Health Economics of Cbt-I

Sleep Medicine Reviews 30 (2016) 72e82
Contents lists available at ScienceDirect
Sleep Medicine Reviews

journal homepage: www.elsevier.com/locate/smrv
CLINICAL REVIEW
Health economics of insomnia treatments: The return on investment

for a good night's sleep
Emerson M. Wickwire a, b, *, Fadia T. Shaya c, Steven M. Scharf d
a
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
Insomnia disorder is a major public health burden, imposing

signicant costs to both the individual and society. Although highly
effective therapies exist, few people with insomnia seek or receive
treatment. Researchers have identied a number of barriers
restricting access to care for patients with insomnia. In terms of
factors that inuence payers, one of the most salient is uncertainty
regarding the nancial return-on-investment of treating insomnia.
That is, in spite of the well-documented efcacy of insomnia treatments for reducing symptoms, relatively less is known about the
cost-effectiveness of these interventions. In our modern era of
rapidly increasing health care costs, policy-makers and payers
require valid cost-effectiveness information in order to guide
decision-making regarding allocation of scarce health care resources.
The purpose of the current review is to explore the health
economic issues related to insomnia disorder. First, the epidemiology of insomnia disorder is briey reviewed. Next, the literature
regarding nancial costs associated with insomnia, as well as the
impact of insomnia on quality of life, is reviewed. Finally, the
* Corresponding author. Division of Pulmonary and Critical Care, University of

Maryland School of Medicine, 100 N Greene St, 2nd Floor Baltimore, MD 21201, USA.
Tel.: 1 (410) 706 4771; fax: 1 (410) 706 0345.
emerging literature regarding the cost-effectiveness of insomnia

treatments is considered and discussed. Practice points are provided, and suggestions for future research are discussed.
Throughout the manuscript nancial costs are adjusted for
ination and presented in 2015 United States dollars (USD), with the
originally published numbers in parentheses. Results originally
published in USD were adjusted for ination using an online calculator (http://www.bls.gov/data/ination_calculator.htm). Results
originally published in non-US currencies were rst converted to
USD for the publication year using an online calculator (http://www.
oanda.com/currency/converter/) and then adjusted for ination.
Insomnia: scope of the problem
Insomnia disorder, dened as difculty initiating or maintaining
sleep with an associated daytime consequence [1], is the most
common sleep disorder among adults. Nearly a third of adults
experience occasional transient insomnia, and prevalence estimates
for chronic insomnia (duration 1 mo) have historically ranged
from 9 to 12% [2,3]. However in perhaps the most methodologically
rigorous prevalence study to date, Roth et al. [4] estimated population prevalence of insomnia to be 3.9% based on International
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E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82
classication of diseases tenth revision (ICD-10) criteria, 14.7% based

on International classication of sleep disorders second edition
(ICSD-2) criteria, and 22.1% based on Diagnostic and statistical
manual of mental disorders fourth edition text revision (DSM-IV)
criteria, with 23.6% of the sample meeting diagnostic criteria according to at least one nosology. Insomnia is more frequent among
those experiencing medical or psychiatric problems [5], and in
clinical settings prevalence rates for chronic insomnia often exceed
30% [6,7]. Roughly twice as many women as men suffer insomnia,
with increased prevalence among the aged [3]. From an economic
perspective, this latter association is especially important in light of
the aging population in the US and elsewhere.
Compared to good sleepers, people with insomnia suffer
numerous health complaints [8]. For example, insomnia is a welldocumented prodromal risk factor for psychiatric disease [2]. A
recent meta-analysis found consistent positive associations between insomnia and both cardiovascular disease and mortality [9].
As well, insomnia is also associated with worsened quality of life in
multiple domains [10,11]. As will be reviewed below, these ndings
bear direct relation to the health economic impact of insomnia.
Indeed, there are substantial societal costs associated with
insomnia including direct treatment costs as well as indirect costs
such as increased health care utilization, decreased workplace
productivity, and increased accident risk.
Fortunately, the effectiveness of both pharmacological and
cognitive-behavioral treatments for insomnia disorder is well
documented. A number of Food and Drug Administration (FDA)
approved insomnia agents are available, each with its own riskbenet and side effect prole [12,13]. Cognitive-behavioral therapies for insomnia (CBTI) are also highly effective, with individual
and meta-analytic studies supporting the long-term efcacy of
multicomponent CBTIs relative to sedative hypnotic therapies
[14e18]. CBTI and sedative hypnotic therapy are equally effective in
the short-term, with gains from CBTI signicantly better maintained over time. In part because of the relative lack of side effects,
both the National Institutes of Health [19] and the American
Academy of Sleep Medicine recommend CBTI as a rst-line treatment for insomnia disorder [20].
In spite of the high prevalence of the disorder, well-documented
negative health consequences, and effective treatment options, few
people experiencing insomnia seek or receive treatment [21e23].
Instead, most people with insomnia engage in self-help behaviors
or seek to self-medicate with alcohol or other substances, including
non-regulated over-the-counter medications with unknown efcacy and risk of side effects [24]. These approaches range from
mildly helpful to harmful, and from an economic perspective, selfmedication with alcohol represents a signicant insomnia-related
expense [25]. It should also be noted that many patients also
employ complementary and alternative medicines (CAM) in hopes
of treating their insomnia complaints [26,27].
Two primary barriers have historically restricted access to
insomnia treatment and continue to inhibit access to care. First,
insomnia was long thought to be merely a symptom of a so-called
primary underlying disease, and thus a mere inconvenience or
epiphenomenon [5]. More recently it has been recognized that even
when it originally develops as a symptom of another disorder,
insomnia can assume a life of its own, develop into a chronic issue,
and warrant specic targeted treatment. As evidence of this paradigm shift, the most recent Diagnostic and Statistical Manual of
Mental Disorders (DSM-V) abandons distinctions between primary
and secondary insomnia, instead including only the more accurate
insomnia disorder [1]. Importantly, evidence suggests that treating
comorbid insomnia improves not only sleep symptoms but also
health outcomes in the comorbid disorder itself [28], including
depression [29,30], anxiety [31,32], post-traumatic stress disorder
73
(PTSD; [33,34]), chronic pain [35,36], alcohol dependence [37], and

