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Does ultrasound screening for abdominal aortic aneurysm reduce mortality?

Author(s)

Yamil Miranda-Usua, MD

Janine Tillett, MSLS, AHIP

EVIDENCE-BASED ANSWER

YES, screening reduces mortality in men, although it’s unclear whether it has the same effect in women. Screening for aortic abdominal aneurysm (AAA) with ultrasound in men 65 to 79 years of age reduces AAA-specific mortality (number needed to screen [NNS] to prevent one death from AAA=769 men over 3 years). However, a trend toward reduced all-cause mortality doesn’t reach significance, possibly because of the low incidence of AAA (strength of recommendation [SOR]: A, systematic review of 4 population-based randomized controlled trials [RCTs]).

Evidence is inadequate to demonstrate benefits of screening in women.

Evidence summary

AAAs occur in 5% to 10% of men and 0.5% to 1.5% of women between 65 and 79 years of age.^1,2 Risk factors include age, smoking, male sex, and family history.² AAAs are 3 to 5 times more likely in patients with a smoking history.² Approximately 9000 deaths annually are linked to AAAs in the United States, mostly in men older than 65 years.² Mortality after rupture approaches 80% for patients who reach a hospital and 50% for patients who undergo emergent surgery.²

Screening reduces AAA deaths in men, but not all-cause mortality

A Cochrane review assessing the use of ultrasound to screen for AAA analyzed 4 population-based RCTs involving 127,891 men and 9342 women.¹ Participants in each trial were randomly assigned to screening with ultrasound or no intervention.

The reviewers reported that screening significantly reduced mortality from AAA in men 65 to 79 years of age (odds ratio [OR]=0.60; 95% confidence interval [CI], 0.47-0.78). They found no support for decreased mortality in women (OR=1.99; 95% CI, 0.36-10.88).

The study also found no significant reduction in all-cause mortality 3 to 5 years after screening in men 65 to 79 years of age (OR=0.95; 95% CI, 0.85-1.07) or women (OR=1.06; 95% CI, 0.93-1.21), probably because of the low overall incidence of AAA.¹ For men 65 to 79 years of age, the NNS is 769 over 3 years to prevent one death.¹

Limitations of the study include disproportionate male representation because only 1 of the 4 trials in the Cochrane review enrolled women. Moreover, the analysis didn’t include smoking, although smoking increases the risk of AAA 3- to 5-fold. The NNS may be significantly different for smokers than nonsmokers.^1,2

Recommendations

The US Preventive Services Task Force (USPSTF) recommends a one-time ultrasound screening for AAA in men between 65 and 74 years of age who have ever smoked.² The USPSTF advises against routine screening in women and concludes that insufficient evidence exists to advocate for or against routine screening in men 65 to 74 years who have never smoked.²

The Canadian Society for Vascular Surgery recommends a population-based screening program for men 65 to 75 years of age who are candidates for surgery and are willing to participate.³

Acknowledgements

The opinions and assertions contained herein are the private views of the authors and not to be construed as official nor as reflecting the views of the United States Air Force Medical Service or the US Air Force at large.

References

1. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD002945.-

2. Fleming C, Whitlock EP, Beil TL, et al. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the US Preventive Services Task Force. Ann Intern Med. 2005;142:203-211.

3. Mastracci TM, Cina CS. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg. 2007;45:1268-1276.

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Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

James D. Whitworth, PhD
University of West Florida, Pensacola

Janine Tillett, MSLS, AHIP
Wake Forest University School of Medicine, Winston-Salem, NC

ASSISTANT EDITOR
Christopher P. Paulson, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

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Janine Tillett, MSLS, AHIP

Author(s)

Yamil Miranda-Usua, MD

Janine Tillett, MSLS, AHIP

Author and Disclosure Information

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Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

James D. Whitworth, PhD
University of West Florida, Pensacola

Janine Tillett, MSLS, AHIP
Wake Forest University School of Medicine, Winston-Salem, NC

ASSISTANT EDITOR
Christopher P. Paulson, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

Author and Disclosure Information

Yamil Miranda-Usua, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

James D. Whitworth, PhD
University of West Florida, Pensacola

Janine Tillett, MSLS, AHIP
Wake Forest University School of Medicine, Winston-Salem, NC

ASSISTANT EDITOR
Christopher P. Paulson, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

Article PDF

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EVIDENCE-BASED ANSWER

Evidence is inadequate to demonstrate benefits of screening in women.

