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Treatment Options for Insomnia


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9.22.2017 | Nathan Becker
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Treatment Options for Insomnia

Bedtimes are then increased or decreased progressively depending on improvement or deterioration of sleep quality and duration.

Benzodiazepines are effective for treating chronic insomnia but have significant adverse effects and the risk of dependency. B.

Death or illness of a loved one.

Hypnotics are recommended when immediate symptom response is desired, when insomnia produces serious impairment, when nonpharmacologic measures do not produce the desired improvement, or when insomnia persists after treatment of an underlying medical condition. Table 5 outlines prescribing guidelines for hypnotics. 18 View/Print Table.

Information from references 4, 7, and 12 through 17.

Sleep restriction (paradoxical intention therapy).

Nonbenzodiazepines (e.g., eszopiclone, zaleplon, zolpidem ) are effective treatments for chronic insomnia and, based on indirect comparisons, appear to have fewer adverse effects than benzodiazepines. B 4.

Uses a paradoxical approach in which the patient spends less time in bed (by associating time spent in bed with time spent sleeping).

Useful if sleep apnea or periodic limb movement disorder is suspected.

Environmental stressors (e.g., noise).

View/Print Table. Information from reference 5.

Moderate-intensity exercise (should not occur just before bedtime) Relaxation therapy.

Use if a structural lesion (e.g., mass lesion, arteriovenous malformation) is suspected on history and examination.

Watch for requests for escalating doses or resistance to tapering or discontinuing hypnotic.

For information about the SORT evidence rating system, see page 483 or /afpsort.xml. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.

Attention, concentration, or memory impairment; concerns or worries about sleep; daytime sleepiness; errors or accidents at work or while driving; fatigue or malaise; gastrointestinal symptoms; lack of motivation; mood disturbance or irritability; social or vocational dysfunction or poor school performance; tension headaches.

Selected causes of acute insomnia (< 30 days)*

Anticholinergic agents; antidepressants (SSRIs, bupropion ), MAOIs; antiepileptics (lamotrigine, phenytoin ); antineoplastics; beta blockers; bronchodilators (beta agonists); CNS stimulants (methylphenidate, dextroamphetamine, nicotine ); interferon alfa; miscellaneous (diuretics, atorvastatin, levodopa, quinidine); steroids, oral contraceptives, progesterone, thyroid hormone Primary sleep disorder.

Selected causes of chronic insomnia (≥ 30 days) Medical disorders.

note : More information on behavioral treatments is available at http://familydoctor.org and http://ageing.oxfordjournals.org/cgi/reprint/32/1/19.pdf.

Prescribe the lowest effective dose of the hypnotic.

2 Insomnia is associated with increased morbidity and mortality caused by cardiovascular disease and psychiatric disorders and has other major public health and social consequences, such as accidents and absenteeism. 3 Risk factors for chronic insomnia include increasing age, female sex, psychiatric illness, medical comorbidities, impaired social relationships, lower socioeconomic status, separation from a spouse or partner, and unemployment. 4 View/Print Table. 1 More than one third of adults report some degree of insomnia within any given year, and 2 to 6 percent use medications to aid sleep. The American Academy of Sleep Medicine defines insomnia as unsatisfactory sleep that impacts daytime functioning.

COPD = chronic obstructive pulmonary disease; HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome; SSRIs = selective serotonin reuptake inhibitors; MAOIs = monoamine oxidase inhibitors; CNS = central nervous system.

Minimize evening fluid intake; leave the bedroom if unable to fall asleep within 20 minutes; limit use of the bedroom to sleep and intimacy Temporal control measures.

Arthropathies, cancer, chronic pain, congestive heart failure, COPD, end-stage renal disease, gastroesophageal reflux disease, HIV/AIDS, hyperthyroidism, nocturia caused by prostatic hypertrophy, stroke Medications.

An activity monitor or motion detector, typically worn on the wrist, records movement; the absence of movement for a given continuous period is consistent with sleep.

Information from references 6 through 8.

