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Conventional Treatment
The first task is to determine the exact cause of insomnia. Insomnia may be:
• A sign of depression
• A side effect of medication
• A reaction to stress
• A consequence of poor sleep habits
• A response to pain or anxiety
• A combination of these and other factors.
In most cases, more than one cause for insomnia is likely. Thus, a careful evaluation and diagnosis are important before strategies for treatment can be determined. The underlying cause or causes should be treated, if possible.
In considering what medication would be appropriate, physicians will consider the patient's age, medical condition, use of alcohol, and need to function when awakened during his or her normal sleep time.
Transient Insomnia
Transient insomnia, which may occur during travel, usually disappears when you return to a regular sleep pattern. The usual treatment consists of educating the patients about sleep and sleep hygiene and follow up with temporary drug therapy.
Education
Provide understandable information about sleep, the causes of insomnia, and healthy sleep practices. Information about basic sleep needs, the influence of circadian rhythms on sleep, and the effects of aging help establish realistic expectations and goals for treatment. Tips to help patients obtain good sleep are generally provided. Discuss with the patient what is causing the insomnia and how to manage it. Awareness of what is the cause of insomnia and how to manage it should help resolve the current episode and prevent chronic symptoms and relapse in the future.
Medication (Drug Therapy)
If education and sleep hygiene measures are not sufficient to combat insomnia, a short-term treatment plan will be devised with sleep medication. Newer prescription drugs such as nonbenzodiazepine hypnotics have been found to be effective for improving sleep with minimal morning sedation.
Zaleplon is a prescription medication that significantly reduces time to sleep onset in adults (at 10 mg) and elderly (at 5 mg) insomniacs.
Zolpidem is another prescription medication that is effective for both sleep onset and sleep maintenance insomnia. It should be used only at the beginning of the night. There is a greater potential for morning residual effects and some rebound insomnia immediately following abrupt withdrawal from dosages greater than 10 mg.
If these medications are found to be ineffective, then benzodiazepines may be used. Antidepressant medications may also be used especially when the insomnia is associated with mood disorders.
Chronic Insomnia
Chronic insomnia requires a thorough physical examination, alteration of some life habits, and perhaps psychotherapy to identify a hidden cause. Cognitive Behavioral therapy and drug therapy, if necessary, are the preferred approach in this case.
Education
Education about good sleep practices is useful, but not sufficient, for treating chronic insomnia.
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy has been shown to be a highly effective approach for the treatment of primary insomnia. Cognitive behavioral therapy for insomnia typically involves:
• Stimulus control
• Sleep restriction
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Relaxation strategies
• Cognitive restructuring
In a recent study of CBT versus benzodiazepine treatment, CBT was found to be superior at long-term (2 years) follow-up.
Stimulus control
Stimulus control is a set of instructions aimed at undoing conditioned arousal at bedtime by reassociating the bedroom with rapid sleep onset.
Typical instructions are as follows:
• Go to bed only when you are sleepy.
• If you do not fall asleep within 15 minutes or wake up and can't resume sleep within 15 minutes, leave the bedroom and return only when sleepy again. Repeat as often as necessary.
• Use the bedroom only for sleep and sex. Do not read, watch TV, work, or eat in bed.
Get up at the same time every morning, including weekends.
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Avoid daytime napping.
Sleep restriction
Sleep restriction involves curtailing the amount of time the patient spends in bed to increase the efficiency of sleep.
First, restrict the time allowed in bed to equal the average amount of time the patient actually spends sleeping.
After each week, the percent of time spent sleeping in bed is calculated. This is called sleep efficiency (SE) index.
sleep efficiency (SE) index = time spent asleep/time spent in bed x 100
If SE is greater than 85%, an additional 15 to 20 minutes of time in bed is added to the beginning of the night. If SE is less than 85%, time in bed is further restricted by 15 to 20 minutes. Reducing the time in bed to less than 5 hours is not generally recommended.
Sleep restriction is very effective if followed closely. Needs discipline on the part of patient for its success.
Relaxation
Various relaxation techniques are useful for inducing sleep. Examples are progressive muscle relaxation, diaphragmatic breathing, and nonguided imagery.
Cognitive restructuring
Cognitive therapy is used to identify dysfunctional beliefs and attitudes patients may have about their sleep and replace them with more adaptive substitutes.
Cognitive restructuring can be used to overcome all concerns regarding sleep and eliminate anxieties associated with poor sleep or inability to sleep.
Light phase shift
Used for insomnia associated with circadian rhythm disturbances. The use of timed exposure to bright light can be very effective in shifting the timing of the major sleep period.
Evening light is indicated if you sleep too early and wake up early (phase advance syndrome) and morning light is used if you sleep late and wake up late (phase delay syndrome). Natural sunlight and bright-light boxes can be used.
Hypnotic treatment
This is used for chronic insomnia only if non- pharmacologic approaches have been exhausted or as a complement to these treatments.
• Long-term administration of low doses of zaleplon or zolpidem.
• Benzodiazepines may be useful in patients not prone to abuse, dependence, or dose escalation. It should be monitored carefully.
• Antidepressant medications are used when the insomnia is associated with mood disorders.
Support, counseling, or psychotherapy
Patients may require special considerations at work or school. Some may benefit from support groups and/or marriage or family counseling.
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