Evidence summary

Screening reduces AAA deaths in men, but not all-cause mortality

Recommendations

The Canadian Society for Vascular Surgery recommends a population-based screening program for men 65 to 75 years of age who are candidates for surgery and are willing to participate.³

Acknowledgements

EVIDENCE-BASED ANSWER

Evidence is inadequate to demonstrate benefits of screening in women.

Evidence summary

Screening reduces AAA deaths in men, but not all-cause mortality

Recommendations

The Canadian Society for Vascular Surgery recommends a population-based screening program for men 65 to 75 years of age who are candidates for surgery and are willing to participate.³

Acknowledgements

References

1. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD002945.-

2. Fleming C, Whitlock EP, Beil TL, et al. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the US Preventive Services Task Force. Ann Intern Med. 2005;142:203-211.

3. Mastracci TM, Cina CS. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg. 2007;45:1268-1276.

References

1. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD002945.-

2. Fleming C, Whitlock EP, Beil TL, et al. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the US Preventive Services Task Force. Ann Intern Med. 2005;142:203-211.

3. Mastracci TM, Cina CS. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg. 2007;45:1268-1276.

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How can we minimize recurrent ankle sprains?

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Christopher P. Paulson, MD

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How can we minimize recurrent ankle sprains?

Author(s)

Brandon Hemphill, MD

Rita F. Smith, MLS, MBA

EVIDENCE-BASED ANSWER

USING EXTERNAL ANKLE SUPPORTS during physical activity significantly reduces the likelihood of primary and secondary sprains (strength of recommendation [SOR]: A, systematic review).

Proprioception rehabilitation substantially decreases further injury after an ankle sprain (SOR: A, 3 randomized control trials [RCTs] and 1 prospective cohort study).

Evidence summary

A Cochrane review of 14 randomized and quasi-randomized trials concluded that patients who used external ankle supports, such as semi-rigid orthotics or air cast braces, suffered significantly fewer ankle sprains than controls (relative risk [RR]=0.53; 95% confidence interval [CI], 0.40-0.69; number needed to treat [NNT]=22).¹ Participants in the trials ranged in age from adolescence to middle age and were either at risk of injury or had suffered a previous ligament injury.

The benefits of ankle supports were most apparent in patients with previous injuries but still evident in patients who hadn’t been injured. External ankle support is recommended for sports with a high risk of ankle injury, such as soccer and basketball, but the decision to use it should be based on perceived risk of injury as opposed to perceived loss of performance.¹

Research is insufficient to support wearing high-top shoes to prevent primary and secondary ankle sprains.

Also helpful: Balance and proprioceptive training
A systematic review of 2 RCTs with 703 and 1057 patients concluded that completing a minimum of 6 weeks of balance and coordination training after an acute injury substantially reduced the risk of recurrent ankle sprains for as long as a year (NNT=22; absolute risk reduction=4.5%).²

Proprioceptive training appears to effectively prevent primary and secondary ankle injuries but is more beneficial for patients with a previous ankle injury. A recent RCT that enrolled 522 active sports participants with recent ankle injuries found that those who completed an 8-week, self-guided, proprioceptive training program suffered significantly fewer recurrent sprains at 1 year than the control group (22% vs 33%; relative risk reduction=35%; NNT=9).³

Recommendations

The American Orthopaedic Society for Sports Medicine continues to endorse rest, ice, compression, and elevation for optimal initial care of ankle sprains.⁴ The American College of Sports Medicine suggests that rehabilitation after an ankle injury should include guided stretching and strengthening of the ankle joint as well as balance training to prevent future injuries.⁵ Both groups also recommend external ankle supports instead of taping to prevent ankle reinjury.^4,5

References

1. Handoll HH, Rowe BH, Quinn KM, et al. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2009;(3):CD000018.-

2. Patrick OM, Hertel J. Systematic review of postural control and lateral ankle instability, part II: is balance training clinically effective? J Athletic Trng. 2008;43:305-315.