Difficulty initiating and/or maintaining sleep; sleep that is poor in quality; trouble sleeping despite adequate opportunity and circumstances for sleep; waking up too early.

Use when behavioral and psychopharmacologic treatments are unsuccessful Actigraphy.

Irregular sleep–wake cycle, jet lag, shift work Substance abuse.

Attention, concentration, or memory impairment; concerns or worries about sleep; daytime sleepiness; errors or accidents at work or while driving; fatigue or malaise; gastrointestinal symptoms; lack of motivation; mood disturbance or irritability; social or vocational dysfunction or poor school performance; tension headaches.

Information from references 3, 8, and 10.

An approach to the evaluation and treatment of the patient with insomnia is shown in Figure 1. Ideally, treatment for insomnia would improve sleep quantity and quality, improve daytime function (greater alertness and concentration), and cause minimal adverse drug effects. 17 View/Print Figure Figure 1. 4, 7, 12 – 17 Good evidence supports a benefit for relaxation therapy and cognitive behavior therapy (CBT) 4, 12 that may be sustained over six to 24 months. 13 – 15 Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Most experts recommend starting with nonpharmacologic therapy ( Table 4 ). 7, 16 Behavioral and cognitive interventions have minimal risk of adverse effects, but disadvantages include high initial cost, lack of insurance coverage, few trained therapists, and decreased effectiveness in older adults.

Useful if sleep apnea or periodic limb movement disorder is suspected.

Situational stress (e.g., occupational, interpersonal, financial, academic, medical).

3, 8, 10 Following this evaluation, the need for further testing or pharmacotherapy can be determined. Evaluation should include an assessment of sleep dysfunction and a sleep diary ( Table 3 ). The evaluation of chronic insomnia should involve a detailed history and examination to detect any coexisting medical or psychiatric illness and may include an interview with a partner or caregiver. 3, 8, 10, 11 View/Print Table History and examination.

*— Listed in order from most common to least common.

Tensing and relaxing different muscle groups; biofeedback or imagery (visual and auditory feedback) to reduce somatic arousal; meditation; hypnosis.

A two-week sleep diary should record information on bedtime, rising time, daytime naps, sleep-onset latency, number of nighttime awakenings, total sleep time, and the patient's mood on arousal.

An activity monitor or motion detector, typically worn on the wrist, records movement; the absence of movement for a given continuous period is consistent with sleep.

Approach to the evaluation and treatment of the patient with insomnia. (BPH = benign prostatic hypertrophy; CHF = congestive heart failure; MSLT = multiple sleep latency test.) Figure 1.

Selected causes of acute insomnia (< 30 days)*

Helps detect any coexisting medical or psychiatric illness.

Useful in evaluating sleep patterns in patients with insomnia, analyzing the beneficial effects of treatment measures, diagnosing circadian rhythm disorders, and evaluating sleep in patients unable to tolerate polysomnography Neuroimaging.

Prescribe hypnotics for short durations (two to four weeks) and intermittently (duration based on patient's return to an acceptable sleep cycle).

Use if a structural lesion (e.g., mass lesion, arteriovenous malformation) is suspected on history and examination.

Consistent time of wakening; minimal daytime napping.

Periodic limb movement disorder, restless legs syndrome, sleep apnea Psychiatric disorders.

Take medication history; physical examination should include neurologic examination, Mini-Mental State Examination Sleep diary.

Initiate hypnotic use with identifying and addressing specific behaviors, circumstances, and underlying disorders contributing to insomnia.

Helps change incorrect beliefs and attitudes about sleep (e.g., unrealistic expectations, misconceptions, amplifying consequences of sleeplessness); techniques include reattribution training (i.e., goal setting and planning coping responses), decatastrophizing (aimed at balancing anxious automatic thoughts), reappraisal, and attention shifting Exercise.

Use when behavioral and psychopharmacologic treatments are unsuccessful Actigraphy.

Minimize evening fluid intake; leave the bedroom if unable to fall asleep within 20 minutes; limit use of the bedroom to sleep and intimacy Temporal control measures.

Information from references 6 through 8.

Sleep history must span the entire day and should include an interview with the partner or caregiver.

