently.
-<WRAP group> +
-<WRAP third column>​ +
-== Symptoms == +
-  * Insomnia disorder involves daytime impairments (fatigue and daytime sleepiness) as well as nighttime sleep difficulties (this is more common among older individuals,​ chronic pain, and sleep apnea)  +
-  * Cognitive impairment includes difficulties with attention, concentration,​ and memory (even with performing simple tasks) +
-  * Mood changes include irritability,​ mood lability, and less commonly as depressive or anxiety symptoms+
  
-</​WRAP>​ 
-<WRAP third column> 
 == Prevalence == == Prevalence ==
   * Insomnia disorder is the most prevalent of all sleep disorders   * Insomnia disorder is the most prevalent of all sleep disorders
     * About 30% of the general population have insomnia symptoms and 10% have an associated functional daytime impairment     * About 30% of the general population have insomnia symptoms and 10% have an associated functional daytime impairment
     * Up to 10% have symptoms that meet criteria for insomnia disorder.     * Up to 10% have symptoms that meet criteria for insomnia disorder.
-</​WRAP>​ +
-<WRAP third column>+
 == Risk Factors == == Risk Factors ==
-  * Older age, women (more prevalent among females than males), widowed, lower socioeconomic status, smokers, drinkers, and with co-morbid psychiatric and medical conditions. Disrupted sleep and insomnia also have a familial disposition. Insomnia is higher in monozygotic twins compared to dizygotic twins; it is also higher in first-degree family members.+  * Older age, women (more prevalent among females than males), widowed, lower socioeconomic status, smokers, drinkers, and with co-morbid psychiatric and medical conditions. ​Close to 50% of individuals with psychosis experience insomnia, and this is predictive of the onset of psychotic experiences.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC7327507/​|Waite,​ F., Sheaves, B., Isham, L., Reeve, S., & Freeman, D. (2020). Sleep and schizophrenia:​ From epiphenomenon to treatable causal target. Schizophrenia research, 221, 44-56.]])] 
 +  * Disrupted sleep and insomnia also have a familial disposition. Insomnia is higher in monozygotic twins compared to dizygotic twins; it is also higher in first-degree family members.
   * Poor sleep hygiene, irregular sleep scheduling, and the fear of not sleeping also exacerbate symptoms   * Poor sleep hygiene, irregular sleep scheduling, and the fear of not sleeping also exacerbate symptoms
   * Noise, light, uncomfortably high or low temperature,​ and high altitude may also increase vulnerability to insomnia.   * Noise, light, uncomfortably high or low temperature,​ and high altitude may also increase vulnerability to insomnia.
-</​WRAP></​WRAP>​ +===== DSM-5 Diagnostic Criteria =====
-===== Diagnostic Criteria =====+
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
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 ==== Behavioural Insomnia ==== ==== Behavioural Insomnia ====
-**Behavioural insomnia** is the most common type of insomnia in the pediatric population (i.e. - bedtime problems and/or awakenings). Children may refuse to sleep, want to be rocked, or sleep in their parents’ bed. This "​flocking"​ behaviour is common in all mammals and a natural protective instinct. Popular methods that demand that children "cry it out" can actually impede development of healthy self-regulation.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3218792/​|Vriend,​ J., & Corkum, P. (2011). Clinical management of behavioural insomnia of childhood. Psychology research and behaviour management, 4, 69.]])] Soothing with an aim toward //​learning//​ self-soothing provides better long-term results for emotional growth and resilience. Behavioural insomnia should not be treated pharmacologically!+**Behavioural insomnia** is the most common type of insomnia in the pediatric population (i.e. - bedtime problems and/or awakenings, or "bed time resistance"​). Children may refuse to sleep, want to be rocked, or sleep in their parents’ bed. This "​flocking"​ behaviour is common in all mammals and a natural protective instinct. Popular methods that demand that children "cry it out" can actually impede development of healthy self-regulation.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3218792/​|Vriend,​ J., & Corkum, P. (2011). Clinical management of behavioural insomnia of childhood. Psychology research and behaviour management, 4, 69.]])] Soothing with an aim toward //​learning//​ self-soothing provides better long-term results for emotional growth and resilience. Behavioural insomnia should not be treated pharmacologically! 
 + 
 +The 3 principles to treating bedtime resistance are:  
 +  - Creating an emotional state of calmness and safety 
 +  - Consistent limit setting 
 +  - Establishing good bedtime habits (i.e. - have a wind-down 
period and a sequence of activities that begin 30 to 60 minutes before bedtime, and promote sleep hygiene).  
  
