Improving insomnia care in patients with medical comorbidity Addressing sleepless nights and fatigued days

This thesis describes studies investigating insomnia in patients with medical comorbidity, focusing on both sleepless nights and daytime fatigue. In a cross-sectional case-controlled study the prevalence of clinical insomnia and subjective sleep characteristics were examined in patients with post-COVID-19 fatigue. Insomnia was reported by 65% percent of patients. It is important that healthcare providers recognize and address insomnia, particularly when severe fatigue is present. In an observational study it was investigated whether the co-occurrence of fatigue and insomnia influences the outcomes of Cognitive Behavioural Therapy for fatigue (CBT-F) and for insomnia (CBT-I). Symptom-focused CBT was found effective even when insomnia and fatigue co-occur, though both symptoms should be re-assessed post-treatment for possible additional interventions if the co-occurring symptom persist. In the TIMELAPSE study, it was examined if a low dose Amitriptyline (AM), a sedating antidepressant often used off-label as sleep medication, was a safe alternative to CBT-I in treating insomnia in patients with medical comorbidity. TIMELAPSE was a multicenter randomized controlled non-inferiority trial. AM was found to be non-inferior to CBT-I at 12 weeks treatment. However, fewer patients showed clinical improvement with AM, AM had more side-effects and there were indications that it had limited long-term efficacy. CBT-I was also effective in patients who initially preferred pharmacological treatment. Therefore, CBT-I should remain the first-line treatment for patients with insomnia with medical comorbidity. Implementation of the clinical implications of our studies can improve insomnia care for patients with medical comorbidity.