cannabis withdrawal [38]. Nonetheless in spite of this progress and
robust evidence base, insomnia often remains an overlooked or
minimized condition. The second and related barrier to insomnia
treatment has been poor reimbursement for clinical insomnia services and the resulting shortage of trained insomnia treatment providers [39]. The present review posits that a prerequisite for universal
coverage for insomnia treatment services is demonstration to policy
makers and payers of direct monetary gain from treating insomnia.
Financial costs of insomnia
The total costs of insomnia include both direct treatment expenditures as well as indirect and related costs, such as health care
utilization, decreased workplace productivity, and increased accident risk. Estimates of total costs of insomnia have ranged from
$28.1 billion ($15.4 billion in 1990 USD; [40]) to $186.3 e $216.6
billion ($92.5 e $107.5 billion in 1988 USD) [41] Methodologies
have varied widely, and a detailed analysis is beyond the scope of
this paper. (Readers are referred to past reviews for more detailed
discussion [41,42].) Instead key and recent ndings will be
reviewed to highlight the economic consequences of insomnia.
Direct costs
Direct costs of insomnia include expenditures associated with
treatment, such as outpatient encounters and procedures, prescription and other treatment costs, and transportation to and from
insomnia-related treatment. A small number of studies provide
insight into the magnitude of direct costs of insomnia, but these
estimates vary widely due to varying operational denitions and
primary data sources. Chilcott and Shapiro [43] estimated annual
direct costs of insomnia in the US to be $2.9 billion ($1.8 billion in
1994 USD), whereas Stoller [44] estimated direct costs of insomnia
to $45.3 to $51.2 billion ($22.5 to $25.4 billion in 1988 USD). Between these two endpoints, Walsh and Englehardt [45] proposed
direct annual costs of $21.8 billion ($13.93 billion in 1995 USD). In a
study aggregating previously published data, annual direct costs
were estimated to be $3.2 billion ($2.1 billion in 1995 USD) in
France [46]. More recently, Daley et al. [25] found annual direct
costs in the province of Quebec to be $476.5 to $509.9 million USD
($547.5 e $585.9 million 2009 Canadian dollars [CDN]).
Indirect costs
Indirect costs include costs that are not directly attributable to
medical care specic to the condition, but that are incurred in its
pathway. Examples are lost workplace productivity (ie, absenteeism or presenteeism, wherein employees are physically present
but perform at reduced productivity) or increased vulnerabilities
(e.g., higher accident risk).
Indirect costs e health care utilization
Overall medical expenditures are also higher among both
younger and older patients with insomnia relative to matched noninsomnia controls [47,48]. For example, insomnia has been associated with emergency room (ER) visits, days hospitalized, and provider visits [49], and insomnia severity has been linearly associated
with health-care utilization [23]. Annual medical costs among
people with insomnia have been found to be 26% higher than noninsomnia controls [50], with estimated costs of hospitalization of
people with insomnia and insomnia-related depression to be $36.6
and $1.5 billion ($25 billion and $1 billion in 1998 USD) per year,
respectively [44]. In a seminal study, Ozminkowski and colleagues
74
[51] found six-month direct medical expenditures to be $1062