  
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   * Normal sleep variations   * Normal sleep variations
   * Situational/​acute insomnia   * Situational/​acute insomnia
-  * [[sleep:​5-circadian-rhythm-sleep-wake-disorders|Delayed sleep phase and shift work types of circadian rhythm sleep-wake disorders]] +  * [[sleep:​5-circadian-rhythm-sleep-wake-disorders:home|Delayed sleep phase and shift work types of circadian rhythm sleep-wake disorders]] 
-  * [[sleep:parasomnias:​rls|Restless legs syndrome]]+  * [[sleep:movement:​rls|Restless legs syndrome]]
   * [[sleep:​breathing:​|Breathing-related sleep disorders]],​ including sleep apnea   * [[sleep:​breathing:​|Breathing-related sleep disorders]],​ including sleep apnea
   * Sleep disorder-related:​ narcolepsy, parasomnias   * Sleep disorder-related:​ narcolepsy, parasomnias
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     * Up to 70% of GAD patients have insomnia     * Up to 70% of GAD patients have insomnia
   * Medical: Chronic pain, neurological disorders, **menopause**   * Medical: Chronic pain, neurological disorders, **menopause**
-  * [[sleep:​parasomnias:substance-sleep|Substance/​medication-induced sleep disorder]]+  * [[sleep:​substance-medication|Substance/​medication-induced sleep disorder]
 +  * Postural tachycardia syndrome (PoTS)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4083342/​|Mallien,​ J., Isenmann, S., Mrazek, A., & Haensch, C. A. (2014). Sleep disturbances and autonomic dysfunction in patients with postural orthostatic tachycardia syndrome. Frontiers in neurology, 5, 118.]])]
  
 ===== Investigations ===== ===== Investigations =====
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 <panel title="​Measurement Scales for Sleep Quality"​ no-body="​true">​ <panel title="​Measurement Scales for Sleep Quality"​ no-body="​true">​
-!^Name                                               ^ Rater      ^ Description ​                                                                                                                                                                                  ^ Download ​ ^+<​mobiletable 1> 
 +^ Name                                               ^ Rater      ^ Description ​                                                                                                                                                                                  ^ Download ​ ^
 ^ Epworth Sleepiness Scale (ESS)                    | Patient ​   | The ESS is a self-administered questionnaire with 8 questions. ​     | [[http://​epworthsleepinessscale.com/​about-the-ess/​|ESS Information]] ​        | ^ Epworth Sleepiness Scale (ESS)                    | Patient ​   | The ESS is a self-administered questionnaire with 8 questions. ​     | [[http://​epworthsleepinessscale.com/​about-the-ess/​|ESS Information]] ​        |
-^ Insomnia Severity Index (ISI)                | Patient ​   | The ISI has seven questions rated on a scale of 0 to 4.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3079939/​|Morin,​ C. M., Belleville, G., Bélanger, L., & Ivers, H. (2011). The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep, 34(5), 601-608.]])] ​                                                                   | {{ :​sleep:​2-insomnia-disorder:​the_pittsburgh_sleep_quality_index_psqi.pdf |ISI Download}} ​         | +^ Insomnia Severity Index (ISI)                | Patient ​   | The ISI has seven questions rated on a scale of 0 to 4.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3079939/​|Morin,​ C. M., Belleville, G., Bélanger, L., & Ivers, H. (2011). The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep, 34(5), 601-608.]])] ​                                                                   | {{ :​sleep:​2-insomnia-disorder:​insomnia-severity-index_isi.pdf |ISI Download}} ​         | 
-^ Pittsburgh Sleep Quality Index (PSQI) ​ | Patient ​ | The PSQI is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates “poor” from “good” sleep quality by measuring 7 components. ​ | {{ :​sleep:​2-insomnia-disorder:​insomnia-severity-index_isi.pdf |PSQI Download}} ​         |+^ Pittsburgh Sleep Quality Index (PSQI) ​ | Patient ​ | The PSQI is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates “poor” from “good” sleep quality by measuring 7 components. ​ | {{ :​sleep:​2-insomnia-disorder:​the_pittsburgh_sleep_quality_index_psqi.pdf |PSQI Download}} ​         | 
 +</​mobiletable>​
 </​panel>​ </​panel>​
  
