Sleep initiation and maintenance disorders: Difference between revisions

From Citizendium
Jump to navigation Jump to search
imported>Robert Badgett
imported>Robert Badgett
Line 6: Line 6:
While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a [[polysomnogram]] is often needed for the differential diagnosis.
While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a [[polysomnogram]] is often needed for the differential diagnosis.
==Treatment==
==Treatment==
{| class="wikitable" align="right"
|+ Randomized controlled trial of treatment options for insomnia.<ref name="pmid19454639">{{cite journal|  author=Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et  al.| title=Cognitive behavioral therapy, singly and combined with  medication, for persistent insomnia: a randomized controlled trial. |  journal=JAMA | year= 2009 | volume= 301 | issue= 19 | pages= 2005-15 |  pmid=19454639
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19454639 | doi=10.1001/jama.2009.682 }} </ref>
! rowspan=2|Treatment!! colspan=2|Outcome at 6 months
|-
! Responders!! Remitters
|-
| 6 weeks of [[Cognitive behavioral therapy|CBT]]|| 55% || 40%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]|| 63% || 44%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 weeks of [[zolpidem]]||style="background:lightgreen"| 81% ||style="background:lightgreen"| 68%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 months of [[zolpidem]]|| 65% || 42%
|-
| colspan=3 | Adapted from Table 4 of Morin et al.<ref name="pmid19454639"/>
|-
|}
Treatment options for [[geriatrics|geriatric]] patients have been reviewed.<ref name="pmid19484833">{{cite journal| author=Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al.| title=Evidence-based recommendations for the assessment and management of sleep disorders in older persons. | journal=J Am Geriatr Soc | year= 2009 | volume= 57 | issue= 5 | pages= 761-89 | pmid=19484833  
Treatment options for [[geriatrics|geriatric]] patients have been reviewed.<ref name="pmid19484833">{{cite journal| author=Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al.| title=Evidence-based recommendations for the assessment and management of sleep disorders in older persons. | journal=J Am Geriatr Soc | year= 2009 | volume= 57 | issue= 5 | pages= 761-89 | pmid=19484833  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19484833 | pmc=PMC2748127 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19484833 | pmc=PMC2748127 }}</ref>


===Non-drug treatment===
===Non-drug treatment===
No-drug treatments such as  light therapy, exercise, and sleep-hygiene modification have been reviewed.<ref name="pmid19256583">{{cite journal| author=Shub D, Darvishi R, Kunik ME| title=Non-pharmacologic treatment of insomnia in persons with dementia. | journal=Geriatrics | year= 2009 | volume= 64 | issue= 2 | pages= 22-6 | pmid=19256583  
No-drug treatments such as  light therapy, exercise, and sleep-hygiene modification have been reviewed.<ref name="pmid19256583">{{cite journal| author=Shub D, Darvishi R, Kunik ME| title=Non-pharmacologic treatment of insomnia in persons with dementia. | journal=Geriatrics | year= 2009 | volume= 64 | issue= 2 | pages= 22-6 | pmid=19256583  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19256583 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19256583 }}</ref>


A combination of education, sleep hygiene, exercise, and light therapy helped patients with [[Alzheimer's disease]] in the NITE-AD [[randomized controlled trial]].<ref name="pmid15877554">{{cite journal| author=McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L| title=Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial. | journal=J Am Geriatr Soc | year= 2005 | volume= 53 | issue= 5 | pages= 793-802 | pmid=15877554  
A combination of education, sleep hygiene, exercise, and light therapy helped patients with [[Alzheimer's disease]] in the NITE-AD [[randomized controlled trial]].<ref name="pmid15877554">{{cite journal| author=McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L| title=Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial. | journal=J Am Geriatr Soc | year= 2005 | volume= 53 | issue= 5 | pages= 793-802 | pmid=15877554  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=15877554 | doi=10.1111/j.1532-5415.2005.53252.x }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=15877554 | doi=10.1111/j.1532-5415.2005.53252.x }}</ref>


