Insomnia is a very common symptom in a variety of psychiatric and medical disorders. It can also be a primary diagnosis for some patients. The approaches to treating insomnia vary widely.
It is almost always good clinical practice to begin with a focus on patient education and a review of the tenets of good sleep hygiene. Do not assume that patients know this information—it is sometimes surprising to learn of the misconceptions that so many of our patients have about sleep.
I typically begin with an introduction of what a normal night of sleep should look like, with patients hopefully falling asleep within 12 to 20 minutes of getting into bed and sleeping for 7 to 8 hours with no more than a few brief interruptions in sleep in which they are able to fall quickly back to sleep within a few minutes. I also describe how they should awaken in the morning feeling reasonably refreshed and as if their night of sleep was restful and restorative.
I also review good sleep hygiene practices with patients, including:
- Trying to maintain a consistent sleep and wake time throughout the week.
- Avoiding eating large amounts of food immediately before bed.
- Avoiding the use of stimulants such as caffeine or nicotine close to bedtime.
- Avoiding strenuous physical activity immediately prior to sleep.
- Maintaining a sleep environment that is comfortable, quiet (or with white noise), and free from distractions such as televisions, video games, loud music, laptops, tablets, etc.
If a patient’s symptoms of insomnia have not responded adequately to non-pharmacologic interventions such as those mentioned above, as well as cognitive behavioral therapy, patients may benefit from pharmacologic intervention.
There are several families of medications commonly used for the treatment of insomnia. They can be broken down in the following ways:
- GABA Acting Agents
- Barbiturates – phenobarbital, secobarbital
- Benzodiazepines – temazepam, estazolam, flurazepam, quazepam, triazolam
- Non-Benzodiazepine Hypnotics – zolpidem, zaleplon, eszopiclone
- Sedating Antidepressants – trazodone, amitriptyline, doxepin, mirtazapine
- Antihistamines - diphenhydramine
- Antipsychotic Medications – quetiapine, olanzapine, asenapine, etc.
- Other Hypnotic Medications – ramelteon, DORAs (dual orexin receptor antagonists, a new class of hypnotics expected to come to market in the coming months)
While it is beyond the scope of this blog to provide details for each individual agent, there are some general comments that can be made about the various classes of medications.
Barbiturates, benzodiazepines, and antidepressant medications can help with sleep onset and increasing the amount of time spent in bed, but they may reduce the more important/restorative stage of sleep—slow wave sleep/stage 3 sleep—and lead to sleep that is less efficient or restorative.
The barbiturates and benzodiazepines carry higher risks of dependency and the development of tolerance over time. The non-benzodiazepine hypnotics appear to have less of a negative impact on sleep architecture, and less (but not zero) risk of dependency and tolerance.
Antihistamines are generally sedating, and do not cause dependence, but patients may find that they develop tolerance over time and may suffer from next day drowsiness (which can be a potential issue with most of these medications to some extent).
Antipsychotic medications can be very sedating, though better at preserving normal sleep architecture, but they also are associated with more potentially significant side effects such as weight gain and metabolic symptoms. In addition, they pose an increased risk of death from cerebrovascular causes in geriatric patients.
Other, novel hypnotics such as ramelteon and DORAs target more specific psychopharmacology that may offer different levels of efficacy and side effect burden.
The effective treatment of insomnia can offer patients an improved quality of life, and it also may enhance clinicians’ ability to more effectively treat comorbid conditions such as fatigue, chronic pain, and cognitive impairment, as well as a variety of other illnesses.
How aggressive are you in treating insomnia in your patients, and how do you choose which agent to use?
Chris Bojrab, MD, is the president of Indiana Health Group, the largest multidisciplinary behavioral health private practice in Indiana, established in 1987. He is a board certified psychiatrist and a Distinguished Fellow of the American Psychiatric Association who treats child, adolescent, adult, and geriatric patients. His areas of interest include psychopharmacology, sleep disorders, and gambling addiction. For more information and disclosures, visit www.chrisbojrabmd.com
The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors