The Economics of Treating Insomnia

The consequences of insomnia to health, safety, performance and quality of life are enormous. So is the financial toll.
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Insomnia treatments improve lives -- and save money

Despite its status as the most common sleep disorder among adults in the U.S., many people who suffer from insomnia aren't receiving treatment. Research indicates that insomnia disorder is significantly underdiagnosed among American adults. What's more, treatment for insomnia isn't always -- or even often -- made accessible and affordable by insurers and health-care organizations, or addressed actively by physicians.

Many people with symptoms of insomnia -- whether they recognize them as such or not -- take a go-it-alone approach to managing their sleep problems. They muddle through their waking days on insufficient sleep, expending precious effort to maintain their focus and productivity during the day and doing their best to patch together a consistent sleep routine at night. They attempt to treat their sleep issues themselves, relying on over-the-counter sleep aids and supplements, or using alcohol -- mistakenly -- as a sleep aid. (Alcohol functions in the body as both sedative and stimulant, and can be highly disruptive to sleep quality and sleep quantity.)

The consequences of insomnia to health, safety, performance and quality of life are enormous. So is the financial toll. A recent review by Emerson M. Wickwire, PhD., investigated the staggering financial costs associated with insomnia. Dr. Wickwire is assistant professor of psychiatry and director of the Insomnia Program at University of Maryland School of Medicine. Together with his colleagues, Dr. Wickwire rigorously reviewed the available research on the economic impact of insomnia disorder.

Their tally? Insomnia costs the U.S. economy more than $100 billion a year, stemming largely from increased health-care reliance, lost productivity, and more frequent injuries and accidents.

As their analysis points out, there is an abundance of research that demonstrates the therapeutic effectiveness of treatments for insomnia in alleviating symptoms, improving health and boosting quality of life. There's been far less attention paid to measuring the cost effectiveness of insomnia treatments. As part of their review, the researchers examined the existing research about the cost effectiveness of treating insomnia. They found consistent evidence that multiple forms of treatment for insomnia are cost effective, with cost savings that "pay" for the treatments themselves within relatively short periods of time, and additional, often significant reductions to the indirect costs associated with untreated insomnia.

Let's take a look at how two forms of well established, therapeutically effective treatment for insomnia fare when it comes to being cost effective.

What makes a treatment cost effective?
First, let's look briefly at how cost effectiveness is measured. One of the most common tools to assess the cost effectiveness of health-care treatment is known as QALY, or quality-adjusted life year. A QALY figure takes into account both the quantity of time and the quality of time that is afforded by virtue of the treatment. QALY measurements allow researchers, policymakers, and health-care payers to gauge the cost effectiveness of a treatment on its own, and in comparison to other health care treatments. For example, the cost effectiveness of substance abuse treatment and the cost effectiveness of insomnia disorder can be compared by comparing their QALY figures.

A QALY of $50,000 is generally considered a threshold for cost-effective care (though some scientists believe this figure is too low).

Considering the scope of the problem of insomnia, there is very little research that investigates the cost effectiveness of treatments for the sleep disorder -- the current review examines a total of 10 different studies. These studies consistently show, however, that treatment for insomnia disorder is highly cost effective, as assessed by QALY measurements.

Treating insomnia with sleep meds
Prescription sleep medications are one form of treatment for insomnia that studies have shown to be effective, in terms of both treatment and cost. The current review looked at several studies of pharmacotherapy treatment for insomnia, and each one demonstrated the cost-effectiveness of one or more prescription sleep medications, including some of the most commonly prescribed sleep aids.

Analyses within these different studies found that treating insomnia with pharmacotherapy reduced health-care costs, costs of workplace absenteeism and presenteeism, and costs related to injury and accident, such as short-term disability and workers' compensation. QALY figures in these studies were below the standard cost-effectiveness threshold of $50,000 -- and they remained below this threshold even when indirect costs of insomnia were factored out. The indirect costs of insomnia, which include increased overall health-care utilization, diminished productivity in the workplace, and more frequent accidental injuries, account for the bulk of the total economic costs of insomnia.

Behavioral therapy for insomnia pays off
Behavioral treatments for insomnia address symptoms of the sleep disorder by seeking to change thoughts, emotions, habits and actions that influence sleep. Cognitive-behavioral therapy, or CBT, is an effective treatment for insomnia and other sleep problems. Scientific research has strongly established the therapeutic effectiveness of CBT for insomnia. Research has demonstrated that CBT can be as or more effective than sleep medications in reducing symptoms of insomnia, particularly over the long term.

Several studies investigating the cost of CBT for insomnia show that this form of insomnia treatment is both therapeutically effective and also cost effective. CBT for insomnia reduces health care utilization and health care costs, according to this research.

Sleep meds vs. CBT-I
One study has compared directly the cost effectiveness of sleep medication to CBT for insomnia. This researched analyzed cost effectiveness of the two treatments in a group of older adults, with a no-treatment group used as a control. Among older adults, CBT for insomnia was found to be significantly more cost effective than pharmacotherapy, with both lower direct costs of treatment and significant savings as a result of treatment. A major factor in the greater cost effectiveness of CBT for older adults came as a result of the risks associated with sleep medication use in this population -- specifically, the risk of injury from falls.

While one study is not sufficient to declare CBT more cost effective than pharmacotherapy for older adults, this single study does make an important argument in favor of CBT for insomnia among this age group. The American Geriatrics Society recommends limiting use of several of the most common sleep medications, based on research suggesting these medications deliver minimal improvements while increasing risks for falls, injury, and episodes of delirium in older adults.

As Dr. Wickwire's review notes, insomnia among older adults has the potential for significant economic impact, both at present and particularly in the future. Age is one important risk factor for insomnia. The sleep disorder appears with greater frequency in older populations. With the population in the U.S. and in other countries aging, insomnia is poised to become an even more pressing health problem -- and one with even greater economic impact. It is of vital importance that we see more comparative studies of pharmacotherapy and behavioral therapy, for older adults and among different age groups.

Delving deeper into cost effectiveness
Determining the degree of cost effectiveness among insomnia treatments needs greater attention. Dr. Wickwire and colleagues make a number of important recommendations. They call for more research into measuring the improvements that treating insomnia delivers to workplace performance. Their analysis of the costs of insomnia suggests that the majority of insomnia-related expenses -- $67 billion annually in the U.S. -- derive from lost productivity in the workplace. We know a good deal about how insomnia interferes with workplace productivity, performance, and safety, but we're still lagging considerably in evidence of how insomnia treatment can lower costs in these areas.

They also advocate that measuring costs (both direct and indirect) should be a component of all insomnia trials. This would generate a wealth of data for further exploration of cost effectiveness. It would also help to bridge gaps in thinking among scientists, policymakers, and health-care payers about the sleep disorder, it's characteristics and it's treatments, as well as the costs linked to these factors.

Combining investigation and discussion of both therapeutic and economic values linked to insomnia disorder and its treatment is a necessary response to today's health care market, and could help move us closer to meaningful, lasting improvements to making the most effective therapies more widely understood and accessible -- delivering better care to more people, and reducing society's costs at the same time. That's a win for patients, payers, and all of us.

Sweet Dreams,

Michael J. Breus, PhD
The Sleep Doctor™

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