($924 in 2007 USD) higher among young adults and $1314 ($1143 in
2007 USD) higher among older adults with insomnia relative to
matched non-insomnia peers. From an economic perspective, the
increased cost of insomnia among older adults is especially notable
in light of the increased prevalence of insomnia in this population
as well as the aging populace.
Indirect costs e Insomnia in the workplace
A major indirect cost associated with insomnia results from lost
productivity in the workplace. Early investigations found insomnia
to be associated with essential but somewhat crude measures of
missed days from work [52e55] as well as disability [56,57]. In the
rst study to quantify associated nancial costs, Stoller [44] estimated that insomnia-related absenteeism cost employers $9670
($4800 in 1988) per year per employee. Leger and colleagues [58]
estimated the cost of insomnia-related absenteeism to be $112
(V77 in 2005 Euros [EUR]) per employee per year. More recently,
Ozminkowski and colleagues [51] found that relative to controls
absenteeism due to insomnia was associated with $466 ($405 in
2007 USD) greater cost over six months.
Increased recognition of the impact of disturbed sleep in the
workplace has resulted in improved measurement of workplace
performance and insomnia-related impairment. Not surprisingly,
insomnia has since been found to be associated with absenteeism,
presenteeism, and increased cost to employers [53,59e63]. Kessler
and colleagues [64] were among the rst to quantify the nancial
impact of presenteeism, nding annual loss of work performance to
be 7.8 days per employee with insomnia (11.3 days when not
controlling for comorbid conditions) at a cost of $2416 ($2280 in
2011 USD) per employee, suggesting a cost within the US workforce
of $67 billion ($63.2 billion in 2011 USD) per year.
Indirect costs e Insomnia increases accident risk
Insomnia has also been identied as a reliable risk factor for
workplace accidents [65] as well as workplace and non-workplace
injuries [66], resulting in signicant cost. Shahly and colleagues
[67] found the average costs of insomnia-related accidents or errors
to be $10,534 ($10,148 in 2012 USD) higher than other accidents
and errors ($32,062 vs $21,914, p < .01; $33,280 vs $22,746 in 2012
USD), to account for 23.7% of the total costs of all accidents and
errors, and to result in estimated annual costs of $32.3 billion ($31.1
billion in 2012 USD).
Insomnia treatments can also increase the risk for accidents. For
example, although there has been controversy in the literature
whether falls are due to hypnotic therapies or the underlying sleep
disturbance [68,69], the seminal meta-analysis of Glass et al. [70]
found sedative hypnotics to be strongly associated with psychomotor accidents such as falls among older adults. In the European
Union (EU) falls in hospital have been estimated to cost between
$1.97 to $2.89 million (V1.5 to 2.2 million in 2002 EUR) per year
[70,71]. Further, reduced total sleep time and decreased daytime
performance have been identied as potential risks during the
acute phase of sleep restriction therapy, a common component of
many behavioral interventions [72]. Future studies should seek to
delineate these costs in nancial terms, as they are important
contributors to a comprehensive health economic model of
insomnia [73].
Costs of comorbid insomnia
An increasing number of studies document that comorbid
insomnia increases both direct and indirect costs. Not surprisingly,
studies to date have focused on the most prevalent insomnia

comorbidities, including depression. For example, relative to patients with depression alone, patients with comorbid insomnia and
depression have been found to have annual indirect costs $930
($851 in 2010 USD) [74] and $1390 ($1251 in 2009 USD) [75] higher,
as well as $4067 ($3918 in 2012 USD) higher annual all-cause
health care costs, $557 ($537 in 2012 USD) higher annual
depression-related health care costs, and $1144 ($1102 in 2012
USD) higher indirect costs for days-out-of-role (short-term
disability) at 12-mo [76]. Although it remains to be tested, it seems
a reasonable hypothesis that insomnia also incurs signicant
nancial costs in other comorbid conditions.
Summary of economic consequences
Studies have shown that insomnia carries signicant costs, both
direct and indirect, through direct treatment expenditures,
increased health care utilization, decreased workplace productivity,
and increased accident risk. However, research methodologies and
operational denitions have varied greatly among studies, and the
impact of these methodological differences remains unclear.
Further, signicant knowledge gaps remain. For example, the additive negative economic impact of comorbid insomnia warrants
much greater study, as the incremental costs, mechanisms, and
long-term consequences of comorbid insomnia remain largely
unexplored. In the next section of the paper, the impact of insomnia
on patient subjective experience and quality of life is considered.
Insomnia and health-related quality of life (HrQOL)
It is now recognized that in addition to physiologic and mortality outcomes, HrQOL is also an important outcome for patients
with chronic disease, and clinical trials [77]. The term HrQOL is
used to indicate that widely different aspects of life exist that may
not be included in other measures of health. These can include
such varied qualities as perceived role in society or family, lack of
freedom of choice, perceived disability, and overall happiness. The
common feature of these domains is patient subjective experience,
a core feature of insomnia disorder. People with insomnia consistently report lower HrQOL than their non-insomnia peers, even
after controlling for anxiety, depression, and medical disease status
[78e80]. Further, insomnia is associated with diminished HrQOL in
comorbid populations including cancer [81e84], Parkinson's disease [85], dialysis [86,87], human immunodeciency virus (HIV)
[88], and anxiety and depression [89].
Measurement of HrQOL in insomnia
A number of instruments have been developed to assess HrQOL,
which may be general (i.e., applicable to all or most population
groups) or disease-specic. As an example, the most commonly
used general HrQOL instrument in insomnia research is the Medical
Outcomes Study Short-Form 36 (SF-36) [90]. This instrument
contains 36 items assessing eight domains of HrQOL. Individual
subscales are scored from 0 to 100, based on community norms and
with higher scores indicating greater HrQOL. Thus, HrQOL is presented as a spectrum of scores in eight domains. Of note, because
generic HrQOL measures such as the SF-36 might not be sensitive to
detect disease-specic impairments, disease specic HrQOL scales
are often used along with generic scales to provide distinct insight
into the nuances of patient subjective experience in differing disease states. Advantages and disadvantages of other generic and
insomnia-specic HrQOL measures [91e93] are reviewed elsewhere [78,79].
Insomnia treatment improves HrQOL

