Insomnia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Randomized controlled trial of treatment options for insomnia.

Treatment	Outcome at 6 months
	Responders	Remitters
6 weeks of CBT	55%	40%
6 months of CBT	63%	44%
6 months of CBT 6 weeks of zolpidem	81%	68%
6 months of CBT 6 months of zolpidem	65%	42%
Adapted from Table 4 of Morin et al.

In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful.

A combination of short term pharmacotherapy and long-term behavioral therapy may be best according to a randomized controlled trial (see Table to the right).

According to clinical practice guidelines by the American Academy of Sleep Medicine, "Psychological and behavioral interventions are effective for adults of all ages, including older adults, and chronic hypnotic users... These treatments should be utilized as an initial intervention when appropriate and when conditions permit".

Behavior Therapy

Clinical practice guideline by the American Academy of Sleep Medicine (AASM) noted about cognitive behavior therapy for insomnia:

• “Initial approaches to treatment should include at least one behavioral intervention such as stimulus control therapy or relaxation therapy, or the combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy—otherwise known as cognitive behavioral therapy for insomnia (CBT-I).”

Cognitive behavior therapy for insomnia has been studied in a meta-analysis of 20 randomized controlled trials that compared a combination of two modalities of CBT-i versus various control therapies. Different modalities of CBT-i were defined as cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation techniques. The meta-analysis found:

• Sleep onset latency improved by 19 (95% CI, 142 to 25) minutes
• Wake after sleep onset was reduced by 26 (95% CI, 15 to 37) minutes
• Total sleep time increased by 8 (95% CI, 1 to 16) minutes
• Sleep efficiency percentage improved by 10% (95% CI, 8% to 12%)

Sleep restriction therapy for insomnia has been studied in a meta-analysis of 4 randomized controlled trials that reported "Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement"; however, the authors add "variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy".

Implementing behavior therapy

Behavior therapy may require as many as 16 sessions.

A shorter number of sessions has been studied:

• "Brief behavioral therapy for insomnia" (BBTI) consists of "a 45 to 60-minute individual intervention session followed by a 30-minute follow-up session 2 weeks later and 20-minute telephone calls after 1 and 3 weeks." Goals of therapy were “reduce time in bed, get up at same time every day regardless of sleep duration, do not go to bed unless sleepy, do not stay in bed unless asleep.” In a trial of 82 older adults (mean age 71.7) BBTI led to a response rate of 67% which yielded a relative benefit increase of 2.7 and number needed to treat in their population of 2.4.

Medications

Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.

In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was insignificantly more than for antidepressants. Benzodiazepines had an insignificant tendency for more adverse drug reactions.

Benzodiazepines

Main article: Benzodiazepine

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABA_A receptor. This includes drugs such as temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long periods of time.

Non-benzodiazepines

Main article: Nonbenzodiazepine

Nonbenzodiazepine prescription drugs, including the nonbenzodiazepines zolpidem(Stilnoct) and zopiclone(Imovane), are more selective for the GABA_A receptor and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence, and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.

Antidepressants

Main article: Antidepressants

Some antidepressants such as mirtazapine, trazodone and doxepin have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture.

Melatonin

Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation.

Antihistamines

The antihistamine diphenhydramine is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.

Atypical antipsychotics

Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.

Herbal medicines

Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.

Other substances

Cannabis has also been suggested as a very effective treatment for insomnia.

Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.

Insomnia may be a symptom of magnesium deficiency, or lower magnesium levels. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.

Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal.

Complimentary and alternative therapies

Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get up early in the morning and to retire to bed at a reasonable hour.

Many believe that listening to slow paced music will help insomniacs fall asleep.

The more relaxed a person is, the greater the likelihood of getting a good night's sleep. Relaxation techniques such as meditation have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.

Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, herbology and other techniques, with the goal of resolving the problem at a subtle level.

In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or metta. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the Mettā (Mettanisamsa) Sutta, Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.

Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness. Horlicks is marketed as a sleeping aid.