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Q: What can I do about insomnia?

Angela Dunaway, PharmD, PA-C

Angie Dunaway practices at the Immediate Care Clinic, Calhoun, Georgia. She has indicated no relationships to disclose relating to the content of this article.

Insomnia is defined as difficulty initiating or maintaining sleep or not feeling rested after sleep.¹ Up to 30% of the general population reports experiencing sleep disturbances.² In clinical settings, up to 50% of patients complain of sleep-related problems.² According to the International Classification of Sleep Disorders, there are 11 types of insomnia.³ The three most common are adjustment insomnia, psychophysiologic insomnia, and insomnia secondary to a mental disorder.³

Adjustment insomnia is associated with an identifiable stressor. This type of insomnia is more common in females and older adults; it is usually short-term, lasting from days to weeks. Adjustment insomnia ceases with resolution of or adaptation to the stressor.³

Psychophysiologic insomnia is characterized by the patient’s preoccupation with his or her sleep problem, which causes increased wakefulness at bedtime. Patients with this type of insomnia typically report sleeping better away from home.³

Insomnia secondary to a mental disorder may be caused by major depressive disorder, dysthymic disorder, bipolar disorder, cyclothymic disorder, and most anxiety disorders.³ A comprehensive history should consider sleep latency, number and time of sleep interruptions, time of morning awakening, and frequency and duration of naps. To increase the accuracy of the history, the patient should keep a diary of sleep habits.

TREATMENT OPTIONS

Treatment depends on the cause and duration of the insomnia. Nonpharmacologic treatment strategies should be implemented for short-term and chronic insomnia. However, pharmacologic treatment may be indicated for some patients with short-term insomnia. Patients with chronic insomnia should be evaluated for a possible medical, psychiatric, or pharmacologic cause.⁴

Nonpharmacologic treatment includes good sleep hygiene and lifestyle modifications. The patient should go to bed only when sleepy and use the bed only for sleeping and sexual activity. If still awake after 20 minutes, the patient should get out of bed and return to bed only when sleepy. A regular sleep schedule should be established, and the patient should wake up at the same time each morning. Caffeine and nicotine should be avoided or consumption stopped in the late afternoon. Alcohol should be avoided close to bedtime. Fluids should be limited in the evening to avoid night trips to the bathroom. Relaxation techniques are beneficial.⁵

Pharmacologic options include antihistamines, antidepressants, zolpidem, zaleplon, and ramelteon. Antihistamines are not as effective as benzodiazepines, and their use is often limited by anticholinergic side effects. Antidepressants such as amitriptyline, doxepin, and trazodone are often prescribed for sleep problems. But some antidepressants may contribute to insomnia. Trazodone is an effective treatment for patients with insomnia induced by other antidepressants. Zolpidem is comparable in effectiveness to benzodiazepines but does not produce the anxiolytic and muscle relaxant effects of these drugs. Zaleplon is a good alternative for patients with prolonged sleep latency.⁴ The newest pharmacologic agent is ramelteon, a nonscheduled melatonin agonist indicated for difficulty with sleep onset.⁶

Benzodiazepines reduce sleep latency and number of awakenings, resulting in increased total sleep time. However, their use may be limited by tolerance, anterograde amnesia, and rebound insomnia. These drugs should not be prescribed for patients with a history of substance abuse, pregnant patients, or patients with sleep apnea. Tolerance and dependence may be minimized by using the lowest effective dose and limiting therapy to short durations. To minimize withdrawal effects, taper the medications and warn the patient of possible rebound insomnia upon discontinuation.⁴

BOTTOM LINE

Treatment options vary and depend on the cause and the duration of the insomnia. Good sleep hygiene and pharmacologic therapy can effectively treat most cases.

For information that can be photocopied and handed to patients, please see the next section.

Katie Iverson, PA-C, MPAS, department editor

DRUGS MENTIONED

Amitriptyline
Doxepin (Sinequan)
Ramelteon (Rozerem)
Trazodone
Zaleplon (Sonata)
Zolpidem (Ambien)

REFERENCES

1.
Beers MH, Porter RS, Jones TV, eds. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006.

2.
NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia of adults. NIH Consens State Sci Statements. 2005;22(2):1-30.

3.
Summers MO, Crisostomo MI, Stepanski EJ. Recent developments in the classification, evaluation, and treatment of insomnia. Chest. 2006;130(1):276-286.

4.
Curtis JL, Jermain DM. Sleep disorders. In: Dipiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York, NY: The McGraw-Hill Companies Inc; 2002:1323-1334.