Results from intervention studies generally support the positive
impact of insomnia treatment on HrQOL. Pharmacotherapies that
have been shown to improve HrQOl include zolpidem [94e96],
zopiclone [97,98] and eszopiclone [99,100], and valerian hops [101].
At the same time, not all pharmacotherapy studies have reported
positive results [102,103]. Similarly, most but not all [104] studies
have found HrQOL to improve following CBTI [104e107], including
nurse-administered CBT in primary care [108], individual and
group-administered CBTI [109], and an automated internet intervention for insomnia [110]. In terms of comorbid insomnia, CBTI
improves sleep as well as HrQOL in cancer patients [111e113], and
both eszopiclone [114] and CBTI [115] have been found to improve
sleep and HrQOL among patients suffering comorbid insomnia and
depression. In aggregate, insomnia treatments are associated with
improvements in HrQOL in both primary and comorbid insomnia
populations. Further investigation of mechanisms of change and
quality of life is clearly warranted, particularly as relates to potential differences between pharmacotherapies and CBTI.
75
common metric for establishing cost-effectiveness, they are not

without controversy in insomnia research [10].
Cost effectiveness of insomnia treatment
In light of the substantial costs associated with insomnia disorder, researchers and policy makers have become increasingly
interested in the cost-effectiveness of insomnia treatments. A
decade ago, Martin and colleagues [41] conducted a comprehensive
review of this topic and found no published cost-effectiveness
analyses (CEAs) of targeted treatments at that time. However,
since then, ten studies have provided insight into the costeffectiveness of insomnia therapies. These studies will now be
reviewed in detail, with particular attention to various research
methods employed. For each study, model inputs are presented
including insomnia denition, measurement of HrQOL, treatment
effectiveness, and direct and indirect medical costs. Results include
cost savings as well as cost per QALY, where possible. Results are
summarized in Table 1.
Sedative-hypnotic therapy
Summary of insomnia and quality of life

Currently available data have consistently demonstrated that
people with insomnia suffer worse HrQOL than their non-insomnia
peers. More important, it appears that treatment of primary and
comorbid insomnia improves HRQOL e an important nding in the
context of health economic analyses. The next section of the paper
highlights the direct economic relevance of HrQOL and places
HrQOL ndings within an insomnia health economic framework.
Introduction to health economics of Insomnia
In a context of rising health care costs, policy-makers and payers
require a clear framework for decision-making regarding allocation
of scare economic resources. Such a health economic perspective
must consider not only the clinical efcacy of disease-specic interventions but also their overall value relative to other disease and
treatment options. To perform these contrasts, there must be a
common metric to compare unrelated treatments.
The most common of these metrics is the quality-adjusted life
year (QALY), a standardized unit of measurement that accounts for
both time as well as quality of time in a specic state. QALYs are
computed by multiplying survival time and a so-called utility
score. Utility scores are either computed by transforming scores on
general HrQOL measures such as the SF-36 or measured directly
using utility scales. Most utility scales use weighted questionnaire
responses to express general HrQOL as a single number between
0 and 1 (death to perfect health, respectively), although numbers
less than 0 are often allowed as patients may in fact rate their
HrQOL as worse than dead. As an example, the health utilities index
(HUI) Mark 3 [116] has been validated for patients with a variety of
sleep disorders in a sleep center, with a mean utility of 0.6 0.35
[117]. Similarly, a more recent study by Leger and colleagues [118]
employed the SF-36 and found derived utility scores for those
with insomnia to be 0.67 in Japan, 0.57 in France, and 0.63 in the US.
The product of time and utility is then expressed in QALY. For
example, if a patient lives 1 y in a health state with a 0.6 utility, this
patient would accumulate 0.6 QALY (i.e., 1 y * 0.6 utility). An
intervention that increased this patient's utility to 0.8 for 1 y would
increase QALYs by 0.2 units. Cost-effectiveness can then be established by comparing the mean incremental cost per QALY between
unrelated treatments. In turn, these comparisons across disease
states can guide funding decisions. Although QALYs are the most
Botteman and colleagues [119] were the rst to demonstrate the