Indirect evidence suggests a warm bath may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352  
Indirect evidence suggests a warm bath may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }}</ref>


Exercise, perhaps by raising body temperature, may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352  
Exercise, perhaps by raising body temperature, may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }}</ref>


===Medications===
===Medications===
Line 34: Line 57:


In [[geriatrics]], the benefits of [[zolpidem]] for insomnia to not clearly exceed the [[drug toxicity]].<ref name="pmid16284208">{{cite journal| author=Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE| title=Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. | journal=BMJ | year= 2005 | volume= 331 | issue= 7526 | pages= 1169 | pmid=16284208  
In [[geriatrics]], the benefits of [[zolpidem]] for insomnia to not clearly exceed the [[drug toxicity]].<ref name="pmid16284208">{{cite journal| author=Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE| title=Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. | journal=BMJ | year= 2005 | volume= 331 | issue= 7526 | pages= 1169 | pmid=16284208  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16284208 | doi=10.1136/bmj.38623.768588.47 | pmc=PMC1285093 }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16813362 Review in: ACP J Club. 2006 Jul-Aug;145(1):14]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=17213123 Review in: Evid Based Med. 2006 Aug;11(4):110]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16865838 Review in: Evid Based Nurs. 2006 Jul;9(3):87] <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid9417012">{{cite journal| author=Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ| title=Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. | journal=JAMA | year= 1997 Dec 24-31 | volume= 278 | issue= 24 | pages= 2170-7 | pmid=9417012  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16284208 | doi=10.1136/bmj.38623.768588.47 | pmc=PMC1285093 }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16813362 Review in: ACP J Club. 2006 Jul-Aug;145(1):14]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=17213123 Review in: Evid Based Med. 2006 Aug;11(4):110]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16865838 Review in: Evid Based Nurs. 2006 Jul;9(3):87]</ref><ref name="pmid9417012">{{cite journal| author=Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ| title=Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. | journal=JAMA | year= 1997 Dec 24-31 | volume= 278 | issue= 24 | pages= 2170-7 | pmid=9417012  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=9417012 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=9417012 }}</ref>


The benefit of [[eszopiclone]] may not be strong.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841  
The benefit of [[eszopiclone]] may not be strong.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }}</ref>


====Melatonin agonists====
====Melatonin agonists====
[[Ramelteon]] is one available agonist. Its magnitude of benefit may be small. among outpatients.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841  
[[Ramelteon]] is one available agonist. Its magnitude of benefit may be small. among outpatients.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }}</ref>


[[Tasimelteon]] can help transient insomnia due to shift changes related to employment..<ref name="pmid19054552">{{cite journal| author=Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al.| title=Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9662 | pages= 482-91 | pmid=19054552  
[[Tasimelteon]] can help transient insomnia due to shift changes related to employment..<ref name="pmid19054552">{{cite journal| author=Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al.| title=Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9662 | pages= 482-91 | pmid=19054552  
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19054552 | doi=10.1016/S0140-6736(08)61812-7 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19054552 | doi=10.1016/S0140-6736(08)61812-7 }}</ref>


==References==
==References==
<references/>
<references/>

Revision as of 22:27, 24 May 2011

This article is developing and not approved.
 Main Article
 Discussion
Related Articles  [?]
Bibliography  [?]
External Links  [?]
Citable Version  [?]
 
https://en.citizendium.org/wiki/index.php?title=Sleep_initiation_and_maintenance_disorders&printable=yes
This editable Main Article is under development and subject to a disclaimer.

In medicine, sleep initiation and maintenance disorders, including insomnia, are "disorders characterized by impairment of the ability to initiate or maintain sleep. This may occur as a primary disorder or in association with another medical or psychiatric condition."[1][2]

Diagnosis

While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a polysomnogram is often needed for the differential diagnosis.