3. Hupperets MW, Verhagen EA, VanMechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised control trial. Available at: www.bmj.com/cgi/content/full/339/jul09_1/b2684?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hupperets&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT. Accessed July 29, 2010.

4. American Orthopaedic Society for Sports Medicine. Ankle sprains: how to speed your recovery. Available at: http://www.evanekman.com/pdfs/3ST%20Ankle%20Sprains%2008.pdf. Accessed October 10, 2011.

5. American College of Sports Medicine. Current comment: ankle sprains and the athlete. Available at: http://www.acsm.org/docs/current-comments/anklesprainstemp.pdf. Accessed on October 10, 2011.

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Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

James D. Whitworth, PhD
University of West Florida, Pensacola

Rita F. Smith, MLS, MBA
Lackland Air Force Base Medical Library, Lackland AFB, Tex

ASSISTANT EDITOR
Christopher P. Paulson, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

The opinions and assertions herein are the private views of the authors and not to be construed as official or as reflecting the views of the United States Air Force Medical Service or the US Air Force at large.

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759-760

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Christopher P. Paulson, MD

Author(s)

Brandon Hemphill, MD

Christopher P. Paulson, MD

Rita F. Smith, MLS, MBA

Author(s)

Brandon Hemphill, MD

Rita F. Smith, MLS, MBA

Author and Disclosure Information

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Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

James D. Whitworth, PhD
University of West Florida, Pensacola

Rita F. Smith, MLS, MBA
Lackland Air Force Base Medical Library, Lackland AFB, Tex

ASSISTANT EDITOR
Christopher P. Paulson, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

Author and Disclosure Information

Brandon Hemphill, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

James D. Whitworth, PhD
University of West Florida, Pensacola

Rita F. Smith, MLS, MBA
Lackland Air Force Base Medical Library, Lackland AFB, Tex

ASSISTANT EDITOR
Christopher P. Paulson, MD
Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla

Article PDF

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EVIDENCE-BASED ANSWER

USING EXTERNAL ANKLE SUPPORTS during physical activity significantly reduces the likelihood of primary and secondary sprains (strength of recommendation [SOR]: A, systematic review).

Proprioception rehabilitation substantially decreases further injury after an ankle sprain (SOR: A, 3 randomized control trials [RCTs] and 1 prospective cohort study).

Evidence summary

Research is insufficient to support wearing high-top shoes to prevent primary and secondary ankle sprains.

Recommendations

EVIDENCE-BASED ANSWER

USING EXTERNAL ANKLE SUPPORTS during physical activity significantly reduces the likelihood of primary and secondary sprains (strength of recommendation [SOR]: A, systematic review).

Proprioception rehabilitation substantially decreases further injury after an ankle sprain (SOR: A, 3 randomized control trials [RCTs] and 1 prospective cohort study).

Evidence summary

Research is insufficient to support wearing high-top shoes to prevent primary and secondary ankle sprains.

Recommendations

References

1. Handoll HH, Rowe BH, Quinn KM, et al. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2009;(3):CD000018.-

2. Patrick OM, Hertel J. Systematic review of postural control and lateral ankle instability, part II: is balance training clinically effective? J Athletic Trng. 2008;43:305-315.

4. American Orthopaedic Society for Sports Medicine. Ankle sprains: how to speed your recovery. Available at: http://www.evanekman.com/pdfs/3ST%20Ankle%20Sprains%2008.pdf. Accessed October 10, 2011.

5. American College of Sports Medicine. Current comment: ankle sprains and the athlete. Available at: http://www.acsm.org/docs/current-comments/anklesprainstemp.pdf. Accessed on October 10, 2011.

References

1. Handoll HH, Rowe BH, Quinn KM, et al. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2009;(3):CD000018.-

2. Patrick OM, Hertel J. Systematic review of postural control and lateral ankle instability, part II: is balance training clinically effective? J Athletic Trng. 2008;43:305-315.