cost-effectiveness of pharmacotherapy. A cost-effectiveness model
was constructed by combining efcacy data from a published
clinical trial of 6 mo nightly eszopiclone [120] with claims data
gathered from a large (>5 million) payer database. Insomnia was
operationalized as having an ICD-9 diagnosis of insomnia or having
been prescribed an FDA-approved insomnia medication. HrQOL
was estimated via utility scores derived by transforming SF-36
scores from previous literature [80] using a published algorithm
[121]. Participants were categorized as insomnia-remitted or nonremitted using an ad hoc cutoff, and matched non-insomnia controls were identied using a propensity score. Direct medical costs
included claims for inpatient care, outpatient care, provider services, and prescription drugs over 6 mo prior to insomnia diagnosis
or treatment. Cost of eszopiclone was based on national average
costs (average wholesale price), a dispensing fee, one physician
visit, and time away from work for this appointment. The indirect
cost of days-out-of-role, including disability and worker's
compensation was also assessed from the same large claims database. Presenteeism costs were estimated by extrapolating from
extant literature on similar medical conditions. Finally, the impact
of treatment discontinuation was considered. Multiple sensitivity
analyses were conducted. After controlling for multiple confounders, the total per-patient direct medical costs over 6 mo prior
to insomnia diagnosis or treatment were $1708 ($1453 in 2006
USD) higher for those in the insomnia group (n 16,757) than in a
propensity-matched control group (n 16,784). Similarly, the incremental costs of absenteeism ($273; $231 in 2006 USD) and
presenteeism ($1015; $860 in 2006 USD) over the preceding 6
m were both higher in the insomnia group than in the control
group. Based on the per-person 6-mo treatment cost of $586.78
($497.15 in 2006 USD), including drug costs, physician visit, and
time missed from work for physician visit, the resulting cost savings
was $506.72 ($429.32 in 2006 USD) per patient, including $289.32
($245.13 in 2006 USD) and $217.40 ($184.19 in 2006 USD) for direct
and indirect costs, respectively, over the 6-mo study period. Finally,
the authors applied the derived utility scores (0.7603 and 0.8413
with and without insomnia, respectively) to both the insomnia and
no insomnia groups. The estimated QALY gain from eszopiclone
was 0.006831 over 6-mo, suggesting an incremental total cost per
QALY gained of $43,546 ([$586.78e289.32]/0.006831; $36,894 in
2006 USD), which was reduced to $11,413 when indirect cost savings were included in the model ([$586.78e506.72]/0.006831;
76
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
Direct: drug cost,

dispensing fee,
physician visit
Indirect: absenteeism,
presenteeism, travel to
medical visit
Direct: drug AWP
Indirect: HCU
previous Compared to non-remitters, remitted patients had lower monthly

literature healthcare and productivity costs ($286 and $217, respectively; $242
and $184 in 2007) and higher QALY (net gain 0.081). Relative to placebo,
incremental cost per QALY was $11,720 ($43,545excluding productivity
gains; $9930 and $36,894, respectively, in 2006 USD).
Direct: drug cost,

dispensing fee,
physician visits
Indirect: HCU,
absenteeism,
presenteeism
SF-36
Direct: drug costs and

dispensing fee
Indirect: HCU,
absenteeism,
presenteeism
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).
No signicant differences in QALY between groups. At maximum WTP of

$51,415 (30,000 in 2013 GBP), the likelihood of cost-effectiveness is
only 80%. However, if CEAC methodology is applied and WTP is $257
(150 in 2013 GBP) per 1-point reduction on ISI, likelihood of costeffectiveness is 97%.
Patients who completed treatment (attended 3 encounters) were
found to have lower costs in all domains excepting medication usage,
where no differences were observed. For treatment completers, CPT
costs decreased $201 ($200 in 2014) over 6 months. For responders, CPT
costs decreased $211 ($210 in 2014).
Payer
6m
[122] 88,305 adults ages 18y,

receiving 1 hypnotic
prescription
Payer
12 m
[123] 824 adults ages 21e64y,

randomized to
eszopiclone
(n 550) or placebo
(n 280)
Patient
6m
Patient
8w
Patient
3m
Direct: CBTI costs