*— Listed in order from most common to least common.

KALYANAKRISHNAN RAMAKRISHNAN, MD, and DEWEY C. SCHEID, MD, MPH, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

Helps change incorrect beliefs and attitudes about sleep (e.g., unrealistic expectations, misconceptions, amplifying consequences of sleeplessness); techniques include reattribution training (i.e., goal setting and planning coping responses), decatastrophizing (aimed at balancing anxious automatic thoughts), reappraisal, and attention shifting Exercise.

At least one of the following types of daytime impairment related to sleep difficulty :

Cognitive behavior therapy. Information from references 4, 7, and 12 through 17.

B. Benzodiazepines are effective for treating chronic insomnia but have significant adverse effects and the risk of dependency.

Interview partner or caregiver about patient's sleep habits, daytime functioning, substance use (e.g., alcohol, tobacco, caffeine), snoring, apnea, and unusual limb movement.

Questions should include daytime symptoms such as somnolence and frequency of napping.

Polysomnography, multiple sleep latency testing.

Melatonin is effective in patients with circadian rhythm sleep disorders and is safe when used in the short term. B 20.

Exercise, cognitive behavior therapy, and relaxation therapy are recommended as effective, nonpharmacologic treatments for chronic insomnia. A.

Uses a paradoxical approach in which the patient spends less time in bed (by associating time spent in bed with time spent sleeping).

Routine use of over-the-counter drugs containing antihistamines should be discouraged. Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. Opiates are valuable in pain-associated insomnia. Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. Alcohol has the potential for abuse and should not be used as a sleep aid. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. The better safety profile of the newer-generation non-benzodiazepines (i.e., zolpidem, zaleplon, eszopiclone, and ramelteon) makes them better first-line choices for long-term treatment of chronic insomnia. There is good evidence supporting the effectiveness of cognitive behavior therapy. Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for evaluation and treatment.

Anxiety disorders, bipolar disorder or schizophrenia, major depressive or dysthymic disorders, personality disorders, post-traumatic stress disorder Sleep–wake schedule disorder.

Periodic limb movement disorder, restless legs syndrome, sleep apnea Psychiatric disorders.

(BPH = benign prostatic hypertrophy; CHF = congestive heart failure; MSLT = multiple sleep latency test.) View/Print Table Cognitive behavior therapy. Approach to the evaluation and treatment of the patient with insomnia.

A. Exercise, cognitive behavior therapy, and relaxation therapy are recommended as effective, nonpharmacologic treatments for chronic insomnia.

Patient information: See related handout on insomnia, written by the authors of this article.

Criteria for the diagnosis of insomnia are provided in Table 1. 5 Although there are several classification systems, it is practical to divide insomnia into two categories by duration: acute (i.e., less than 30 days) and chronic (i.e., 30 days or longer). 9 View/Print Table. If insomnia is associated with another condition, it is designated as comorbid insomnia ( Table 2 ). 6 – 8 Only about 15 to 20 percent of patients with chronic insomnia have no other associated diagnosis (primary insomnia).

Information from references 3, 8, and 10. History and examination.

Sleep restriction (paradoxical intention therapy).

A more recent article on insomnia is available.

Moderate-intensity exercise (should not occur just before bedtime) Relaxation therapy.

Nonbenzodiazepines (e.g., eszopiclone, zaleplon, zolpidem ) are effective treatments for chronic insomnia and, based on indirect comparisons, appear to have fewer adverse effects than benzodiazepines. B 4.

Alcohol, caffeine, drug withdrawal, stimulants (e.g., amphetamines, methamphetamines).

Useful in evaluating sleep patterns in patients with insomnia, analyzing the beneficial effects of treatment measures, diagnosing circadian rhythm disorders, and evaluating sleep in patients unable to tolerate polysomnography Neuroimaging.

note : More information on behavioral treatments is available at http://familydoctor.org and http://ageing.oxfordjournals.org/cgi/reprint/32/1/19.pdf.

