Dr Dieter Riemann, the founder of the European Insomnia Network, reflects on the evolving field of insomnia research and considers how modern society has an impact on our sleep.
The European Insomnia Network (EIN) was founded in 2009 by Dr Dieter Riemann, a professor of clinical psychophysiology, as a platform for interested members of the European Sleep Research Society (ESRS) to come together to advance teaching, clinical and research activities at the EU level.
Since the network’s launch almost a decade ago, the previously stalled research field of insomnia has flourished, and today the condition is increasingly being recognised as not only an independent disorder but also an important target of mental health research. Treatment options have similarly expanded, with cognitive behavioural therapy for insomnia (CBT-I) now being recognised by many as the most effective intervention to improve sleep.
In conversation with Health Europa Quarterly, Riemann reflects on the achievements of the European Insomnia Network, considers how modern-day lifestyles are interfering with when and how well we sleep, and examines the obstacles to the rollout of CBT-I.
Is insomnia taken seriously enough as a health condition in its own right but also as a possible symptom of other disorders?
Insomnia is increasingly being recognised as an important condition that is detrimental to health, but this is an ongoing process. Research over the last 20 or so years has demonstrated that insomnia is a risk factor in many other disorders, including cardiovascular disease and diabetes, but especially in the mental health arena.
We have suspected this for some time, but only over the last ten years or so have we seen several meta-analyses pop up to confirm this.
We know about the close coupling of insomnia and depression – that it’s not just a symptom of depression but also a very early predictor of it, and, of particular relevance to my own specialty, clinical psychophysiology, we now also know that insomnia is very relevant to the course of a mental disorder. Depression and insomnia often go hand in hand, and when the depression is treated, the insomnia often remains and acts as a persistent risk factor for relapses into depression.
We now know that treating insomnia specifically, especially with cognitive behavioural therapy, can have a very positive impact on the course of a mental disorder – this has been shown not only for depression but also for schizophrenia and psychosis.
There is already preliminary evidence suggesting that treating insomnia in itself reduces a person’s risk of developing depression later in life. That is to say, the treatment of insomnia could be a very valuable strategy for preventing mental disorders. This is probably the most recent new insight to really make insomnia an important target, in particular in the field of mental disorders.
The European Insomnia Network was set up in part with the aim of establishing insomnia as a research target at EU level – to what extent has this been achieved?
For a long time insomnia was considered to be a symptom of depression but not anything important in itself – as something that will go away if you treat the underlying disorder. Now, insomnia is being thought of as much more of an independent disorder.
This is reflected in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM5), which removes the distinction somewhat between ‘primary’ (insomnia alone) and ‘secondary’ (insomnia due to a mental or medical disorder, which was believed to make up the majority of insomnia cases) insomnia, now speaking of insomnia disorder instead.
This paradigm shift has been the result of a worldwide effort by researchers, clinicians and more, who have come to the same conclusion that ascribing insomnia merely as a symptom does not give it the credit it deserves. This realisation has in turn led to new research and neurological studies, and inspired a huge interest in the (neuro)biology of insomnia – and all of this over the last 10-20 years.
When I first entered the field of insomnia in the 1980s it was dominated entirely by pharmacology and hypnotics, and not so much interested in pathophysiology or etiology. This was largely due to the fact of it being dominated by the psychopharmacological industry.
Hypnotics are perhaps helpful in the short term, but they are of absolutely no help to anyone with chronic insomnia. This knowledge, combined with a disillusion with the use of drugs as insomnia treatment, has led to a refocus on many other aspects of insomnia, and that has opened up new avenues for research.
At the same time, initiatives like the Society of Behavioural Sleep Medicine, an interdisciplinary organisation based in the US, and the EIN at the European Sleep Research Society have also given a much-needed boost to the insomnia field.
‘European guideline for the diagnosis and treatment of insomnia’ recommends CBT-I as the first-line treatment for chronic insomnia – how far has this been translated into practice?
This is now something of a worldwide consensus. In 2016 guidelines published by the American College of Physicians also concluded on the basis of an evidence-based analysis that CBT-I should be the first-line treatment. Germany has published guidelines to the same effect, and now of course so has Europe.