Indirect: HCU
EQ-5D
Patient
6m
Direct: CBTI costs

Indirect: HCU
NA
Patient
6m
Direct: CBTI costs

Indirect: HCU
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
Direct: TAU CBTI costs HAMIndirect: NA

D17
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
Direct and indirect
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
Direct:Drug costs, CBTI

costs, physician visit
Indirect: Fall-related
costs (ER, inpatient
costs)
SF-6D
EQ-5D
Based on a WTP of $50,000, the NMB of treating a patient was $10,287

for CBTI and $4851 for sedative hypnotics. The NMB of no treatment
was -$7993.
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.
Participants (N 88,305) from a large (>55 million) medical claims

database were considered to have insomnia if they had at least one
insomnia-specic hypnotic prescription e zolpidem (n 72,290),
zaleplon (n 6854), or trazodone 100 mg (n 9161) e during the
past 12 mo. Clinical effectiveness was estimated from multiple
published randomized controlled trials (RCTs) evaluating eszoplcone, indiplon, ramelteon, zaleplon, zolpidem, zolpidem ER, and
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
78
age 54.25 19.08 years) treated in a behavioral sleep medicine

(BSM) clinic within an American Academy of Sleep Medicine
(AASM) accredited sleep center. Health care utilization (total
costs, outpatient costs, primary care visits, current procedural terminology (CPT) costs, number of ofce visits, and number of
medications) in the 6 mo before and after treatment was estimated
by combining patient-level electronic medical record (EMR) data,
CPT costs based on local Medicare relative value payments, and
chronic disease score (CDS), an algorithm validated to estimate
overall health care costs based on medications used [129]. Indirect
costs were not assessed. Controlling for baseline costs, completers
who attended >3 treatment encounters (n 37), demonstrated
$196.86 ($195.86 in 2014 USD) lower post-treatment CPT costs
(p < .05), 0.73 fewer ofce visits (p < .05), and $72.53 ($72.16 in
2014 USD) lower estimated total costs (p < .05) and borderline
signicant $39.04 ($38.84 in 2014 USD) lower estimated outpatient
costs (p .07) and 0.21 fewer estimated primary care visits
(p .07). No pre-post cost differences were observed for noncompleters who attended <3 encounters; (n 47). Notably, over
half of patients in this clinical sample were categorized as noncompleters who experienced no reduction in future healthcare
costs, highlighting the importance of patient adherence in maximizing cost-effectiveness.
Comparison of sedative-hypnotic therapy and CBTI
Tannenbaum and colleagues [130] incorporated fall risk into a
direct comparison of the cost-effectiveness of sedative-hypnotic
therapy and CBTI among older adults. To construct their decisiontree model, they assumed equal treatment effectiveness from pharmacotherapy and CBTI. HrQOL was estimated based on published
literature, and estimated costs included treatment, medical visits,
and inpatient hospitalizations. Fall risk was estimated from published literature for sedative hypnotic therapy [131] and untreated
insomnia [132] or estimated to be equal to the base case model (e.g.,
no insomnia) for CBTI. Multiple sensitivity analyses were conducted
and showed a dominance of CBTI (cost: $19,442 USD; QALYs: 0.594)
over sedative hypnotics (cost: $32,452; QALYs: 0.552) and no treatment (cost: $33,853 USD; QALYs: 0.517). Further, a NMB analysis was
conducted based on a WTP of $50,000, which resulted in a positive
NMB value for CBTI ($10,287) and negative values for sedative hypnotics ($4851) and no treatment ($7993). These important data
provide further support for previous consensus recommendations
[133] to minimize sedative hypnotic use among older adults and
highlight the relative cost-effectiveness of CBTI in this population.
Multiple treatment modalities
Another approach to estimating cost effectiveness is to consider
all possible treatment pathways and associated costs in a
population-level decision-tree analysis. Scott and colleagues [134]
performed such an analysis among adults (ages 20e59) in New
Zealand. First, treatment pathways were identied based on semistructured interviews of 21 insomnia treatment providers, with an
equal number of general practitioners, specialist physicians, psychologists, pharmacists, health practitioners, and alternative health
practitioners. Next, prevalence of insomnia as well as direct and
indirect costs associated with each possible action in the decision
tree were estimated based on published literature, as were improvements in HrQOL resulting from successful insomnia treatment. Finally, probability estimates were assigned to each potential
clinical decision e diagnosis, initiation of treatment, successful
treatment, or referral to various provider types. Multiple simulations were performed, and the estimated direct cost of treating an
insomnia patient was $164 ($145 in 2011 Australian dollars [AUD])
across all provider types. Health costs avoided were estimated at

