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CLINICAL REVIEW
Department of Psychiatry, University of Maryland School of Medicine, 100 N Greene St, 2nd Floor Baltimore, MD 21201, USA
Sleep Disorders Center, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, 100 N Greene St, 2nd Floor Baltimore, MD
21201, USA
c
University of Maryland School of Pharmacy, USA
d
Department of Medicine, Division of Pulmonary and Critical Care, University of Maryland School of Pharmacy, USA
b
a r t i c l e i n f o
s u m m a r y
Article history:
Received 5 June 2015
Received in revised form
20 November 2015
Accepted 23 November 2015
Available online 28 November 2015
Chronic insomnia is the most common sleep disorder among adults and is associated with a wide range
of negative outcomes. This article reviews the economic consequences of the disorder and the cost
effectiveness of insomnia treatments. First, the total costs of insomnia are reviewed; in aggregate these
costs exceed $100 billion USD per year, with the majority being spent on indirect costs such as poorer
workplace performance, increased health care utilization, and increased accident risk. Next, the deleterious impact of insomnia on quality of life and the impact of treatment on quality of life are briey
considered. Finally, ten published studies evaluating the cost effectiveness of both pharmacological and
behavioral treatments for insomnia are reviewed in detail. A signicant majority of studies reviewed
found that the cost of treating primary and comorbid insomnia is less than the cost of not treating it.
Treatments were generally found to be cost-effective using commonly employed standards, with
treatment costs being recouped within 6e12 mo.
2015 Elsevier Ltd. All rights reserved.
Keywords:
Insomnia
Economics
Quality of life
Treatment
Sedative hypnotic therapy
Cognitive-behavioral therapy
Cost-effectiveness
http://dx.doi.org/10.1016/j.smrv.2015.11.004
1087-0792/ 2015 Elsevier Ltd. All rights reserved.
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Table 1
Summary of treatment cost-effectiveness studies.
Study Sample
Pharmacotherapy studies
[119] Adults ages 21e64y,
~17,000
with insomnia and
~17,000
matched controls
Perspective
Follow-up
Costs
HrQOL
Results
SF-36
HAMD17
SF-12
Relative to PBO FLX, ESZ FLX gained 0.0058 QALY at direct cost of
$88 ($81 in 2010 USD). Incremental cost per QALY was $15,277 ($14,000
in 2010 USD).
Payer
6m
Payer
12 m
Patient
6m
Patient
8w
Patient
3m
EQ-5D
Patient
6m
NA
Patient
6m
SF-36
At 6mo follow-up, the cost per QALY was $7313 (3418 in 2003 GBP),
with cost effectiveness reach in year 4. If treatment costs were assumed
to decrease, cost per QALY at year 10 was $578 (270 in 2003 GBP).
Patient
4w
Relative to TAU alone, TAU CBT gained additional 0.019 QALY at direct
cost of $255 ($254 in 2014 USD). Incremental cost per QALY was $13,838
($13,768 in 2014 USD).
Comorbid insomnia
[135] Subset of 434 adults with
comorbid MDD and
insomnia,
originally randomized to
FLX ESZ (n 270) or
FLX PBO (n 275)
CBTI studies
[126] 151 London adults
randomized
to group CBT education
(n 75)
or WLC (n 76)
[128] 84 adult patients (mean
age
54.25 19.08 y treated in
BSM
clinic in AASM-accredited
center
[125] Chronic hypnotic users
ages 31e92y, randomized
to CBT (n 209) or
TAU (n 201)
Comorbid insomnia
[137] 37 patients with refractory
depression and comorbid
insomnia,
randomized to TAU
(n 17) or
TAU CBTI (n 20)
Other studies
[134] Estimates based on NZ
population.
Decision tree inputs based
on interviews
with 21 representative
insomnia treatment
providers.
[130] Estimates based on US
older adult
population. Decision tree
analysis to
compare no treatment,
pharmacotherapy,
and CBTI.
NA
After controlling for medication costs, the greatest cost savings resulted
from low-dose trazodone ($1129; $984 in 2007 USD), zolpidem ($1335;
$1163 in 2007 USD), and zolpidem extended-release ($1415; $1233 in
2007 USD).
Eszopiclone increased HrQOL by 0.0137 QALY at cost of $73 ($67 in
2010). Incremental cost per QALY was <$5456/QALY ($36,010 excluding
indirect costs; $5000 and $33,000, respectively, in 2010 USD).
