Insomnia Treatment

• If there are comorbidities, clinical judgment should decide whether the insomnia or the comorbid condition is treated first or they can be treated at the same time

• Improve sleep quality & quantity
• Improve insomnia-related daytime dysfunction

The following may be measured to determine treatment outcomes:

• Wake time after sleep onset
• Sleep onset latency (time to fall asleep following bedtime)
• Number of awakenings
• Sleep time or sleep efficiency
• When patient forms a clear association between the bed & sleeping
• Improvement of sleep-related psychological distress

• Prescribe the lowest effective dose & do not increase the dose
• Individualized drug regimen may be short-term or long-term but intermittent
• Can be offered if cognitive behavioral therapy is not sufficiently effective or not available
• Good sleep practices are still necessary
• Avoid long-term nightly use
• Regular follow-up is recommended to make sure hypnotics remain effective & side effects do not develop

Benzodiazepines

• Most commonly prescribed agents for treatment of insomnia
  • May be used as adjunctive therapy with behavioral therapy

• Proven effective for short-term insomnia treatment
  • Reduce time to sleep onset; prolong stage 2 sleep; prolong total sleep time; may slightly reduce rapid eye movement sleep
  • Decrease anxiety; impair memory; prevent seizure occurrence

• Use is usually limited to a 4-6 weeks duration only
  • Long-term use increases chances of habituation & withdrawal symptoms
  • Tolerance to hypnotic effects develops on repeated administration

• Rebound insomnia has occurred
• Short-acting: Triazolam
  • Has been associated with rebound anxiety & is therefore not first line for insomnia
  • Suggested as treatment for sleep onset insomnia

• Intermediate-acting: Estazolam, Temazepam
  • Temazepam is suggested as treatment for sleep onset & sleep maintenance insomnia
• Long-acting: Flurazepam, Quazepam
• Diazepam is generally not used in the treatment of insomnia due to its long duration of effect & possibility of accumulating active metabolites

Benzodiazepine-like Hypnotics

• Decrease sleep latency & number of awakenings
• Improve sleep duration & sleep quality

Eszopiclone

• Longest half-life among benzodiazepine-like hypnotics: 5-7 hours
• Effective for sleep onset & maintenance insomnia
• No associated hangover effects
• Has no short-term usage restriction
  • In one randomized clinical trial, patients treated with Eszopiclone for 6 months reported an improved quality of life, reduced work limitations & improved sleep, compared to placebo

Zaleplon

• Suggested for treatment of sleep onset insomnia
• Effective for patients with difficulty in falling asleep but not in patients with difficulty in maintaining sleep
• Does not alter normal sleep patterns & is not associated with tolerance or rebound insomnia
• Recommended duration of treatment is up to a maximum of 2 weeks

Zolpidem

• Suggested for treatment of sleep onset & sleep maintenance insomnia
• Does not alter normal sleep patterns & is usually not associated with rebound insomnia
• Tolerance & dependence have occurred in some patients
• Recommended duration of treatment is from 2-4 weeks

Zopiclone

• Decreases sleep latency when compared to placebo & generally increases sleep duration without changing normal sleep patterns
•  Rebound insomnia has occurred but not as severe as with benzodiazepines
•  Recommended for short-term use limited to a maximum of 4 weeks

Melatonin Receptor Agonist

Ramelteon

•  Effective for sleep onset insomnia
•  Has no short-term usage restriction
•  Has not been associated with hypnotic side effects, withdrawal or rebound insomnia

Other Agents

Antidepressants

• Eg Doxepin 
  
• Tricyclic antidepressants (TCAs) have been used in lower doses to treat insomnia in patients with comorbid depressive disorders
• Doxepin is a suggested treatment for sleep maintenance insomnia
• Trazodone should not be used as a treatment for sleep onset or sleep maintenance insomnia
• Little scientific evidence to support use in non-depressed patients

Antihistamines

•  Generally less effective than benzodiazepines & are associated with daytime drowsiness
•  Not recommended for chronic insomnia due to limited evidence of efficacy

Melatonin

•  Limited clinical data on use for chronic insomnia
•  May be beneficial to patients with delayed sleep phase syndrome & in a subgroup of patients with low melatonin levels
  •  Limit use to a maximum of 3 months