4. American Orthopaedic Society for Sports Medicine. Ankle sprains: how to speed your recovery. Available at: http://www.evanekman.com/pdfs/3ST%20Ankle%20Sprains%2008.pdf. Accessed October 10, 2011.

5. American College of Sports Medicine. Current comment: ankle sprains and the athlete. Available at: http://www.acsm.org/docs/current-comments/anklesprainstemp.pdf. Accessed on October 10, 2011.

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What are the most practical primary care screens for post-traumatic stress disorder?

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What are the most practical primary care screens for post-traumatic stress disorder?

Author(s)

Stephanie M. Davis, MD

Katherine Rickett, MSLS, MSEd

EVIDENCE-BASED ANSWER

The 4-item Primary Care Post-Traumatic Stress Disorder screen (PC-PTSD) is a simple and effective tool to identify symptoms of post-traumatic stress disorder (PTSD) in primary care patients (strength of recommendation [SOR]: B, 1 good-quality prospective cohort study and 1 good-quality retrospective cohort study). The 7-item Breslau screen also predictably identifies patients with PTSD symptoms (SOR: B, 1 good-quality prospective cohort study).

Evidence summary

About 8% of the US population will develop symptoms of PTSD at some point in their lives—usually as the result of a traumatic event, such as combat, a natural disaster, accident, or physical or sexual assault.¹ Primary care settings tend to be the principal point of contact for patients with PTSD, although such patients rarely identify themselves as suffering from the disorder.^2,3

FAST TRACK

About 8% of the US population will develop symptoms of PTSD at some point in their lives.

Detailed diagnostic interviews and assessments are generally impractical in primary care.⁴ Brief, easy-to-complete screening tools can help clinicians identify patients with primary symptoms of PTSD.⁴

4-item screen assesses key characteristics of PTSD

The PC-PTSD (TABLE) is a 4-item screen that assesses the underlying characteristics specific to PTSD: re-experiencing, numbing, avoidance, and hyperarousal.⁴ It’s designed to be understandable to patients with an eighth-grade reading level and has been validated in a Department of Veterans Affairs (VA) primary care population (N=188).⁴

With a cutoff score of 3, the PCPTSD has a sensitivity of 78% and specificity of 87%, compared with the gold-standard Clinician-Administered PTSD Scale (CAPS).⁴ Positive responses warrant further evaluation of trauma symptoms and completion of the CAPS by a mental health provider to determine whether the patient may have PTSD or other trauma-related problems.^5-7

TABLE
The primary care PTSD screen (PC-PTSD)⁴

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…
1. Have had nightmares about it or thought about it when you did not want to? YES NO
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO
3. Were constantly on guard, watchful, or easily startled? YES NO
4. Felt numb or detached from others, activities, or your surroundings? YES NO

Breslau’s short screen addresses 7 specific symptoms

Breslau’s 7-item screening scale (available at http://ajp.psychiatryonline.org/cgi/content/full/156/6/908#T2) is another empirically tested, brief, simple means of identifying PTSD symptoms in primary care patients.² (See also: www.pubmedcentral.nih.gov/articlerender.fcgifiartid=1484617.) Each item addresses a specific symptom.

FAST TRACK

The 4-item PC-PTSD screen is designed to be understandable to patients with an eighth-grade reading level and has been validated.

The screen has been validated in a VA primary care clinic (N=134). With a cutoff score of 4, it has a sensitivity of 85% and specificity of 84%, yielding a positive predictive value of 71% and negative predictive value of 98%.² The likelihood of a score <3 is 0.04 and a score >5 is 13.5. Scores of 3 to 5 have an indeterminate likelihood value (1.8). Patients with a positive screen should undergo further evaluation by a mental health provider.²

Leave lengthy screens to mental health professionals

The CAPS and the civilian version of the PTSD Symptom Checklist (PCL-C), both with 17 items, are widely used as “screens” for PTSD.⁷ However, their length and the recommendation that they be administered by a mental health professional make them cumbersome and impractical for use in primary care.⁷

Recommendations

A 2007 point-of-care guide written for primary care clinicians recommends Breslau’s short screening scale and the PCPTSD screen for use in this setting.¹ Both the National Center for PTSD and Department of Defense Clinical Guidelines on PTSD recommend initial and annual screening using the PC-PTSD, PTSD Brief Screen, or Short Screening Scale for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) PTSD.⁸

Acknowledgements

The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the United States Air Force Medical Service or the United States Air Force at large.

