By Richard Bedrosian, Ph.D
It is arguably the most prevalent health problem. It costs employers in lower productivity and higher healthcare expenditures. It negatively affects job functioning, safety, and wellbeing, and aggravates other health conditions. It is, however, often overlooked, underestimated, and under treated.
It is insomnia, and it’s estimated to affect almost a third of all adults. Attributable costs are believed to be more than $100 billion a year in the United States. It is a growing problem: As the population in the United States becomes older, the prevalence of insomnia among the elderly—and the problems that result from it—become a growing concern.
Most people will define insomnia as the inability to fall asleep. That is correct, to a point. Insomnia typically involves one or more of the following symptoms: difficulty initiating sleep; difficulty remaining asleep; waking up too early in the morning, or chronically poor quality, non-restorative sleep.
In order to be classified as insomnia, these sleep difficulties must persist despite ample opportunity and circumstance for sleep, and result in daytime impairment.
There are many causes of insomnia, from lifestyle factors to neurological disorders. Quite often there is an initial cause, like chronic pain or life stress, but perpetuating factors such as poor lifestyle choices or negative thoughts create a vicious cycle, which transform an acute problem into a more chronic one.
Considering that rest is one of the body’s restorative functions; insomnia has a profound effect on overall health and wellbeing. Insomnia is associated with poor outcomes across many medical problems. Conversely, successful treatment of insomnia can improve outcomes from other medical conditions.
Related health conditions
Obesity is one of many health conditions with which insomnia is associated. Obesity is related to higher incidences of sleep apnea and other respiratory problems which can exacerbate insomnia. It has been reported that 38 percent of people with body mass index considered “obese” and 44 percent of those considered “extremely obese” sleep six or fewer hours a night.
Research has indicated that medical patients with insomnia had higher rates of disability and were hospitalized twice as frequently as those without sleep problems. Insomniac adults visited physician offices more frequently and took more medications. They also reported higher incidences of depression and other medical disorders. Older adults with insomnia fall more frequently, and are more likely to require nursing home placement.
Bottom line implications
While the impact of insomnia on health is well recognized, what is often overlooked is its cost to employers, who shoulder a dual economic burden associated with chronic health conditions, in that they pay for both lowered productivity and higher healthcare costs.
It is not just absenteeism or disability leaves that negatively affect a company’s bottom line, but also presenteeism, the diminished performance of a worker on the job. The Work Productivity Activity Impairment questionnaire reported the average productivity impairment of more than 197,000 people who sleep six hours per night or less is more than 12 percent, compared with those who sleep seven or eight hours per night, who have a level of impairment of around eight percent.
What does this mean to the bottom line? For an employee with a salary of $50,000, this translates into more than $2,000 in lost productivity a year. For a company with 10,000 employees and a 30 percent rate of insomnia (the population average) this would result in a productivity loss of about $6 million per year.
When it comes to healthcare costs, the price is steep as well. Sleeping problems rank fifth among chronic conditions in total annual cost.
For such an expensive and prevalent problem, most sufferers receive no medical help at all, opting for self-medication with OTC products or alcohol. That’s unfortunate as a report from the National Institutes of Health has indicated that cognitive-behavior therapy (CBT) and one class of medications (benzodiazepine receptor antagonists) have been proven to be effective treatments for insomnia.
The short term use of benzodiazepine receptor antagonists has produced improvements in sleep latency (the time to fall asleep initially); wakefulness during the night; number of awakenings; sleep duration and ratings of sleep quality.
While the newer classes of medications are much safer and less addictive than the drugs commonly used in the past, there are still concerns with side effects, medication interactions, and abuse and dependence.
These sleep medications are most appropriate for acute and transient insomnia and for immediate relief. Medication may also be the treatment of choice if unstable medical and/or psychiatric conditions are present, if there is a strong patient preference for it, and/or if CBT is not available.
For long term, effective treatment of insomnia, CBT offers strategies to combat the vicious cycle associated with chronic insomnia. This treatment focuses on reducing anticipatory anxiety, modifying attitudes about sleep, altering the sleep schedule, and teaching new sleep habits.