5.
Tierney LM Jr, McPhee SJ, Papadakis MA, eds. 2005 Current Medical Diagnosis & Treatment. New York, NY: Lang Medical Books/McGraw-Hill; 2005.

6.
Rozerem [package insert]. Deerfield, IL: Takeda Pharmaceuticals America Inc; 2006.

Q: What can I do about insomnia?

WHAT IS INSOMNIA?

If you have trouble falling asleep or staying asleep, you have insomnia. Insomnia also is when you do not feel well-rested when you wake up. Insomnia is a very common problem. Many people have insomnia at some time in their life.

WHAT CAUSES INSOMNIA?

Many conditions can cause insomnia. Different conditions create different types of insomnia. The most common types of insomnia are adjustment insomnia, psychophysiologic insomnia, and insomnia caused by a mental disorder.

A stressful event can cause adjustment insomnia. This type of insomnia is more common in women and older adults. Adjustment insomnia goes away when you adjust to the stress or the stressful event is over. Psychophysiologic insomnia is when worrying about sleeping causes you to have trouble sleeping. If you have this type of insomnia, you may have less trouble sleeping when you are away from home. Some mental disorders can cause insomnia. Some examples are depression and bipolar disorder. Anxiety disorders can cause insomnia, too. Usually the insomnia goes away when the mental disorder is treated.

WHAT ARE THE EFFECTS OF INSOMNIA?

Poor sleep, or not enough sleep, can make it difficult to perform daytime activities. You may not be able to think clearly. You may have trouble concentrating. You may feel very sleepy during the day. You may make mistakes that you would not ordinarily make.

HOW DO I KNOW IF I HAVE INSOMNIA?

If you think you may have insomnia, you should make a diary of your sleep habits. Take notes on how long it takes you to fall asleep. Take notes on how many times you wake up during the night. Also take notes if you take naps during the day. Take notes on how much alcohol, nicotine, and caffeine you have during the day. Take notes on how much you exercise. What time of day you exercise also is important. Write down how you feel during the day. Do you feel very sleepy? Do you feel very sad? Do you get nervous?

Share your sleep diary with your PA or doctor. He or she can help you determine if you have insomnia. Your PA or doctor can make sure the insomnia is not caused by a serious health condition. He or she also can determine the best way to treat the insomnia.

WHAT CAN I DO IF I HAVE INSOMNIA?

You need to have good sleep habits. You should wake up at the same time each morning, even on the weekend. You should go to bed only to sleep and for sex. Don’t watch television in bed. Do not read in bed. Don’t have soda, tea, or chocolate late in the evening. Caffeine can keep you awake. Don’t drink alcohol late in the evening. Even though alcohol may make you feel sleepy, you will not have a restful sleep. Avoid cigarettes, nicotine gum, and nicotine patches in the evening. The nicotine may keep you awake. Don’t drink large amounts of fluids in the evening. Drinking too much can make you wake up during the night to go to the bathroom.

You should do something that relaxes you close to bedtime. Taking a bath may help you feel sleepy. Exercising regularly also can help you sleep better. But you should not exercise too close to bedtime. Your body needs time to relax after exercising, before you try to sleep. If you cannot fall asleep in 20 minutes, get out of bed. You should do something that will help you relax. Then go back to bed when you feel sleepy.

WHAT MEDICINES CAN TREAT INSOMNIA?

There are many medications that are used to treat insomnia. Medications for insomnia that you can buy without a prescription usually contain antihistamines. You should speak with your PA or doctor before using antihistamines for a sleep problem, especially if you are older than 65 years or if you take other medications. Antihistamines can make you feel sleepy the next day. They can impair your ability to perform daily functions. Antihistamines should be used carefully if you have certain health conditions. These medications can interact with other medications you may be taking. Be sure to tell your PA or doctor about any other health conditions you have. Be sure to tell your PA or doctor about any medications you are taking.

Insomnia can be treated with prescription medications, too. Usually these medications are used along with good sleeping habits. Prescription medications used for insomnia are often called hypnotics. These medications should be used only for a short time. Your PA or doctor can determine if you should take a hypnotic medication. Prescription sleep medications can make some health conditions worse. Your PA or doctor can determine which medication would be the best choice for you.

BOTTOM LINE

Insomnia is a very common problem. Many people will experience insomnia at some time in their life. It can be caused by many things. Insomnia can be treated in different ways. If you are having problems sleeping, talk to your PA or doctor.