References

1. Ebell MH. Screening instruments for post-traumatic stress disorder. Am Fam Physician. 2007;76:1848-1849.

2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.

3. Screen for PTSD symptoms. PTSD core annotation E. Available at: www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/content/core/annoC.htm. Accessed April 15, 2008.

4. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.

5. Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary care: comparison of the primary care-PTSD screen (PC-PTSD) and the general health questionnaire-12 (GHQ). J Anxiety Disord. 2008;22:337-343.

6. National Center for PTSD. Screening for PTSD in a primary care setting. Available at: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed April 15, 2008.

7. Griffin MG, Uhlmansiek MH, Resick PA, et al. Comparison of the posttraumatic stress disorder scale versus the clinician-administered posttraumatic stress disorder scale in domestic violence survivors. J Trauma Stress. 2004;17:497-503.

8. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0; January 2004. Available at: www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5187. Accessed April 15, 2008.

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James D. Whitworth, PhD
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Katherine Rickett, MSLS, MSEd
East Carolina University, Greenville, NC

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East Carolina University, Greenville, NC

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East Carolina University, Greenville, NC

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EVIDENCE-BASED ANSWER

Evidence summary

FAST TRACK

About 8% of the US population will develop symptoms of PTSD at some point in their lives.

4-item screen assesses key characteristics of PTSD

TABLE
The primary care PTSD screen (PC-PTSD)⁴

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…
1. Have had nightmares about it or thought about it when you did not want to? YES NO
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO
3. Were constantly on guard, watchful, or easily startled? YES NO
4. Felt numb or detached from others, activities, or your surroundings? YES NO

Breslau’s short screen addresses 7 specific symptoms

FAST TRACK

The 4-item PC-PTSD screen is designed to be understandable to patients with an eighth-grade reading level and has been validated.

Leave lengthy screens to mental health professionals

Recommendations

Acknowledgements

EVIDENCE-BASED ANSWER

Evidence summary

FAST TRACK

About 8% of the US population will develop symptoms of PTSD at some point in their lives.

4-item screen assesses key characteristics of PTSD

TABLE
The primary care PTSD screen (PC-PTSD)⁴

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…
1. Have had nightmares about it or thought about it when you did not want to? YES NO
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO
3. Were constantly on guard, watchful, or easily startled? YES NO
4. Felt numb or detached from others, activities, or your surroundings? YES NO

Breslau’s short screen addresses 7 specific symptoms

FAST TRACK

The 4-item PC-PTSD screen is designed to be understandable to patients with an eighth-grade reading level and has been validated.

Leave lengthy screens to mental health professionals

Recommendations

Acknowledgements

References

1. Ebell MH. Screening instruments for post-traumatic stress disorder. Am Fam Physician. 2007;76:1848-1849.

2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.

3. Screen for PTSD symptoms. PTSD core annotation E. Available at: www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/content/core/annoC.htm. Accessed April 15, 2008.

4. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.

6. National Center for PTSD. Screening for PTSD in a primary care setting. Available at: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed April 15, 2008.

References

1. Ebell MH. Screening instruments for post-traumatic stress disorder. Am Fam Physician. 2007;76:1848-1849.

2. Kimerling R, Ouimette P, Prins A, et al. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J Gen Intern Med. 2006;21:65-67.

3. Screen for PTSD symptoms. PTSD core annotation E. Available at: www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/content/core/annoC.htm. Accessed April 15, 2008.

4. Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry. 2003;9:9-14.

6. National Center for PTSD. Screening for PTSD in a primary care setting. Available at: www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_screen_disaster.html. Accessed April 15, 2008.

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What are the most practical primary care screens for post-traumatic stress disorder?

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Which nondrug alternatives can help with insomnia?

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Display Headline

Which nondrug alternatives can help with insomnia?