$712 ($628 in 2011 AUD) per patient, resulting in a cost savings of
$547 ($482 in 2011 AUD) per patient treated. The cost per QALY was
$3483 ($3072 in 2011 AUD). The authors note that this is well
within the threshold established by the New Zealand public Pharmaceutical Management Agency (PHARMAC) of $7783 ($6865 in
2011 AUD) per QALY gained. The unique contributions of this study
are the decision tree model and breadth of treatment approaches
considered. However, the study provides little insight into the
relative cost-effectiveness of various treatment options.
Cost effectiveness of treating comorbid insomnia
Sedative-hypnotic therapy
Snedecor and colleagues aggregated cost-effectiveness of eszopiclone relative to placebo among patients suffering comorbid
insomnia and depression treated with uoxetine [135]. Medical care
expenses, absenteeism, and lost workplace productivity were estimated from the Hamilton depression rating scale [136] and the WLQ,
respectively. Relative to uoxetine alone, uoxetine plus eszopiclone
was associated with a net gain of 0.0058 QALY (0.0392 and 0.0034
gained in treatment and control, respectively) at a cost increase of
$88 ($81 in 2010 USD), suggesting an incremental cost per QALY of
$15,277 ($14,000 in 2010 USD). Ninety-six percent of sensitivity
analyses resulted in an ICER below $54,561 ($50,000 in 2010 USD).
Behavioral treatment
More recently, Watanabe and colleagues [137] conducted a costeffectiveness analysis on a previously published trial of CBTI in
patients with comorbid insomnia and depression [115]. Direct costs
included the costs for treatment as usual (TAU) for depression and
insomnia, individual CBTI, prescribed medications, and inpatient
hospital expenses. Cost-effectiveness was calculated by relating the
additive cost differential for including CBTI to the incremental
improvement in outcomes (ICER Dcost/DQALY). Relative to TAU
alone, TAU CBTI increased QALY by between 0.018 and 0.027.
Incremental treatment costs ranged from $160 to $787 ($159 to 783
in 2014 USD). CBTI demonstrated a 95% likelihood of being costeffective when the willingness to pay was $60,306 ($60,000 in
2014 USD), around 90% for a WTP of $40,204 ($40,000 in 2014 USD),
and around 70% for a WTP of $20,102 ($20,000 in 2014 USD).
Summary of cost effectiveness of insomnia treatment
Researchers have employed a large number of study designs to
investigate the cost effectiveness of insomnia treatments, including
RCTs, administrative review, decision-tree analysis, and retrospective clinical chart review. Most of the studies reviewed adopted the
perspective of the payer or the patient, and included direct and
indirect costs, assessing quality of life. In general follow up period
did not exceed six months. Two studies evaluated cost-effectiveness
in patients experiencing comorbid insomnia and depression.
Although there was a range of cost-effectiveness results, a signicant majority of studies reviewed found insomnia treatment to be
cost-effective using commonly employed standards, or the
threshold of incremental cost-effectiveness ratios of $50,000/QALY.
Conclusions and future directions
Insomnia is the most common sleep disorder among adults
worldwide, with well-documented positive associations with a
broad range of negative health outcomes and diminished quality of
life. In addition to these health-related consequences, untreated
insomnia also results in signicant economic costs. Although
methodological differences between studies make it very difcult
to obtain accurate estimates of the total costs of insomnia at a