The problem lies in the implementation, which is something we’re working on now. There is a lack of trained therapists and health professionals for people to seek and find adequate help. Of course, the situation in Europe is totally different between countries. In places such as Germany, for example, there is already a mass of expertise, but other countries boast far fewer psychotherapists. As a while, CBT-I is still very much tied to academic and research institutions; it needs now to be disseminated across the whole healthcare arena.
Within the EIN we are currently pursuing an initiative to set up a European CBT-I academy, which will hopefully help to resolve this problem. We would like to establish at least one specialised centre for CBT-I in each European country, which could then become a key point of contact for CBT-I knowledge and help to spread that expertise throughout the nation.
We want to define CBT-I – what it is, what it does, who can do it, and what kind of background or training practitioners need, and then we want to establish standards for that training and disseminate them.
Is it fair to say that the bulk of research interest now lies with CBT-I?
Right now there is very little research going on in terms of pharmacology, which reflects very little interest from industry. But there has been a fair amount of research into CBT-I.
Of course, the interest in CBT-I does not mean the case is closed; we should absolutely be open to new developments. Mindfulness, light and music therapy, exercise, and neuromodulation and stimulation are all important areas, as well, but little work on these has been published.
This is largely because funding for mindfulness or exercise studies is much more difficult to obtain than money for a pharmacological investigation. The latter is more likely to be funded by a company and receive a large amount of investment; the former are dependent on public funding, and a medium-sized study is lucky if it attracts just a few hundred thousand euros.
This is where consortia and networks such as those I have already mentioned become so important. In order to do proper research into any kind of therapy you need a national or even international network of centres, because if you only have one centre you’ll only get very small samples and they won’t prove anything.
This is why it’s so advantageous that within the EIN and ESRS there’s a really good basic networking background.
To what would you attribute the perceived rise in the prevalence of insomnia in recent years?
It’s important to put such statements into context: we cannot definitively say that the prevalence of insomnia has risen, because to do so we would need to be able to compare high-quality studies from today with those done in the 1950s or 60s. But while now we have certain standards in place for carrying out such studies, in the past we didn’t. This poses a problem: the work we have done post-2000 is of a high quality, but the work we did in 1980, for example, is not so good. To some extent, then, we’re comparing pears and apples.
Nonetheless, there does appear to be an increase in insomnia rates. What could be behind that?
Namely, society is changing. The world of work has changed dramatically since the 1950s: working hours have decreased, but home offices and email have brought work into the home, resulting in less leisure time and a culture whereby people are available almost 24/7. Our experience of stress has in turn increased hugely, and people are putting themselves under much more of a strain, psychologically, than they did say 50 years ago.
There is also a much greater sense of insecurity thanks to economic crises, high unemployment levels, and climbing divorce rates. People are switching between jobs more frequently, and family ties are becoming less stable.
At the same time, television, social media and the internet are becoming ever-more ubiquitous; people go to sleep with their phones by their pillows, they take calls while in bed – all of which impact on sleep.
Ultimately, insomnia rates have risen because there are so many more distractions in today’s society. It’s much harder to relax, to wind down, to shut out disturbing thoughts, and having a lot on your mind can interfere with how well you sleep.
How does the EIN support further study in the field of insomnia?
The EIN is based in Europe but is open to members from around the world, and is committed to facilitating exchange between insomnia clinicians and researchers and boosting the level of research in the insomnia field.
The EIN provides a platform for its members to communicate ideas, stay up to date with the latest developments and attend conferences, but most importantly to interact with one another. The number of people within medicine and research who are interested in insomnia has grown, and thanks to the EIN they all know and can interact with each other.
It has done a marvellous job at bringing together a community of people involved in the study, diagnosis and treatment of insomnia, and in particular has allowed those from less well-off European countries to access a much wider bank of resources and knowledge than they might otherwise be able to enjoy.
I’m particularly pleased that there is no kind of national competition between countries – nobody thinks in those terms anymore; instead we are working together, and this is having a great impact in the output of the field.
1 Riemann D et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res, 26: 675-700 (2017). doi:10.1111/jsr.12594
Dr Dieter Riemann
European Insomnia Network
This article will appear in issue 4 of Health Europa Quarterly, which will be published in February.