Author(s)

Brian K. Crownover, MD, FAAFP

William Nichols, MLS

EVIDENCE-BASED ANSWER

Cognitive behavioral therapy (CBT) interventions—particularly stimulus control and sleep hygiene—are well-validated, effective treatments for chronic insomnia that are equivalent or superior to pharmacological interventions (strength of recommendation: A, based on systematic reviews). The long-term efficacy of CBT interventions, and their successful implementation by primary care physicians (as compared with behavioral science providers), is unclear.

Clinical commentary

Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK

A large proportion of people in my patient population are shift workers, so chronic insomnia plays a large role in my daily workload, both directly and indirectly. This summary tells me that I have a proven and equally efficacious alternative to drugs for these sufferers—which is great.

However, I was disappointed to see that none of the CBT interventions were performed by family physicians in the office. So the good news is that I have a nondrug intervention for insomnia; the bad news is I don’t know if it’s something I can provide without a referral. Maybe it’s time for some practice-based research to see if that is possible.

Evidence summary

Approximately 10% to 15% of adults complain of chronic insomnia, best defined as difficulty initiating or maintaining sleep 3 or more nights per week for 6 months or longer, with secondary impairments in daytime functioning, including fatigue and disturbed mood.^1-3

Behavioral and psychological treatments have emerged as increasingly popular adjunctive interventions to pharmacotherapy and as independent interventions for chronic insomnia. No evidence exists that behavioral treatments have adverse effects.¹

FAST TRACK

Stimulus control and sleep hygiene are effective treatments for insomnia

Sleep hygiene, relaxation training, and cognitive therapy improve sleep

CBT interventions are based on the notion that distorted thoughts about sleep and learned behavior patterns hyperarouse the central nervous system and deregulate sleep cycles, resulting in chronic insomnia.⁴ CBT interventions combine empirically tested behavioral, cognitive, and educational procedures to alter faulty beliefs and attitudes, modify sleep habits, and regulate sleep-wake schedules.³

These interventions include stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy.⁵ These methods can be used separately; however, they are increasingly being used together to treat the complexities of individual patients.⁵

FAST TRACK

Cognitive behavioral therapy reduced sleep onset latency by an additional 8.8 minutes over medication, according to one meta-analysis

Five recent high-quality randomized control trials (RCTs) confirmed findings from earlier RCTs that CBT methods improve sleep.⁵ Compared with those given a placebo or placed on a waiting list, CBT-treated patients in these RCTs reported clinically significant improvements in sleep onset latency, sleep efficiency, time awake after sleep onset, and total sleep time. In one RCT, 64% of CBT patients had improvements in sleep efficiency and time awake after sleep onset, compared with 8% who improved with a placebo intervention (number needed to treat [NNT]=1.8).⁵ Further, sleep onset latency for primary care patients with chronic insomnia was decreased from 61 to 28 minutes, compared with 74 to 70 minutes for a waiting-list group.⁵ The maintenance of sleep gains from CBT beyond 1 year is unknown since no published RCT clinical trials to date have lasted longer than 12 months.¹

An important related meta-analysis of 21 studies validated behavior therapy, and revealed CBT reduced sleep onset latency by an additional 8.8 minutes over medication (95% confidence interval, 0.17–1.04 minutes).⁶ Although not superior on other outcomes, behavior therapy produced similar short-term results to pharmacotherapy across all other sleep measures, without attendant medication side effects.

FAST TRACK

The APA recommends cognitive behavioral therapy as the treatment of choice for chronic insomnia

Stimulus control is the most effective CBT intervention

A recent systematic review with meta-analysis of 37 clinical investigations determined that stimulus control was the most effective CBT intervention.³ Stimulus control consists of 5 basic instructions (TABLE) designed to help the patient reassociate sleep stimuli (ie, bed/bedroom) with falling asleep and establishing consistent sleep-wake schedules. These 5 instructions are frequently used in combination with CBT sleep hygiene techniques (TABLE) and can be easily integrated into the office setting.^3,4

Among the CBT techniques, stimulus control and sleep hygiene are the least time-consuming and may be more easily applied in the primary care setting; however, minimal research has been done into the specific incorporation of CBT into primary care settings.