Treatment

Randomized controlled trial of treatment options for insomnia.[3]
Treatment Outcome at 6 months
Responders Remitters
6 weeks of CBT 55% 40%
6 months of CBT 63% 44%
6 months of CBT
6 weeks of zolpidem		 81% 68%
6 months of CBT
6 months of zolpidem		 65% 42%
Adapted from Table 4 of Morin et al.[3]


Treatment options for geriatric patients have been reviewed.[4]

Non-drug treatment

No-drug treatments such as light therapy, exercise, and sleep-hygiene modification have been reviewed.[5]

A combination of education, sleep hygiene, exercise, and light therapy helped patients with Alzheimer's disease in the NITE-AD randomized controlled trial.[6]

Indirect evidence suggests a warm bath may help.[7]

Exercise, perhaps by raising body temperature, may help.[7]

Medications

GABA agonists

These medications are agonists of the gamma aminobutyric acid.

Nonselective BZ1 and BZ2 agonists
For more information, see: Benzodiazepine.


BZ1 selective agonists

These medications include zopiclone, eszopiclone, zolpidem, and zaleplon. In treating persistent insomnia in adults, 6 weeks of zolpidem 10 mg nightly along with weekly sessions of cognitive behavioral therapy followed by 6 months of monthly sessions and no medications yielded the most remission of insomnia in a randomized controlled trial.[3]

In geriatrics, the benefits of zolpidem for insomnia to not clearly exceed the drug toxicity.[8][9]

The benefit of eszopiclone may not be strong.[10]

Melatonin agonists

Ramelteon is one available agonist. Its magnitude of benefit may be small. among outpatients.[10]

Tasimelteon can help transient insomnia due to shift changes related to employment..[11]

References

  1. ↑ Anonymous (2024), Sleep initiation and maintenance disorders (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Silber MH (2005). "Clinical practice. Chronic insomnia.". N Engl J Med 353 (8): 803-10. DOI:10.1056/NEJMcp043762. PMID 16120860. Research Blogging.
  3. ↑ 3.0 3.1 3.2 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.". JAMA 301 (19): 2005-15. DOI:10.1001/jama.2009.682. PMID 19454639. Research Blogging. Cite error: Invalid <ref> tag; name "pmid19454639" defined multiple times with different content
  4. ↑ Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al. (2009). "Evidence-based recommendations for the assessment and management of sleep disorders in older persons.". J Am Geriatr Soc 57 (5): 761-89. PMID 19484833. PMC PMC2748127.
  5. ↑ Shub D, Darvishi R, Kunik ME (2009). "Non-pharmacologic treatment of insomnia in persons with dementia.". Geriatrics 64 (2): 22-6. PMID 19256583.
  6. ↑ McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L (2005). "Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial.". J Am Geriatr Soc 53 (5): 793-802. DOI:10.1111/j.1532-5415.2005.53252.x. PMID 15877554. Research Blogging.
  7. ↑ 7.0 7.1 Horne JA, Moore VJ (1985). "Sleep EEG effects of exercise with and without additional body cooling.". Electroencephalogr Clin Neurophysiol 60 (1): 33-8. PMID 2578352.
  8. ↑ Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE (2005). "Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.". BMJ 331 (7526): 1169. DOI:10.1136/bmj.38623.768588.47. PMID 16284208. PMC PMC1285093. Research Blogging. Review in: ACP J Club. 2006 Jul-Aug;145(1):14 Review in: Evid Based Med. 2006 Aug;11(4):110 Review in: Evid Based Nurs. 2006 Jul;9(3):87
  9. ↑ Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ (1997 Dec 24-31). "Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy.". JAMA 278 (24): 2170-7. PMID 9417012.
  10. ↑ 10.0 10.1 Schwartz LM, Woloshin S (2009). "Lost in transmission--FDA drug information that never reaches clinicians.". N Engl J Med 361 (18): 1717-20. DOI:10.1056/NEJMp0907708. PMID 19846841. Research Blogging.
  11. ↑ Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al. (2009). "Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials.". Lancet 373 (9662): 482-91. DOI:10.1016/S0140-6736(08)61812-7. PMID 19054552. Research Blogging.
Retrieved from "https://citizendium.org/wiki/index.php?title=Sleep_initiation_and_maintenance_disorders&oldid=711626"