Insomnia Treatment
Principles of Therapy
- 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
- Choice of agent should be based on type of insomnia and presence of comorbidities
- Concomitant treatment of insomnia and psychiatric disorders is recommended to accelerate recovery and increase the likelihood of sustained response
- Other sleep disorders such as obstructive sleep apnea and restless leg syndrome may present with insomnia but will most likely not improve without treatment of the specific disorder
- Insomnia due to nocturia, pain or shortness of breath will most likely not improve without treatment of the medical disorder
- Choice of agent should be based on type of insomnia and presence of comorbidities
- Improve sleep quality and quantity
- Improve insomnia-related daytime dysfunction
The following may be measured using a sleep log and specific questionnaires to determine treatment outcomes:
- Sleep onset latency (time to fall asleep following bedtime)
- Total sleep duration
- Number of nighttime awakenings
- Sleep efficiency
- Satisfaction with sleep and reduction in sleep-related distress
- Daytime functioning
- Wake time after sleep onset
- When patient forms a clear association between the bed and sleeping
- ISI may be used to monitor the effect of treatment interventions
Pharmacotherapy
- Considered as adjunctive therapy to non-pharmacological therapy
- Prescribe the lowest effective dose and do not exceed the maximum recommended 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 or when patient is not motivated
- Good sleep hygiene is still necessary
- Avoid long-term nightly use
- Regular follow-up is recommended to ensure effectiveness, monitor for side effects, dependence (both psychological and physiological), and assess continuing need for medication
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 ≤4 weeks
- Long-term use increases chances of habituation and withdrawal symptoms
- Tolerance to hypnotic effects develops on repeated administration
- Rebound insomnia has occurred
- Short-acting: Triazolam
- Has been associated with rebound anxiety and 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 and sleep maintenance insomnia
- Long-acting: Flurazepam, Quazepam
- Diazepam is generally not used in the treatment of insomnia due to its long duration of effect and possibility of accumulating active metabolites
Non-benzodiazepine Hypnotics
- Decrease sleep latency and number of awakenings
- Improve sleep duration and sleep quality
Eszopiclone
- Longest half-life among non-benzodiazepine hypnotics: 5-7 hours
- Effective for sleep onset and maintenance insomnia
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
Zolpidem
- Suggested for treatment of sleep onset and sleep maintenance insomnia
- Does not alter normal sleep patterns and is usually not associated with rebound insomnia
Zopiclone
- Decreases sleep latency when compared to placebo and generally increases sleep duration without changing normal sleep patterns
Melatonin Receptor Agonist
Melatonin
- Clinical trials data have shown that prolonged-release Melatonin improves sleep onset latency and quality in patients >55 years old
- Limited clinical data on use for chronic insomnia
- May be beneficial to patients with delayed sleep phase syndrome and in a subgroup of patients with low melatonin level
- Limit use to a maximum of 3 months
- Effective for sleep onset insomnia
- Has no short-term usage restriction
- Has not been associated with hypnotic side effects, withdrawal or rebound insomnia
Dual Orexin Receptor Antagonists (DORAs)
- Eg Daridorexant, Lemborexant, Suvorexant
- Daridorexant and Lemborexant were recently approved for the treatment of insomnia in adults that have difficulties with sleep onset and/or sleep maintenance
- Suvorexant was suggested for treatment of sleep maintenance insomnia
Antidepressants
- Eg Amitriptyline, Dothiepin, Doxepin, Mirtazapine, Trazodone
- Tricyclic antidepressants (TCAs) have been used in lower doses to treat insomnia in patients with comorbid depressive disorders but are dangerous when overdosed
- Low dose Doxepin is a suggested treatment for sleep maintenance insomnia
- Trazodone should not be used as a treatment for sleep onset or sleep maintenance insomnia
- In some studies, low-dose Trazodone in conjunction with another full-dose antidepressant have moderate efficacy in improving sleep quality and/or duration
- Eg Gabapentin, Pregabalin
- Limited evidence for efficacy in the treatment of chronic insomnia
- Gabapentin may be used in patients with insomnia associated with restless leg syndrome, neuropathic pain and substance use disorders (eg alcohol use disorder)