Researchers conducting a single-blind randomized group study in a Veterans Affairs primary care clinic concluded that an abbreviated CBT approach with two 25-minute sessions effectively improved participant sleep onset latency, and time awake after sleep onset.⁷ Researchers reviewed participants’ sleep logs and a behavioral health provider offered patients a condensed education on sleep hygiene, stimulus control, and sleep restrictions strategies. The study was limited because of small sample size (<25). Generalizability to practice is restricted because sessions were conducted by a behavioral health provider, not a family physician.

TABLE
Patient needs a good night’s sleep? Offer this advice

STIMULUS CONTROL INSTRUCTIONS³
Don’t go to bed until you are sleepy Use the bed/bedroom only for sleeping (don’t read, watch TV, eat, or worry) Get out of bed when unable to sleep after 15 minutes; do something relaxing and avoid stimulating activity/thoughts Arise from bed at the same time every day Do not nap during the day
SLEEP HYGIENE INSTRUCTIONS⁴
Sleep only as much as you need to feel refreshed during the following day Exercise regularly Make sure your bedroom is comfortable and free from disturbing light and noise Make sure your bedroom is at a comfortable temperature during the night Eat regular meals and do not go to bed hungry Avoid drinking too many fluids in the evening Reduce your caffeine intake Avoid drinking alcohol—especially in the evening Avoid smoking at night when you are having trouble sleeping Don’t try too hard to fall asleep Put the clock under the bed or turn it so you can’t see it

Recommendations from others

The Agency for Healthcare Research and Quality recommends CBT as an effective treatment in the management of chronic .⁸ It also recommends that further large-scale RCTs be conducted to establish CBT’s effectiveness across subsets of the population of individuals with chronic (ie, gender, age, shift workers, and those with psychiatric illnesses).

The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.⁹

Acknowledgments

The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.

References

1. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. NIH Consensus Science Statement. 2005; 22(2). Available at: consensus.nih.gov/2005/2005InsomniaSOS026main.htm. Accessed on September 4, 2007.

2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.

3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.

4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.

5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.

6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.

7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.

8. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations of chronic insomnia in adults. Evidence report/technology assessment No. 125. (Prepared by the University of Alberta Evidence-based Practice Center, under Contract N. C400000021.) AHRQ Publication No. 05-E021-1. Rockville, Md: Agency for Healthcare Research and Quality. June 2005. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf. Accessed on September 4, 2007.

9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.

Article PDF

5610JFP_ClinicalInquiries1.pdf

Author and Disclosure Information

James D. Whitworth, PhD
Brian K. Crownover, MD, FAAFP
HQ Air Armament Center, Family Medicine Residency, Eglin Air Force Base, Fla

William Nichols, MLS
Eglin Air Force Base, 96th Medical Group, Eglin Air Force Base, Fla

Issue

The Journal of Family Practice - 56(10)

Publications

Topics

Sleep Medicine

Page Number

836-840

Legacy Keywords

insomnia; nondrug; treatment; sleep; disorder; CBT; cognitive; behavioral; therapy; sleep hygiene; stimulus control; James D. Whitworth PhD; Brian K. Crownover MD; William Nichols MLS; Lt Col John D. Hallgren

Sections

Author(s)

Brian K. Crownover, MD, FAAFP

William Nichols, MLS

Author(s)

Brian K. Crownover, MD, FAAFP

William Nichols, MLS

Author and Disclosure Information

James D. Whitworth, PhD
Brian K. Crownover, MD, FAAFP
HQ Air Armament Center, Family Medicine Residency, Eglin Air Force Base, Fla

William Nichols, MLS
Eglin Air Force Base, 96th Medical Group, Eglin Air Force Base, Fla

Author and Disclosure Information

James D. Whitworth, PhD
Brian K. Crownover, MD, FAAFP
HQ Air Armament Center, Family Medicine Residency, Eglin Air Force Base, Fla

William Nichols, MLS
Eglin Air Force Base, 96th Medical Group, Eglin Air Force Base, Fla