Population
12 m
EQ-5D
SF-36
Total net benet of treating a person with insomnia was $547 ($482 in
2011 AUD). Cost estimate per QALY was $3483 ($3072 in 2011 AUD),
which is below locally accepted threshold of $7783 ($6865 in 2011 AUD)
for funding new medicines.
Population
12 m
SF-6D
EQ-5D
AWP: average wholesale price; HCU: health care utilization; HrQOL: health-related quality of life; MDD: major depressive disorder; ; USD: US dollars; QALY: quality-adjusted
life year; NZ: New Zealand; PBO: placebo; WLC: wait-list control.
$9930 in 2006 USD). Although within-subject treatment effectiveness is not actually measured when such administrative
methods are employed, the large sample sizes presumably increase
generalizability and applicability of ndings.
Jhaveri and colleagues [122] employed a similar administrative
methodology to evaluate effects of insomnia medications in
reducing overall health care costs from a managed care perspective.
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trazodone 100 mg. Health care costs were assessed via database
review and included physician visits, inpatient hospitalizations,
outpatient hospital care, emergency department visits, other lab
and ambulatory services, and prescription drugs (excluding
insomnia medications). Indirect costs were not assessed. In order to
establish the relationship between treatment efcacy and health
care costs, general linear models (GLM) were constructed for each
clinical endpoint (total sleep time [TST], sleep onset latency [SOL],
wake after sleep onset [WASO], and sleep efciency [SE]), using
objective PSG and standardizing timeframes when possible and
while controlling for demographic variables and pre-hospital comorbidity. Next, the resulting coefcients were used to conduct
regression analyses to predict future health care costs for all four
clinical endpoints for all insomnia agents. Finally, change in health
care costs was calculated by subtracting the cost of each medication
from the cost savings estimates generated in regression equations.
Overall, the unadjusted mean reduction in per-person total health
care costs was $1262.59 ($1100.20 in 2007 USD) from pre-to postindex periods. In an interesting secondary nding, zolpidem
extended release (ER) was associated with a greater annual cost
savings ($1438 per patient treated; $1253 in 2007 USD) than other
medications in the study. Although this study was not technically a
cost-effectiveness analysis, and utility scores were not reported, it
represents exactly the kind of real-world analysis conducted by
many payers when making formulary and coverage decisions.
In the most rigorous insomnia pharmacotherapy CEA to date,
Snedecor and colleagues [123] aggregated efcacy data from a large
RCT (N 824) [100] with cost data from a claims database. In the
original study [100] participants meeting DSM-IV criteria for
chronic primary insomnia and reporting SOL > 30 m and/or
TST < 6.5 h were randomized to placebo (n 280) or 3 mg eszopiclone nightly for 5 mo (n 550). Participants were considered
remitters if their insomnia severity index scores were in the nonclinical range (<7). HRQoL was assessed at baseline and months 1,
3, and 6 using the SF-36, and scores were transformed into utility
scores. Direct health costs included self-reported medication use,
physician visits, as well as estimates of costs that would have likely
been accrued outside of the controlled study setting. Costs of
eszopiclone included the average wholesale price, a dispensing fee,
and one or two physician visits, depending whether participants
were still using eszopiclone at month 3. Days-out-of-role were
estimated to include absences, short-term disability, and worker's
compensation. Lost workplace productivity (presenteeism) was
assessed using the work limitation questionnaire (WLQ; [124]),
with percentage of individual work loss was computed by multiplying the average hourly wage of US workers, average number of
hours worked per week, and percent of participants expected to be
employed. Over the 6-month study period, eszopiclone was associated with a net cost increase of $74 ($67 in 2009 USD) per patient
with estimated gross costs were $549 vs $475 ($495 vs $428 in
2009 USD) for treatment and control groups, respectively. Relative
to placebo, eszopiclone was associated with nearly twice as much
improvement in WLQ workplace productivity, resulting in a $395
($356 in 2007 USD) greater cost savings due to increased productivity at work e $764 vs $369 ($689 vs $333 in 2009 USD) savings
for eszopiclone and placebo, respectively. Relative to control,
treatment was associated with a net gain of 0.0137 QALY (0.0105
QALY gained in treatment, 0.0032 reduced in control), resulting in
an incremental cost of $5456 ($4919 in 2009 USD) per QALY gained.