• A novel dual orexin receptor antagonist (DORA) suggested for treatment of sleep maintenance insomnia

Use of non-pharmacological therapy alone or in combination with pharmacotherapy clinically improves insomnia

Behavioral Therapies

Cognitive Behavioral Therapy (CBT)

• First-line treatment for chronic insomnia
• Combines cognitive therapy with behavioral treatments (eg sleep restriction, stimulus control, & sleep hygiene education) with or without relaxation therapy
  • Patients are asked to complete sleep logs while they apply the various approaches to improve sleep
  • Benefits of cognitive behavioral therapy are reduced when administered by less experienced clinicians

• Targets environmental factors & health practices that may be helpful or detrimental for sleep
• Beneficial when used in combination with other non-pharmacological insomnia treatments
•  Sleep hygiene suggestions
  • Maintain a regular-sleep wake schedule
  • Avoid sleeping in after a poor night’s sleep
  • Avoid daytime naps & decrease the time spent in bed not sleeping (eg work, telephone, internet)
  • Avoid excessive liquids or heavy evening meals
  • Avoid caffeine & nicotine 4-6 hours prior to bedtime
  • Do not use alcohol as a sleep aid
  • Avoid exercising within 3 hours of bedtime, but do exercise 4-5 hours prior to bedtime
  • Minimize light, noise & excessive temperatures
  • Avoid watching the clock
  • Avoid excessive worrying during bedtime

Sleep Restriction Therapy

• Goal is to decrease the amount of time in bed thereby increasing the percentage of time spent in bed asleep
• Helpful for patients who have been increasing their time in bed hoping to increase their actual sleep time
• Creates mild sleep deprivation which promotes shorter sleep onset & longer time asleep
• It is recommended that sleep diaries be used for sleep time estimation, both before starting sleep restriction therapy & also during follow-ups
• Patient should stay in bed only as long as their average sleep time; but no less than 4 hours per night
  • Allowable time in bed is increased by 15-20 minutes as sleep efficiency improves
  • Time in bed is increased over a period of weeks until optimal sleep duration is achieved
  • Usually keep wake-up time the same & adjust bedtime

Stimulus Control Therapy

• Based upon the theory that insomnia is a conditioned response due to temporal (bedtime) & environmental (bedroom/bed) cues that are associated with sleep
• Set of behavioral instructions designed to re-associate the bed/bedroom with sleep & to re-establish a consistent sleep-wake schedule
• Sleep onset & sleep maintenance difficulties can be reduced with stimulus control therapy
• Bed & bedroom should be associated with rapid onset of sleep
  • Go to bed only when sleepy
  • Use bed only for sleep (or sex)
  • Get out of bed & go to another room when unable to fall asleep & return only when sleepy
  • Keep regular morning arising time regardless of duration of sleep the night before
  • Daytime naps are not allowed

Relaxation Therapy

• Insomnia patients tend to have high levels of cognitive, physiologic, &/or emotional arousal both day & night
• Two common techniques for relaxation therapy include progressive muscle relaxation & relaxation response
• In progressive relaxation, patient gently contracts facial muscle for 1-2 seconds & then relaxes it
  • This process is repeated several times & then used in other muscle groups in the following sequence: jaw & neck, upper arms, lower arms, fingers, chest, abdomen, buttocks, thighs, calves, & feet

• In relaxation response, patient begins by lying or sitting comfortably
  • With eyes closed, patient allows relaxation to spread throughout the body
  • A relaxed breathing pattern is established & thoughts are directed away from everyday thoughts & toward a neutral word or image

Cognitive Therapy

• Identify faulty beliefs & attitudes about sleep & replace them with more adaptive ones
• Has been shown to have positive results on insomnia esp when combined with other techniques
• Goal is to provide reassurance to patients regarding beliefs about sleep
  • Attempt to decrease the cycle of insomnia, emotional distress, dysfunctional thoughts which can cause further sleep disturbances

• Patient is advised to deliberately attempt to remain awake, thereby reducing the performance anxiety that is believed to interfere with ability to initiate sleep