- Pregabalin has been found to improve sleep but the mechanism of action is unclear
- Gabapentin and Pregabalin may also be used for the treatment of insomnia with comorbid pain condition
Antihistamines
- Eg Diphenhydramine, Doxylamine
- Generally less effective than benzodiazepines and are associated with daytime drowsiness
- Not recommended for insomnia due to limited evidence of efficacy
Antipsychotics
- Eg Quetiapine
- Quetiapine is the most frequently prescribed antipsychotic for insomnia but should only be considered in patients with insomnia and comorbid psychotic disorder (eg schizophrenia, bipolar disorder)
Non-Pharmacological Therapy
Use of non-pharmacological therapy alone or in combination with pharmacotherapy clinically improves insomnia
Cognitive Behavioral Therapies for Insomnia (CBT-I)
- Multicomponent treatment recommended for chronic insomnia in adults of any age
- Combines cognitive therapy with behavioral treatments (eg sleep restriction, stimulus control, and sleep hygiene education) and relaxation therapy
- Reduces sleep onset latency and nocturnal awakenings, and improve sleep efficiency
- Studies have shown improvement in functional outcomes when used as adjunct to pharmacotherapy in patients with insomnia with psychiatric or medical comorbidities
- May reduce the need for pharmacologic therapy; hence, may decrease the risk of drug-related adverse events
- CBT-I requires patients to be engaged with a multisession approach (usually 4-8 sessions) with a trained clinician/therapist
- Brief therapies for insomnia (typically 1-4 sessions) include abbreviated versions of CBT-I with emphasis on the behavioral components
- Targets environmental and lifestyle factor to build good habits which facilitate good sleep
- Sleep hygiene alone is ineffective for insomnia, but is more beneficial when incorporated into CBT-I
- Sleep hygiene suggestions
- Maintain a regular-sleep wake schedule
- Avoid naps lasting >1 hour or later than 3 pm and decrease the time spent in bed not sleeping (eg work, telephone, internet)
- Avoid excessive liquids or heavy evening meals
- Avoid caffeine and nicotine 4-6 hours prior to bedtime
- Do not use alcohol as a sleep aid
- Avoid exercising within 3 hours of bedtime, but daytime physical activity particularly exercising 4-6 hours prior to bedtime is encouraged to facilitate sleep onset
- Minimize light, noise and excessive temperatures
- Avoid watching the clock
- Place digital devices far away from the bed to minimize intrusions to bedtime
- Engage in a relaxing bedtime routine 30 minutes before sleep such as reading, listening to music, warm bath, light snack or stretching
- Avoid excessive worrying during bedtime, including sleep-related worries
- Based upon the theory that insomnia is a conditioned response due to temporal (bedtime) and environmental (bedroom/bed) cues that are associated with sleep
- Aims to re-associate the bed/bedroom with sleep and to re-establish a consistent sleep-wake schedule
- Bed and 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 and go to another room when unable to fall asleep within 20 minutes and return only when sleepy
- Keep to a regular wake time regardless of duration of sleep the night before
- Avoid daytime naps
Relaxation Therapy
- Insomnia patients tend to have high levels of cognitive, physiologic, and/or emotional arousal both day and night
- Two common techniques for relaxation therapy include progressive muscle relaxation and relaxation response
- In progressive relaxation, patient gently contracts facial muscle for 1-2 seconds and then relaxes it
- This process is repeated several times and then used in other muscle groups in the following sequence: Jaw and neck, upper arms, lower arms, fingers, chest, abdomen, buttocks, thighs, calves, and 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 and thoughts are directed away from intrusive worries and toward a neutral word or image
- Different relaxation methods work for different people; it may take some trial and error and practice before the best method for the patient can be identified
Cognitive Therapy
- Identify faulty beliefs and attitudes about sleep and replace them with more helpful ones
- Goal is to provide reassurance to patients regarding beliefs about sleep
- Attempt to decrease the cycle of insomnia, emotional distress and dysfunctional thoughts which can cause further sleep disturbances
- 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 and longer time asleep
- It is recommended that sleep diaries be used for sleep time estimation, both before starting sleep restriction therapy and 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 and adjust bedtime