A more comprehensive evaluation should be pursued with nonresponders or if a comorbid condition is present or suspected. The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function (e.g., quality of life, work limitations, mood/social life) are probably the most important determinants of the need for evaluation and treatment. If the initial evaluation identifies an acute stressor such as grief or noise, no further evaluation is indicated and treatment can be initiated.

Initiate hypnotic use with identifying and addressing specific behaviors, circumstances, and underlying disorders contributing to insomnia.

Environmental stressors (e.g., noise).

Am Fam Physician. 2007 Aug 15;76(4):517-526.

Avoid hypnotic use or exercise caution if patient has a history of substance abuse, myasthenia gravis, respiratory impairment, or acute cerebrovascular accident.

Questions should include daytime symptoms such as somnolence and frequency of napping.

Sleep history must span the entire day and should include an interview with the partner or caregiver.

Anxiety disorders, bipolar disorder or schizophrenia, major depressive or dysthymic disorders, personality disorders, post-traumatic stress disorder Sleep–wake schedule disorder.

Irregular sleep–wake cycle, jet lag, shift work Substance abuse.

COPD = chronic obstructive pulmonary disease; HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome; SSRIs = selective serotonin reuptake inhibitors; MAOIs = monoamine oxidase inhibitors; CNS = central nervous system.

This state of minimal sleep deprivation eventually leads to more efficient sleep Stimulus control therapy.

Information from reference 5.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 483 or /afpsort.xml.

Interview partner or caregiver about patient's sleep habits, daytime functioning, substance use (e.g., alcohol, tobacco, caffeine), snoring, apnea, and unusual limb movement.

Tensing and relaxing different muscle groups; biofeedback or imagery (visual and auditory feedback) to reduce somatic arousal; meditation; hypnosis.

Avoid bright lights (including evision); noise and temperature extremes; and large meals, caffeine, tobacco, and alcohol at night.

Alcohol, caffeine, drug withdrawal, stimulants (e.g., amphetamines, methamphetamines).

Arthropathies, cancer, chronic pain, congestive heart failure, COPD, end-stage renal disease, gastroesophageal reflux disease, HIV/AIDS, hyperthyroidism, nocturia caused by prostatic hypertrophy, stroke Medications.

At least one of the following types of daytime impairment related to sleep difficulty :

Anticholinergic agents; antidepressants (SSRIs, bupropion ), MAOIs; antiepileptics (lamotrigine, phenytoin ); antineoplastics; beta blockers; bronchodilators (beta agonists); CNS stimulants (methylphenidate, dextroamphetamine, nicotine ); interferon alfa; miscellaneous (diuretics, atorvastatin, levodopa, quinidine); steroids, oral contraceptives, progesterone, thyroid hormone Primary sleep disorder.

A two-week sleep diary should record information on bedtime, rising time, daytime naps, sleep-onset latency, number of nighttime awakenings, total sleep time, and the patient's mood on arousal.

Polysomnography, multiple sleep latency testing.

Situational stress (e.g., occupational, interpersonal, financial, academic, medical).

At least one of the following complaints :

Bedtimes are then increased or decreased progressively depending on improvement or deterioration of sleep quality and duration.

Difficulty initiating and/or maintaining sleep; sleep that is poor in quality; trouble sleeping despite adequate opportunity and circumstances for sleep; waking up too early.

At least one of the following complaints :

Avoid bright lights (including evision); noise and temperature extremes; and large meals, caffeine, tobacco, and alcohol at night.

Take medication history; physical examination should include neurologic examination, Mini-Mental State Examination Sleep diary.

This state of minimal sleep deprivation eventually leads to more efficient sleep Stimulus control therapy.

Information from reference 18.

Death or illness of a loved one.

Melatonin is effective in patients with circadian rhythm sleep disorders and is safe when used in the short term. B 20.

Consistent time of wakening; minimal daytime napping.

Selected causes of chronic insomnia (≥ 30 days) Medical disorders.

Hypnotics should be discontinued gradually (i.e., tapered); physician should be alert for adverse effects (especially rebound insomnia) and withdrawal phenomena.

Helps detect any coexisting medical or psychiatric illness.

Zolpidem sleep aid