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 ===== Treatment ===== ===== Treatment =====
 ==== Sleep Hygiene ==== ==== Sleep Hygiene ====
-Sleep hygiene implementation and sleep education should ​//​always// ​be the first step for patients reporting insomnia. ​There is much evidence ​to suggest that these strategies can provide long-term resolution to sleep problems ​in ways that medications do not (and should not!).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25454674|Irish,​ L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews, 22, 23-36.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12927121|Stepanski,​ E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep medicine reviews, 7(3), 215-225.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12244643|Brown,​ F. C., Buboltz Jr, W. C., & Soper, B. (2002). Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behavioral medicine, 28(1), 33-38.]])] It is important to keep at these habits for at least 2-3 weeks before giving up and trying more aggressive interventions. Key sleep hygiene practices include:+Sleep hygiene implementation and sleep education should be first step for patients reporting insomnia. ​Basic sleep hygiene alone has not been shown to be effective ​in treating chronic insomnia, but is important for patient education.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​25454674|Irish,​ L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews, 22, 23-36.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12927121|Stepanski,​ E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep medicine reviews, 7(3), 215-225.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12244643|Brown,​ F. C., Buboltz Jr, W. C., & Soper, B. (2002). Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behavioral medicine, 28(1), 33-38.]])] It is important to keep at these habits for at least 2 to 3 weeks before giving up and trying more aggressive interventions ​such as CBT-I and/or hypnotics. Key sleep hygiene practices include:
 <WRAP col2> <WRAP col2>
   - **Keep Your Bedroom Cool, and Dark**: A dark room reminds your brain it is nighttime, and a cool room temperature allows your body thermoregulate during sleep.   - **Keep Your Bedroom Cool, and Dark**: A dark room reminds your brain it is nighttime, and a cool room temperature allows your body thermoregulate during sleep.
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 ==== Psychotherapy ==== ==== Psychotherapy ====
-Psychological treatment of insomnia disorder includes ​[[https://​sleepfoundation.org/​sleep-topics/​sleep-hygiene|sleep hygiene]], cognitive behavioural therapy, stimulus control, bed restriction,​ and relaxation techniques. ​CBT for Insomnia (CBT-I) is being an effective and cost-effective treatment for insomnia disorder and should be offered as a first-line treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​30264137|Espie,​ C. A., Emsley, R., Kyle, S. D., Gordon, C., Drake, C. L., Siriwardena,​ A. N., ... & Freeman, D. (2019). Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. JAMA psychiatry, 76(1), 21-30.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27902836|Ritterband,​ L. M., Thorndike, F. P., Ingersoll, K. S., Lord, H. R., Gonder-Frederick,​ L., Frederick, C., ... & Morin, C. M. (2017).ed cognitive behavio ​Effect of a web-basr therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. JAMA psychiatry, 74(1), 68-75.]])] Research evidence has also shown that I-CBT should be a first-line treatment for insomnia in mid-life women experiencing menopause with hot flashes.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29165623|Guthrie,​ K. A., Larson, J. C., Ensrud, K. E., Anderson, G. L., Carpenter, J. S., Freeman, E. W., ... & Newton, K. M. (2018). Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials. Sleep, 41(1)]])] With the advent of the internet, ​many of these therapies have become widely accessible online (see table below).+<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See main article: **[[psychotherapy:cbt-insomnia|]]**</​alert>​ 
 +<WRAP group> 
 +<WRAP half column>​ 
 +  * **CBT for Insomnia (CBT-I)** is an effective and cost-effective treatment for insomnia disorder and should be offered as a first-line treatment.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​30264137|Espie,​ C. A., Emsley, R., Kyle, S. D., Gordon, C., Drake, C. L., Siriwardena,​ A. N., ... & Freeman, D. (2019). Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. JAMA psychiatry, 76(1), 21-30.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27902836|Ritterband,​ L. M., Thorndike, F. P., Ingersoll, K. S., Lord, H. R., Gonder-Frederick,​ L., Frederick, C., ... & Morin, C. M. (2017). Effect of a web-based therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. JAMA psychiatry, 74(1), 68-75.]])] 
