In Reply

Letters to the Editor regarding the article The Function of Sleep and the Treatment of Primary Insomnia by Prof. Dr. med. Wolfgang Freund and PD Dr. med. Frank Weber in issue 50/2023

We thank our correspondents for their interest in our article on the function of sleep and the treatment of insomnia (1). The correspondence submitted by Finkenwirth rightly tackles the difficult subject of implementing evidence and guideline recommendations. Interestingly, the question of why in spite of good evidence, cognitive behavior therapy for insomnia (CBT-I) has been scarcely implemented is multilayered. Obstacles range from lack of knowledge or reticence on the part of primary care doctors to patient related reasons, such as a preference for drugs or a lack of time (2).

If both sides are prepared to prescribe and access CBT-I, the lacking availability of appointments is, however, a crucial barrier. For this reason, the use of digital CBT-I is promising. There is reason for concern, however, that because of its exacting implementation, the digital health application will for some patients share the fate of new year’s resolutions. Especially the very effective intervention of sleep restriction is experienced by many patients as unpleasant and initially frustrating. Models for promoting adherence and motivation (for example, by means of moderated groups) are therefore desirable, in order to fully utilize the potential of the digital health application. Existing effectiveness studies contain motivating control dates administered by the principal investigators, which may mean that without this motivational element the effect may be overestimated. Data on actual unaccompanied routine use are lacking. Suggestions for promoting motivation on the part of our professional associations have thus far not been successful—for the responsible national or regional associations of statutory health insurance physicians, as well as for a large statutory health insurer.

Hauns focused on the central role of melatonin and the circadian regulation of activity via light stimuli and the (inter)connection of the suprachiasmatic nucleus. These connections are undoubtedly highly relevant and their disruption an important cause of insomnia. But the focus of our article was—in addition to the function of health sleep—on primary insomnia, that is, a sleep disorder without an underlying somatic cause. For this reason, psychological factors—such as activation (arousal) and sleep hygiene—were named as the most important aspects. Sleep regulation is hampered by diseases/illness or at an older age by the diminishing activity of the suprachiasmatic nucleus leading to lower melatonin release (3). Melatonin substitution in such situations is certainly helpful as well as low in adverse effects.

DOI: 10.3238/arztebl.m2024.0029

On behalf of the authors

Prof. Dr. med. Wolfgang Freund

Neurozentrum Biberach

Biberach

Conflict of interest statement

WF is a board member (secretary) of the Professional Association of German Neurologists (Berufsverband der Deutschen Neurologen, BDN) as well as an associate neurologist member of the board of the Professional Association of German Neurologists and Psychiatrists (Berufsverband Deutscher Nervenärzte, BVDN) in the state of Baden-Württemberg.

References

1. Freund W, Weber F: The function of sleep and the treatment of primary insomnia. Dtsch Arztebl Int 2023; 120: 863–70

2. Koffel E, Bramoweth AD, Ulmer CS: Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. J Gen Intern Med 2018; 33: 955–62

3. Tatineny P, Shafi F, Gohar A, Bhat A: Sleep in the elderly. Mo Med 2020; 117: 490–5.