population level, the overwhelming burden of evidence indicates
that untreated insomnia results in economic outlays exceeding
$100 billion per year in the US alone. The bulk of these nancial
expenditures results from indirect costs borne by employers and
health insurance payers, such as diminished workplace performance ($67 billion [$63.2 billion in 2011 USD] per year), increased
health care utilization (e.g., $2124 and $2628 per young and older
adult with insomnia, respectively, per year [$924 and $1143 in 2007
USD, respectively, over six months]), and increased accident risk
($32.3 billion [$31.1 billion in 2012 USD] per year). The results of
this review document that both pharmacologic and behavioral
treatments yield substantial savings in terms of reduced health care
utilization costs and improve HrQOL within accepted ranges of
cost-effectiveness (i.e., <$50,000 USD per QALY), even when
excluding reductions in indirect costs. Costs were typically recouped within six and 12-mo study periods.
In spite of the high prevalence of the disorder and documented
negative consequences, the majority of people with insomnia never
receive treatment. This is particularly unfortunate given the availability of highly effective medication and behavioral therapies.
From a policy and payer perspective, a primary barrier restricting
access to care has been uncertainty regarding the nancial returnon-investment of treating insomnia. To obtain increased or universal insomnia coverage, it is no longer enough to ask: Do
insomnia therapies work; it must also be asked: Is it worth it?
As highlighted in this review, extant data consistently support
that both pharmacological and behavioral therapies are costeffective. Studies have employed various methodologies to explore
the nancial aspects of insomnia treatments, with widely varying
inclusion criteria and outcome measures. Nonetheless, ndings
from cost effectiveness analysis nested within randomized clinical
trials, administrative reviews, decision tree analyses, and a clinical
chart review have demonstrated that both pharmacological and
behavioral therapies are cost-effective, both in terms of acceptable
cost per QALY as well as reducing future health care utilization. A
majority of studies found that insomnia treatments paid for themselves during the study periods, lasting from six to 12 months.
Not surprisingly, studies to date have demonstrated a close link
between clinical effectiveness and cost effectiveness. This association
not only highlights the importance of sensitive (and perhaps
insomnia-specic) HrQOL assessment to ensure detection of QALY
gained, but it also likely explains the relatively lesser costeffectiveness of treating insomnia comorbid with depression,
where smaller effect sizes would be expected. Interestingly, in spite
of evidence suggesting diminished clinical effectiveness of insomnia
treatments among older adults, insomnia treatments appear to be
equally cost effective in this population. This is an especially important nding in light of the aging populace in the US and elsewhere.
Although it is a question of high research and policy priority,
extant data do not yet support a determination whether sedative
hypnotic therapy or CBTI is more cost-effective. However, several
points warrant consideration. First, the only direct comparison of
sedative hypnotic therapy and CBTI found CBTI to be more cost
effective among older results, primarily due to increased cost from
falls associated with sedative hypnotic therapies [130]. It is unclear
how these ndings would generalize to non-elderly populations.
Second, unlike pharmacotherapies that require ongoing medication,
CBTI results in gains that are maintained long after treatment ends
[14e20]. It thus seems likely that the nancial gains resulting from
CBTI would similarly be maintained. Third, no studies have yet
evaluated the cost-effectiveness of newer CBTI delivery mechanisms,
including automated and telehealth modalities, which incur lower
direct treatment costs. These empirical questions warrant further
study, including perhaps stratication by risk or demographic groups.
79
The ndings of this review also suggest several additional

research priorities. Most important, measures of direct and indirect
insomnia-related costs should be included in all insomnia trials.
Second, additional research is required to explore the benets of
insomnia treatment on workplace performance. The majority of
insomnia-related costs are related to lost workplace productivity,
but there is a paucity of research exploring the related cost-savings
that result from insomnia treatment. Further, many insomnia
treatments are amenable to tailoring for delivery in a workplace
setting. These studies will be of particular interest to the growing
number of self-insured employers, and research partnerships with
forward-thinking employers are likely to be mutually fruitful.
Third, including measures of generic and/or insomnia-specic
HrQOL in insomnia trials will enable the measurement of costeffectiveness of insomnia treatments employing commonly
accepted standards. Fourth, the economic impact of comorbid
insomnia also warrants much greater study, both in terms of
additional costs incurred as well as the cost-effectiveness of
treating comorbid insomnia in various disease states. Finally,
additional and comparative research is required to evaluate the
relative cost-effectiveness of additional insomnia treatments (e.g.,
complementary and alternative approaches as well as novel delivery mechanisms such as telehealth).
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.
80
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.
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Sleep Medicine Reviews 30 (2016) 72e82

Contents lists available at ScienceDirect

Sleep Medicine Reviews

Health economics of insomnia treatments: The return on investment

Insomnia disorder is a major public health burden, imposing

* Corresponding author. Division of Pulmonary and Critical Care, University of

emerging literature regarding the cost-effectiveness of insomnia

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

classication of diseases tenth revision (ICD-10) criteria, 14.7% based

(PTSD; [33,34]), chronic pain [35,36], alcohol dependence [37], and

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

[51] found six-month direct medical expenditures to be $1062

studies to date have focused on the most prevalent insomnia

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

Insomnia treatment improves HrQOL

common metric for establishing cost-effectiveness, they are not

Summary of insomnia and quality of life

Botteman and colleagues [119] were the rst to demonstrate the

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

Direct: drug cost,

previous Compared to non-remitters, remitted patients had lower monthly

Direct: drug cost,

Direct: drug costs and

No signicant differences in QALY between groups. At maximum WTP of

[122] 88,305 adults ages 18y,

[123] 824 adults ages 21e64y,

Direct: CBTI costs

Direct: CBTI costs

Direct: CBTI costs

Direct: TAU CBTI costs HAMIndirect: NA

Direct and indirect

Direct:Drug costs, CBTI

Based on a WTP of $50,000, the NMB of treating a patient was $10,287

Participants (N 88,305) from a large (>55 million) medical claims

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

age 54.25 19.08 years) treated in a behavioral sleep medicine

across all provider types. Health costs avoided were estimated at

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

to obtain accurate estimates of the total costs of insomnia at a

The ndings of this review also suggest several additional

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

study of managed-care organisation enrollees. Pharmacoeconomics 1998

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

[79] Ishak WW, Bagot K, Thomas S, Magakian N, Bedwani D, Larson D, et al.

E.M. Wickwire et al. / Sleep Medicine Reviews 30 (2016) 72e82

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