In multiple sensitivity analyses, the incremental cost-effectiveness
ration (ICERs) remained below $55,455 ($50,000 in 2009 USD). This
study is important not only because it replicated previous ndings
regarding eszopiclone [119], but also because of its particular
strength in assessing effect of treatment on both direct and indirect
costs of insomnia.
77
Behavioral treatments
The cost-effectiveness of CBTI was rst demonstrated by Morgan and colleagues [125] over a decade ago. Two hundred and nine
chronic hypnotic users were randomized to a 6-session CBTI or
wait-list control. All patients met DSM-IV or ICD-9 diagnostic
criteria for chronic insomnia (1mo duration). HrQOL was assessed
using the SF-36. CBT was associated with improvements in sleep
parameters and reductions in hypnotic use, with gains maintained
at 12-mon. Further, improvements in SF-36 scores were evident at
3-mo (vitality subscale) and 6-mo (physical functioning and mental
health subscales). This was the rst study to report utility in
insomnia patients, which was found to be 0.646. Health care costs
were assessed through review of a UK National Health System
(NHS) claims database. Indirect costs were not assessed. Based on
6-mo follow-up data, the mean incremental cost per QALY was
$7313 (3418 in 2003 GBP). When future costs were assumed to
remain static at 6-mo levels, the CBT intervention was found to
become cost effective in year four. If future costs were assumed to
decline linearly, the ICER incremental cost effectiveness ratio (ICER)
decreased substantially to approximately $578 (270 in 2003 GBP)
per QALY in year 10. The main advantages of this design, wherein a
CEA is nested within a randomized trial, is the ability to evaluate
actual within-subjects changes in sleep and health-care utilization.
Bonin et al. [126] also conducted a randomized trial to explore
the cost-effectiveness of CBTI and reached similar conclusions.
However, this study highlights the importance of measurement
sensitivity in CEA. Self-referred participants were randomized to a
community-based, group-administered CBT educational intervention (n 75) or waitlist control (n 76). HrQOL was measured
using the SF-36. Relative to controls, participants in the treatment
groups reported reduced insomnia severity, increased sleep efciency, and reduced wake after sleep onset. However, only a small
and non-signicant gain in QALY was detected. Direct costs were
estimated based by multiplying the number of self-reported medications and provider visits by the respective unit costs from publicly available sources. Due to the non-signicant gain in QALY, the
authors next sought to increase the sensitivity of their costeffectiveness analyses by employing a cost-effectiveness acceptability curve (CEAC) methodology. In this approach, the net monetary benet (NMB) for an individual is computed by multiplying
possible values for willingness to pay (WTP) by outcome and then
subtracting treatment costs (NMBi lQALYi e COSTi). Positive
NMB values suggest a treatment is worth implementing (i.e., produced a net monetary gain), whereas negative NMB values suggest
the opposite. One advantage of CEAC is the ability to control for
baseline scores, costs, and covariates, rather than relying only on
QALY, which has been criticized as a suboptimal measure of costeffectiveness in insomnia or mental health conditions [78,79]. Using this approach and relative to control, CBT demonstrated a 95%
likelihood of being cost-effective at the low WTP of $257 (150 in
2014 GBP). Considering the number of people above the clinical
cutoff for insomnia disorder instead, the intervention would have
an 80% chance of being cost-effective at a WTP of $3085 (1800 in
2014 GBP). Conversely, when QALYs were considered, the intervention only had a 34e57% likelihood of being cost-effective at a
WTP of $51,415 (30,000 in 2014 GBP). It should be noted that an
alternate explanation for the initial lack of cost-effectiveness is
suboptimal reductions in ISI scores, which were below established
cutoffs for moderate clinical change [127]. Of course, an alternate
interpretation of these data suggests that even small improvements
in sleep are associated with cost-effective improvements in HrQOL.
CBTI has also been shown to reduce future health care costs in a
real-world clinical setting. McCrae and colleagues [128] conducted
a retrospective chart review of 84 patients (58% women, mean
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Practice points
Assess subjective and HrQOL factors, workplace performance, and accident risk as part of routine insomnia care.
Screen, assess, and treat comorbid insomnia disorder,
particularly in mental health conditions.
Emphasize and enhance patient adherence, particularly in
CBTI.
Health care systems and payers should increase access to
insomnia treatments to reduce overall healthcare costs.
Research agenda
Include pre-post measures of indirect cost, including
health care utilization, workplace performance, and accident risk, in all insomnia trials.
Include pre-post measures of generic and/or insomniaspecific HrQOL (including utility scores) in all insomnia
trials.