Article PDF

5610JFP_ClinicalInquiries1.pdf

Article PDF

5610JFP_ClinicalInquiries1.pdf

EVIDENCE-BASED ANSWER

Clinical commentary

Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK

Evidence summary

FAST TRACK

Stimulus control and sleep hygiene are effective treatments for insomnia

Sleep hygiene, relaxation training, and cognitive therapy improve sleep

FAST TRACK

Cognitive behavioral therapy reduced sleep onset latency by an additional 8.8 minutes over medication, according to one meta-analysis

FAST TRACK

The APA recommends cognitive behavioral therapy as the treatment of choice for chronic insomnia

Stimulus control is the most effective CBT intervention

TABLE
Patient needs a good night’s sleep? Offer this advice

STIMULUS CONTROL INSTRUCTIONS³
Don’t go to bed until you are sleepy Use the bed/bedroom only for sleeping (don’t read, watch TV, eat, or worry) Get out of bed when unable to sleep after 15 minutes; do something relaxing and avoid stimulating activity/thoughts Arise from bed at the same time every day Do not nap during the day
SLEEP HYGIENE INSTRUCTIONS⁴
Sleep only as much as you need to feel refreshed during the following day Exercise regularly Make sure your bedroom is comfortable and free from disturbing light and noise Make sure your bedroom is at a comfortable temperature during the night Eat regular meals and do not go to bed hungry Avoid drinking too many fluids in the evening Reduce your caffeine intake Avoid drinking alcohol—especially in the evening Avoid smoking at night when you are having trouble sleeping Don’t try too hard to fall asleep Put the clock under the bed or turn it so you can’t see it

Recommendations from others

The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.⁹

Acknowledgments

EVIDENCE-BASED ANSWER

Clinical commentary

Can I provide these interventions without a referral?
John D Hallgren, Lt Col, USAF, MC
Uniformed Services University of the Health Sciences, RAF Menwith Hill, UK

Evidence summary

FAST TRACK

Stimulus control and sleep hygiene are effective treatments for insomnia

Sleep hygiene, relaxation training, and cognitive therapy improve sleep

FAST TRACK

Cognitive behavioral therapy reduced sleep onset latency by an additional 8.8 minutes over medication, according to one meta-analysis

FAST TRACK

The APA recommends cognitive behavioral therapy as the treatment of choice for chronic insomnia

Stimulus control is the most effective CBT intervention

TABLE
Patient needs a good night’s sleep? Offer this advice

STIMULUS CONTROL INSTRUCTIONS³
Don’t go to bed until you are sleepy Use the bed/bedroom only for sleeping (don’t read, watch TV, eat, or worry) Get out of bed when unable to sleep after 15 minutes; do something relaxing and avoid stimulating activity/thoughts Arise from bed at the same time every day Do not nap during the day
SLEEP HYGIENE INSTRUCTIONS⁴
Sleep only as much as you need to feel refreshed during the following day Exercise regularly Make sure your bedroom is comfortable and free from disturbing light and noise Make sure your bedroom is at a comfortable temperature during the night Eat regular meals and do not go to bed hungry Avoid drinking too many fluids in the evening Reduce your caffeine intake Avoid drinking alcohol—especially in the evening Avoid smoking at night when you are having trouble sleeping Don’t try too hard to fall asleep Put the clock under the bed or turn it so you can’t see it

Recommendations from others

The American Psychological Association (APA) recommends CBT as the “treatment of choice” for chronic , with 70% to 80% of patients showing a treatment response.⁹

Acknowledgments

References

2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.

3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.

4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.

5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.

6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.

7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.

9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.

References

2. Ohayon M. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.

3. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004;65 Suppl 16:33-40.

4. Smith MT, Neubauer DN. Cognitive behavioral therapy for chronic insomnia. Clinical Cornerstone 2003;5:1-9.

5. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA. Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998–2004). Sleep 2006;29:1398-1413.

6. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.

7. Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep 2003;26:177-182.

9. American Psychological Association Web site. Getting a good night’s sleep with the help of psychology. Available at: www.psychologymatters.org/insomnia.html. Accessed on September 4, 2007.

Issue

The Journal of Family Practice - 56(10)

Issue

The Journal of Family Practice - 56(10)

Page Number

836-840

Page Number

836-840

Publications