insomnia
INSOMNIA

Insomnia can be either having difficulty in initiating sleep, maintaining sleep or experiencing early morning awakening wherein returning to sleep is not easily attained.

These disturbances can cause significant distress and impairment in daytime functioning.

It is the most prevalent sleep disorder in the general population thus accurate diagnosis and effective treatment is necessary.

Principles of Therapy

Primary treatment goals

  • 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

Pharmacotherapy

  • Prescribe the lowest effective dose & do not increase the dose
  • Individualized drug regimen may be short-term or long-term but intermittent
  • 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
  • Intermediate-acting: Estazolam, Temazepam
  • 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

  • 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

  • Does not alter normal sleep patterns & is usually not associated with rebound insomnia
  • Tolerance & dependence has 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

  •  Tricyclic antidepressants (TCAs) have been used in lower doses to treat insomnia in patients with comorbid depressive disorders
  •  Efficacy of low-dose trazodone as a sleep aid, in combination with a full dose antidepressant, has been shown in studies
    •  Sleep quality & sleep duration improved in patients with depressive disorders
  •  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

Non-Pharmacological Therapy

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

Behavioral Therapies

Sleep Hygiene Education

  • 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
  • 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
  • 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 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

Paradoxical Intention

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

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

Cognitive Behavioral Therapy (CBT)

  • 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
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