Determine the sensitivity of generic and insomniaspecific HrQOL measures for measuring cost effectiveness of insomnia treatments.
Include cost-effectiveness as a central outcome in all
insomnia trials.
Elucidate the economic impact of comorbid insomnia and
its treatment, particularly in anxiety, chronic pain,
alcohol/substance dependence, pulmonary disease, cardiovascular disease, brain injury, and obstructive sleep
apnea.
Conduct cost-effectiveness analyses of additional
insomnia treatment modalities, including complimentary
and alternative approaches.
Conduct cost-effectiveness analyses of additional delivery mechanisms, including automated and telehealth
modalities.
Determine relative cost-effectiveness between treatments, modalities and delivery mechanisms.
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Conicts of interest
Drs. Shaya and Scharf have no conicts of interest to disclose. Dr.
Wickwire has moderated non-commercial scientic discussion for
Merck and is an equity stakeholder in WellTap, which provides
online screening and multimedia patient education.
References
[24]
[25]
[26]
[1] American Psychiatric Association. American Psychiatric Association. DSM5 Task Force. Diagnostic and statistical manual of mental disorders. 2013.
p. 947.
[2] Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and
psychiatric disorders. An opportunity for prevention? JAMA 1989 Sep
15;262(11):1479e84.
[3] Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States:
results of the 1991 National Sleep Foundation Survey. I Sleep 1999 May
1;22(Suppl. 2):S347e53.
[4] Roth T, Coulouvrat C, Hajak G, Lakoma MD, Sampson NA, Shahly V, et al.
Prevalence and perceived health associated with insomnia based on DSMIV-TR; international statistical classication of diseases and related health
problems, Tenth revision; and research diagnostic criteria/international
classication of sleep disorders, second Edition criteria: results from the
America Insomnia Survey. Biol Psychiatry 2011 Mar 15;69(6):592e600.
[5] Stepanski EJ, Rybarczyk B. Emerging research on the treatment and etiology of secondary or comorbid insomnia. Sleep Med Rev 2006 Feb;10(1):
7e18.
[6] Alattar M, Harrington JJ, Mitchell CM, Sloane P. Sleep problems in primary
care: a North Carolina family practice research network (NC-FP-RN) study.
J Am Board Fam Med 2007 Jul-Aug;20(4):365e74.
[7] Kushida CA, Nichols DA, Simon RD, Young T, Grauke JH, Britzmann JB,
et al. Symptom-based prevalence of sleep disorders in an adult primary
care population. Sleep Breath 2000;4(1):9e14.
[8] Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ.
Comorbidity of chronic insomnia with medical problems. Sleep 2007
Feb;30(2):213e8.
[9] So F, Cesari F, Casini A, Macchi C, Abbate R, Gensini GF. Insomnia and risk
of cardiovascular disease: a meta-analysis. Eur J Prev Cardiol 2014
Jan;21(1):57e64.
[10] Kyle SD, Morgan K, Espie CA. Insomnia and health-related quality of life.
Sleep Med Rev 2010 Feb;14(1):69e82.
[11] Ishak WW, Bagot K, Thomas S, Magakian N, Bedwani D, Larson D, et al.
Quality of life in patients suffering from insomnia. Innov Clin Neurosci
2012 Oct;9(10):13e26.
[12] Neubauer DN. New and emerging pharmacotherapeutic approaches for
insomnia. Int Rev Psychiatry 2014 Apr;26(2):214e24.
[13] Neubauer DN. Suvorexant for sleep-onset insomnia or sleep-maintenance
Insomnia, or both. Curr Psychiatry 2015;14(1):19.
[14] Smith MT, Perlis ML, Park A, Smith MS, Pennington J, Giles DE, et al.
Comparative meta-analysis of pharmacotherapy and behavior therapy for
persistent insomnia. Am J Psychiatry 2002 Jan;159(1):5e11.
[15] Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial.
JAMA 1999 Mar 17;281(11):991e9.
[16] Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior
therapy and pharmacotherapy for insomnia: a randomized controlled trial
and direct comparison. Arch Intern Med 2004 Sep 27;164(17):1888e96.
[17] Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, et al.
Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA 2006
Jun 28;295(24):2851e8.
[18] Morin CM, Vallieres A, Guay B, Ivers H, Savard J, Merette C, et al. Cognitive
behavioral therapy, singly and combined with medication, for persistent
insomnia: a randomized controlled trial. JAMA 2009 May 20;301(19):
2005e15.