 +  * Components of CBT-I include: sleep hygiene education, sleep restriction,​ stimulus control therapy, relaxation-based interventions (e.g. - progressive muscle relaxation),​ and cognitive restructuring. 
 +  * Research evidence has also shown that CBT-I should be a first-line treatment for insomnia in mid-life women experiencing menopause with hot flashes.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29165623|Guthrie,​ K. A., Larson, J. C., Ensrud, K. E., Anderson, G. L., Carpenter, J. S., Freeman, E. W., ... & Newton, K. M. (2018). Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials. Sleep, 41(1)]])] With the advent of the internet, ​CBT-I has become widely accessible online (see table below). 
 +  * There is strong and robust evidence that shows the effectiveness of CBT-I for insomnia.[([[https://​pubmed.ncbi.nlm.nih.gov/​11752485/​|Espie,​ C. A. (2002). Insomnia: conceptual issues in the development,​ persistence,​ and treatment of sleep disorder in adults. Annual review of psychology, 53(1), 215-243.]])] 
 +  * Importantly,​ there is comparable treatment effect with hypnotics, and the effects from CBT-I are more durable than medications.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3481424/​|Mitchell,​ M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC family practice, 13(1), 1-11.]])] 
 +  * CBT-I can also reduce and eliminate the need for hypnotic use. 
 +  * CBT-I can also significantly reduce depression symptoms.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2279754/​|Manber,​ R., Edinger, J. D., Gress, J. L., Pedro-Salcedo,​ M. G. S., Kuo, T. F., & Kalista, T. (2008). Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep, 31(4), 489-495.]])] 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<​HTML>​ 
 +<div id="​amazon">​ 
 +<div class="​ribbon"><​i class="​fa fa-star"></​i>​ Recommended Reading</​div><​a href="​https://​amzn.to/​3SHBkxX"​ target="​_blank"><​img style="​max-width:​ 50%" border="​0"​ src="​ 
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 +</​HTML>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
 <panel title="​Online Insomnia Therapies"​ no-body="​true">​ <panel title="​Online Insomnia Therapies"​ no-body="​true">​
 +<​mobiletable 1>
 ^ Name                                                                               ^ Description ​                                                                                                                    ^ Cost                                                             ^ ^ Name                                                                               ^ Description ​                                                                                                                    ^ Cost                                                             ^
 ^ [[http://​www.cbtforinsomnia.com|CBT for Insomnia]] ​                                | 5-session on-line cognitive behavioural therapy (CBT) program for insomnia. ​                                | $24.95 US to $49.95 US                                       | ^ [[http://​www.cbtforinsomnia.com|CBT for Insomnia]] ​                                | 5-session on-line cognitive behavioural therapy (CBT) program for insomnia. ​                                | $24.95 US to $49.95 US                                       |
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 ^ [[http://​restore.cbtprogram.com/​|Restore CBT-I]] ​                                  | A 6-week CBT-I program evaluated in a randomized trial                 | £99 to £199                                                  | ^ [[http://​restore.cbtprogram.com/​|Restore CBT-I]] ​                                  | A 6-week CBT-I program evaluated in a randomized trial                 | £99 to £199                                                  |
 ^ [[http://​www.sleeptrainingsystem.com/​index.php|Sleep Training System]] ​            | 6-week on-line CBT-I program with money-back guarantee and personalized feedback ​                                              | $29.95 US                                                    | ^ [[http://​www.sleeptrainingsystem.com/​index.php|Sleep Training System]] ​            | 6-week on-line CBT-I program with money-back guarantee and personalized feedback ​                                              | $29.95 US                                                    |
-</​panel>​+</​mobiletable>​</​panel>​
  
