Insomnia Management: A Review and Update.

KEY TAKEAWAYS: Insomnia is a distinct disorder that is common, yet underrecognized and undertreated in primary care. Treating insomnia has been shown to improve outcomes, including reduced risk of developing cardiovascular and mental health disorders. Insomnia is influenced by the brain's regulation of sleep and wake, which are mutually exclusive events. Insomnia should be treated as a distinct condition, even when occurring with a comorbid diagnosis such as depression or anxiety. Clinicians should implement a multimodal approach to insomnia management, including nonpharmacologic interventions and pharmacologic therapy (when indicated). Pharmacologic agents that are approved by the US Food and Drug Administration for insomnia include benzodiazepine receptor agonists (zolpidem, eszopiclone, and zaleplon), low-dose doxepin (tricyclic antidepressant), ramelteon (melatonin receptor agonist), and dual orexin receptor agonists (DORAs, daridorexant, lemborexant, and suvorexant). Unlike other pharmacologic agents, DORAs inhibit wakefulness rather than induce sedation. Additionally, these medications have no evidence of rebound insomnia or withdrawal, and little to no abuse potential. Daridorexant is the newest DORA, has an ideal half-life of 8 hours, and has demonstrated continued efficacy over a 12-month period. Selection of pharmacologic agent should be based on the patient's comorbid conditions, treatment goals and preferences, and other clinical characteristics.

Soldiers' Perception of a Behavioral Intervention for Positive Airway Pressure Therapy Adherence in a Military Treatment Facility.

INTRODUCTION: The incidence of obstructive sleep apnea in military personnel has increased over 500% since the early 2000s. Adherence to continuous positive airway pressure (PAP), an efficacious treatment, has been suboptimal. This article presents a behavioral intervention model for enhancing PAP therapy adherence and describes how the model was received by military personnel. MATERIALS AND METHODS: The study population comprised 254 out of 280 military personnel (93% men, mean age 39 years) who attended a 90-minute behavioral intervention class within the first 8 weeks of PAP use. They were coached on the Knowledge, Skills, Attitudes (KSA) model of PAP therapy success: Knowledge about obstructive sleep apnea and PAP treatment; Skills to develop a habitual loop for nightly PAP use; and Attitudes that address readiness, barriers, and solutions for sustaining PAP use. Participants completed a voluntary, anonymous postclass survey that inquired of their perception of various elements of the class. Data were analyzed using descriptive statistics and a paired sample t-test. RESULTS: In participants' self-rating of how much they know about PAP treatment before and after the class, their ratings indicated that they experienced a significant increase in knowledge (P < 0.0001). On the postclass survey, 77% of the participants (N = 195/254) "agree a lot" or "strongly agree" that the class gave them tools to have a successful treatment and 78% (N = 198/254) noted that it was a valuable educational experience. The Knowledge portion was rated by 79% (N = 201/254) of the participants as "quite a lot" or "extremely" beneficial. The Skills segment was rated as "quite a lot" or "extremely" beneficial by 72% (N = 183/254) of the participants. The Attitudes discussion was perceived as "quite a lot" or "extremely" beneficial by 70% (N = 178/254) of the participants. Participants' free-text responses to "what was most helpful" were generally positive. CONCLUSIONS: A KSA model of behavioral intervention for enhancing PAP therapy adherence was well received by participants. Future research will assess the impact of this intervention on adherence as measured by objective indicators.

Confirmed malaria cases among active component U.S. Army personnel, January-September 2012.

Of 26 cases of malaria reported among active component U.S. Army personnel during January through September 2012, 16 were laboratory-confirmed according to electronic medical records. Medical records and responses on postdeployment health assessment questionnaires were used to assess demographic and clinical characteristics, adherence to malaria prevention measures, and compliance with prescriptions for chemoprophylaxis. All but two cases were confirmed by peripheral blood smears. Twelve cases were caused by Plasmodium vivax, one by P. falciparum, and three unspecified diagnoses were deemed likely to be due to P. vivax. Fourteen cases were associated with deployment to Afghanistan. Adherence to Army malaria prevention measures during deployment and compliance with post-deployment primaquine chemprophylaxis were poor. Prescribed doses of primaquine often varied from current clinical or Department of Defense policy guidelines. Continued education, training and reinforcement of malaria prevention by medical and preventive medicine personnel are indicated, as is blood smear confirmation of suspected malaria cases. Unit commanders and supervisors play a crucial role in ensuring soldiers' adherence to malaria prevention measures.