[19] NIH State of the science conference statement on manifestations and
management of chronic insomnia in adults statement. J Clin Sleep Med
2005 Oct 15;1(4):412e21.
[20] Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline
for the evaluation and management of chronic insomnia in adults. J Clin
Sleep Med 2008 Oct 15;4(5):487e504.
[21] Morin CM, LeBlanc M, Daley M, Gregoire JP, Merette C. Epidemiology of
insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med 2006 Mar;7(2):123e30.
[22] Aikens JE, Rouse ME. Help-seeking for insomnia among adult patients in
primary care. J Am Board Fam Pract 2005 JuleAug;18(4):257e61.
[23] Hatoum HT, Kong SX, Kania CM, Wong JM, Mendelson WB. Insomnia,
health-related quality of life and healthcare resource consumption. A
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
* The most important references are denoted by an asterisk.
Downloaded from ClinicalKey.com at Medical University at South Carolina -SC on March 13, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
81
Downloaded from ClinicalKey.com at Medical University at South Carolina -SC on March 13, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
82
[106] Byles JE, Mishra GD, Harris MA, Nair K. The problems of sleep for older
women: changes in health outcomes. Age Ageing 2003 Mar;32(2):
154e63.
[107] Dixon S, Morgan K, Mathers N, Thompson J, Tomeny M. Impact of cognitive behavior therapy on health-related quality of life among adult hypnotic users with chronic insomnia. Behav Sleep Med 2006;4(2):71e84.
[108] Espie CA, MacMahon KM, Kelly HL, Broomeld NM, Douglas NJ,
Engleman HM, et al. Randomized clinical effectiveness trial of nurseadministered small-group cognitive behavior therapy for persistent
insomnia in general practice. Sleep 2007 May;30(5):574e84.
[109] Verbeek IH, Konings GM, Aldenkamp AP, Declerck AC, Klip EC. Cognitive
behavioral treatment in clinically referred chronic insomniacs: group
versus individual treatment. Behav Sleep Med 2006;4(3):135e51.
[110] Thorndike FP, Ritterband LM, Gonder-Frederick LA, Lord HR, Ingersoll KS,
Morin CM. A randomized controlled trial of an internet intervention for
adults with insomnia: effects on comorbid psychological and fatigue
symptoms. J Clin Psychol 2013 Oct;69(10):1078e93.
[111] Espie CA, Fleming L, Cassidy J, Samuel L, Taylor LM, White CA, et al. Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients
with cancer. J Clin Oncol 2008 Oct 1;26(28):4651e8.
[112] Savard J, Simard S, Ivers H, Morin CM. Randomized study on the efcacy of
cognitive-behavioral therapy for insomnia secondary to breast cancer, part
I: sleep and psychological effects. J Clin Oncol 2005 Sep 1;23(25):
6083e96.
[113] Quesnel C, Savard J, Simard S, Ivers H, Morin CM. Efcacy of cognitivebehavioral therapy for insomnia in women treated for nonmetastatic
breast cancer. J Consult Clin Psychol 2003 Feb;71(1):189e200.
[114] McCall WV, Blocker JN, D'Agostino Jr R, Kimball J, Boggs N, Lasater B, et al.
Treatment of insomnia in depressed insomniacs: effects on health-related
quality of life, objective and self-reported sleep, and depression. J Clin
Sleep Med 2010 Aug 15;6(4):322e9.
[115] Shimodera S, Watanabe N, Furukawa TA, Katsuki F, Fujita H, Sasaki M, et al.
Change in quality of life after brief behavioral therapy for insomnia in
concurrent depression: analysis of the effects of a randomized controlled
trial. J Clin Sleep Med 2014 Apr 15;10(4):433e9.
[116] Horsman J, Furlong W, Feeny D, Torrance G. The Health Utilities Index
(HUI): concepts, measurement properties and applications. Health Qual
Life Outcomes 2003 Oct 16;1:54.
[117] Welch KC, Scharf SM. Construct validity for the Health Utilities Index in a
sleep center. Sleep Breath 2007 Dec;11(4):295e303.
[118] Leger D, Morin CM, Uchiyama M, Hakimi Z, Cure S, Walsh JK. Chronic
insomnia, quality-of-life, and utility scores: comparison with good
sleepers in a cross-sectional international survey. Sleep Med 2012
Jan;13(1):43e51.
*[119] Botteman MF, Ozminkowski RJ, Wang S, Pashos CL, Schaefer K, Foley DJ.