 ==== Medications==== ==== Medications====
-Based on American Academy of Sleep Medicine Guidelines[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2576317/​|Schutte-Rodin,​ S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 4(5), 487.]])] and College of Physicians and Surgeons of Alberta Guidlines.[([[http://​www.topalbertadoctors.org/​download/​439/​insomnia_management_guideline.pdf|Toward Optimized Practice (TOP) Program 2010 Guideline for adult insomnia. Edmonton, Alberta (2010).]])]+Based on 
 + American Academy of Sleep Medicine Guidelines[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2576317/​|Schutte-Rodin,​ S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 4(5), 487.]])] and College of Physicians and Surgeons of Alberta Guidlines.[([[http://​www.topalbertadoctors.org/​download/​439/​insomnia_management_guideline.pdf|Toward Optimized Practice (TOP) Program 2010 Guideline for adult insomnia. Edmonton, Alberta (2010).]])]
  
 <panel type="​info"​ title="​Pharmacological Treatment of Insomnia"​ no-body="​true">​ <panel type="​info"​ title="​Pharmacological Treatment of Insomnia"​ no-body="​true">​
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 </​panel>​ </​panel>​
  
-<callout type="​danger"​ title="​Benzodiazapine as sleep aids" icon="​true">​Although triazolam is FDA-approved for insomnia disorder, it should really not be used given its short half-life and therefore high potential for addiction, misuse, and withdrawal symptoms. Tamazepam or clonazepam would be better choices if you absolutely have to use a benzodiazapine.</​callout>​+  * When taking melatonin, it is recommended to take it 6 hours before the **middle of sleep** (i.e. - if you sleep 8 hours, then take melatonin 2 hours before your typical sleep time). 
 + 
 +<callout type="​danger"​ title="​Benzodiazapine as sleep aids" icon="​true">​ 
 +Although triazolam is FDA-approved for insomnia disorder, it should really not be used given its short half-life and therefore high potential for addiction, misuse, and withdrawal symptoms. Tamazepam or clonazepam would be better choices if you absolutely have to use a benzodiazapine. 
 +</​callout>​
  
-<callout type="​danger"​ title="​Don'​t forget!"​ icon="​true">​Short-term hypnotic treatment should always be supplemented with behavioural and cognitive therapies if possible.</​callout>​+<callout type="​danger"​ title="​Don'​t forget!"​ icon="​true">​Short-term hypnotic treatment should always be supplemented with behavioural and cognitive therapies if possible. 
 +</​callout>​
  
 ==== Clinical Pearls ==== ==== Clinical Pearls ====
-  * If you are at all considering antipsychotics (which you really should not), you must consider the following: weight gain and therefore worsening of sleep apnea, increased leg restlessness,​ hyperlipidemia,​ glucose dysregulation,​ and QT prolongation. All these reasons should make you think twice about prescribing antipsychotics for sleep. For this reason alone, the NIH Chronic insomnia panel states: "all (antipsychotics) agents have significant risks, and thus their use in the treatment of chronic insomnia cannot be recommended."​+If  
 +you are at all considering antipsychotics (which you really should not), you must consider the following: weight gain and therefore worsening of sleep apnea, increased leg restlessness,​ hyperlipidemia,​ glucose dysregulation,​ and QT prolongation. All these reasons should make you think twice about prescribing antipsychotics for sleep. For this reason alone, the NIH Chronic insomnia panel states: "all (antipsychotics) agents have significant risks, and thus their use in the treatment of chronic insomnia cannot be recommended."​
  
  
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-==== For Patients ​====+== For Patients ==
   * [[https://​mysleepwell.ca/​|SleepWell]]   * [[https://​mysleepwell.ca/​|SleepWell]]
   * [[https://​www.cci.health.wa.gov.au/​Resources/​Looking-After-Yourself/​Sleep|Centre for Clinical Interventions (CCI) - Sleep Information Sheets]]   * [[https://​www.cci.health.wa.gov.au/​Resources/​Looking-After-Yourself/​Sleep|Centre for Clinical Interventions (CCI) - Sleep Information Sheets]]
   * [[https://​www.anxietybc.com/​sites/​default/​files/​SleepHygiene.pdf|Sleep Hygiene Tips (PDF)]]   * [[https://​www.anxietybc.com/​sites/​default/​files/​SleepHygiene.pdf|Sleep Hygiene Tips (PDF)]]
-  * [[https://​www.amazon.ca/​Quiet-Your-Mind-Get-Sleep/​dp/​1572246278/​ref=sr_1_1?​ie=UTF8&​qid=1511840644&​sr=8-1&​keywords=quiet+your+mind+and+get+to+sleep|Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety or Chronic Pain]] 
 </​WRAP>​ </​WRAP>​
  
 <WRAP quarter column> <WRAP quarter column>
-==== For Providers ​====+== For Providers ==
   *[[https://​pro.psychcentral.com/​this-months-expert-john-w-winkelman-m-d-ph-d-on-treating-sleep-disorders/​|PsychCentral:​ John W. Winkelman, M.D., Ph.D. On Treating Sleep Disorders]]   *[[https://​pro.psychcentral.com/​this-months-expert-john-w-winkelman-m-d-ph-d-on-treating-sleep-disorders/​|PsychCentral:​ John W. Winkelman, M.D., Ph.D. On Treating Sleep Disorders]]
   *[[http://​www.cpsa.ca/​i-cant-sleep-managing-insomnia-in-the-older-adult/​|CPSA:​ "I Can't Sleep."​ - Managing Insomnia in the Older Adult]]   *[[http://​www.cpsa.ca/​i-cant-sleep-managing-insomnia-in-the-older-adult/​|CPSA:​ "I Can't Sleep."​ - Managing Insomnia in the Older Adult]]