12 Although there are numerous epidemiologic studies of insomnia, criteria for insomnia classification are highly varied among these studies. 11 The presence of a health or mental condition increases the risk, with insomnia seen in 37.8% of individuals with a comorbid condition but in only 8.4% of those without a comorbid condition. 17, 18 Women are at least two times more likely to have insomnia than age-matched men, 10 and an increased prevalence of insomnia has been seen in adolescent girls compared with age-matched boys ( Table 1). 15, 16 However, research suggests that age itself is not the risk instead, the risk is related to inactivity, sleep changes, decreased social activities, and increases in health conditions associated with aging. 1, 15 Older age has been associated with increased risk of insomnia. ![]() 10 Overall, sex, age, and health and mental conditions appear to be the most significant risk factors for insomnia. 9 When separated into age categories, blacks appear to have a greater prevalence of insomnia in middle age (30-59 years), whereas whites have a greater prevalence of insomnia across the life span ( Table 1). 5, 8 The few studies examining racial differences in prevalence have reported rates of 16.4% to 28.3% in whites, 15.3% to 23.7% in blacks, and 13.4% to 17.1% in Hispanics. 1 When the most stringent diagnostic criteria are applied, 7 prevalence remains substantial, but further drops to about 6% of adults. 6 When daytime impairment or distress is a required criterion, prevalence drops to 10%. 5 Thirty percent of adults have insomnia when defined as reporting at least one insomnia symptom. General estimates vary depending on the criteria used to define insomnia, and prevalence rates tend to decrease as the stringency of the criteria increases. Given the currently limited number of trained practitioners, exploration of alternative delivery methods (eg, briefer protocols, self-help, Internet) to improve access to this highly effective treatment and expanded training in these treatments are warranted. Through the Society of Behavioral Sleep Medicine ( and the American Board of Sleep Medicine ( it is possible to find practitioners with expertise in CBTi (as well as other aspects of behavioral sleep medicine) and other behavioral sleep resources. Thus, in 2005, a National Institutes of Health expert consensus panel on chronic insomnia recommended dropping the term ”secondary insomnia” in favor of the term ”comorbid insomnia.” Because CBTi does not carry the risks associated with some sleep medications (eg, dependency, polypharmacy, cognitive and psychomotor impairment), it is an attractive option for patients with other conditions. Cognitive behavioral treatment of insomnia (CBTi) targets those behaviors, cognitions, and associations and is effective across a variety of populations, including those with medical and psychologic comorbidities. ![]() ![]() However, this approach often failed because chronic insomnia is maintained by behaviors, cognitions, and associations that patients adopt as they attempt to cope with poor sleep but that end up backfiring (eg, increasing caffeine, spending more time in bed, trying harder to sleep). Traditionally, chronic insomnia occurring with another condition has been considered secondary and rarely received direct treatment because treatment of the primary condition was expected to improve the insomnia. Chronic insomnia (symptoms for ≥6 months) is the most common sleep disorder, affecting 6% to 10% of adults in the general population, with even higher rates in patients with comorbid conditions (eg, hypertension, 44% cardiac disease, 44.1% breathing problems, 41.5%).
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