Cost effectiveness of long-term treatment with eszopiclone for primary
insomnia in adults: a decision analytical model. CNS Drugs 2007;21(4):
319e34.
[120] Krystal AD, Walsh JK, Laska E, Caron J, Amato DA, Wessel TC, et al. Sustained efcacy of eszopiclone over 6 months of nightly treatment: results
of a randomized, double-blind, placebo-controlled study in adults with
chronic insomnia. Sleep 2003 Nov 1;26(7):793e9.
[121] Nichol MB, Sengupta N, Globe DR. Evaluating quality-adjusted life years:
estimation of the health utility index (HUI2) from the SF-36. Med Decis
Mak 2001 Mar-Apr;21(2):105e12.
[122] Jhaveri M, Seal B, Pollack M, Wertz D. Will insomnia treatments produce
overall cost savings to commercial managed-care plans? A predictive
analysis in the United States. Curr Med Res Opin 2007 Jun;23(6):1431e43.
*[123] Snedecor SJ, Botteman MF, Bojke C, Schaefer K, Barry N, Pickard AS. Costeffectiveness of eszopiclone for the treatment of adults with primary
chronic insomnia. Sleep 2009 Jun;32(6):817e24.
[124] Lerner D, Amick III BC, Rogers WH, Malspeis S, Bungay K, Cynn D. The
work limitations questionnaire. Med Care 2001;39(1):72e85.
*[125] Morgan K, Dixon S, Mathers N, Thompson J, Tomeny M. Psychological
treatment for insomnia in the regulation of long-term hypnotic drug use.
Health Technol Assess 2004 Feb;8(8). iiieiv, 1e68.
*[126] Bonin EM, Beecham J, Swift N, Raikundalia S, Brown JS. Psycho-educational CBT-Insomnia workshops in the community. A cost-effectiveness
analysis alongside a randomised controlled trial. Behav Res Ther 2014
Apr;55:40e7.
[127] Morin CM, Belleville G, Belanger L, Ivers H. The Insomnia Severity Index:
psychometric indicators to detect insomnia cases and evaluate treatment
response. Sleep 2011 May 1;34(5):601e8.
*[128] McCrae CS, Bramoweth AD, Williams J, Roth A, Mosti C. Impact of brief
cognitive behavioral treatment for insomnia on health care utilization and
costs. J Clin Sleep Med 2014 Feb 15;10(2):127e35.
[129] Clark DO, Von Korff M, Saunders K, Baluch WM, Simon GE. A chronic
disease score with empirically derived weights. Med Care 1995;33(8):
783e95.
*[130] Tannenbaum C, Diaby V, Singh D, Perreault S, Luc M, Vasiliadis HM.
Sedative-hypnotic medicines and falls in community-dwelling older
adults: a cost-effectiveness (decision-tree) analysis from a US medicare
perspective. Drugs Aging 2015 Apr;32(4):305e14.
[131] Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, et al.
Meta-analysis of the impact of 9 medication classes on falls in elderly
persons. Arch Intern Med 2009 Nov 23;169(21):1952e60.
[132] Stone KL, Ensrud KE, Ancoli-Israel S. Sleep, insomnia and falls in elderly
patients. Sleep Med 2008 Sep;9(Suppl. 1):S18e22.
[133] American Geriatrics Society 2012 Beers criteria Update Expert Panel.
American Geriatrics society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012 Apr;60(4):
616e31.
*[134] Scott GW, Scott HM, O'Keeffe KM, Gander PH. Insomnia e treatment
pathways, costs and quality of life. Cost Eff Resour Alloc 2011 Jun 21;9(10).
7547-9-10.
*[135] Snedecor SJ, Botteman MF, Schaefer K, Sarocco P, Barry N, Pickard AS.
Economic outcomes of eszopiclone treatment in insomnia and comorbid
major depressive disorder. J Ment Health Policy Econ 2010 Mar;13(1):
27e35.
[136] Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry
1960 Feb;23:56e62.
*[137] Watanabe N, Furukawa TA, Shimodera S, Katsuki F, Fujita H, Sasaki M,
et al. Cost-effectiveness of cognitive behavioral therapy for insomnia comorbid with depression: analysis of a randomized controlled trial. Psychiatry Clin Neurosci 2014 Sep 10;69(6):335e43.
Downloaded from ClinicalKey.com at Medical University at South Carolina -SC on March 13, 2016.
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