Research has found CBT to produce moderate to large improvements in all aspects of insomnia. An analysis of outcome studies comparing CBT with medication found that while improvements are more rapid for medication, they are more durable with CBT, with treatment gains persisting for up to two years. Moreover, CBT has a very low incidence of side effects and is well tolerated by patients.
The drawback to CBT is that a medical doctor or clinical psychologist usually delivers the treatment, which can be costly and potentially inconvenient. Since there are relatively few professionals trained in CBT for insomnia, treatment access may be difficult.
The growing role of the internet in patient self-management provides a unique opportunity to address the insomnia problem. The development of web-based CBT interventions has resulted in programs that can be efficiently and inexpensively deployed to millions of people.
While computer-based programs cannot take the place of one-on-one care with a healthcare professional, their advantages include scalability, consistency, and the ability to be tailored to individual users. Tailored messaging has been shown to be highly effective in changing health-related behaviors.
As CBT for insomnia is relatively straightforward and simple, it translates well into an interactive format. Patients can track their sleep patterns and behaviors online and the program can offer suggestions based on data entered by the individual.
One such online program, HealthMedia® Overcoming Insomnia offered by Wellness & Prevention, Inc., uses a standard CBT protocol. Digital health coaching programs are designed to help users learn more effective sleep habits and relaxation techniques, change negative sleep thoughts, create a stable sleep pattern, make lifestyle changes to improve sleep, and reduce daytime stress.
Users have reported an average increase of 45 minutes of sleep per night and improvements in overall sleep quality, as well as greater confidence in their ability to manage insomnia. They also experienced less difficulty staying and falling asleep, along with less anxiety and fatigue.
For employers, there was a significant drop in productivity impairment among those using the program. Prior to using the program, participants reported a productivity impairment of more than 20 percent. That dropped more than five percent points after program use. Given an average employee salary of $50,000, this level of improvement could result in savings of more than $2,745 per employee per year.
One of the most effective ways to deploy a web-based intervention is in conjunction with an online health-risk assessment (HRA), used by the employer or health plan to screen large populations. That screening can be used as a basis for recruiting employees into specific self-management programs, such as those for insomnia.
One U.S. corporation with 30,000 employees offered its workforce a modest incentive to complete an HRA screening, which resulted in high participation. The HRA revealed that 30 percent of employees reported getting six hours or less of sleep per night. These individuals showed a productivity impairment of more than 11 percent, reflecting an estimated $9.4 million loss in productivity across the company associated with sleep loss.
After the company offered the HealthMedia Overcoming Insomnia digital health coaching program to appropriate employees, recruited through email, those who used the program reported significant improvements. As a result, estimated productivity impairment dropped an average of 6.5 percentage points and saved the company $3,250 per employee, based on an average salary of $50,000.
Considering insomnia affects millions of people and is a major source of healthcare costs and productivity losses, it is surprising that employers and healthcare organizations typically do not address it in any systematic way. CBT has been proven to provide significant and lasting improvements in sleep, but relatively few people with insomnia seek or receive professional help.
The proven effectiveness and affordability of web-based programs provide an opportunity to address this gap in services and reduce insomnia’s impact on health and productivity, thus providing a substantial return on investment to health plans and employers.
Dr. Bedrosian is Director of Behavioral Health and Solution Development at Wellness & Prevention, Inc., a Johnson & Johnson company. Dr. Bedrosian is a clinical psychologist with more than 35 years experience treating depression, addictions, anxiety disorders, and the aftereffects of childhood trauma or abuse. He is also the author of numerous publications focused on depression, suicide, family dynamics, and related problems, including the 1994 volume, "Treating Family of Origin Problems: A Cognitive Approach". He received his B.A. in psychology from Brown University, his M.A. in psychology from Assumption College, and his Ph.D. in clinical psychology from Miami University. Dr. Bedrosian is also an Associate in Psychiatry at the University of Massachusetts Medical School.