Treatment Of Insomnia

Medical Care

Practical management of insomnia

Even when comorbid causes of insomnia (ie, medical, psychiatric) are treated, variable degrees of insomnia persist that require additional interventions.

• The management of insomnia depends upon its etiology. However, even comorbid insomnia can benefit from cognitive behavioral therapy and a short-term course of a sedative-hypnotic or melatonin receptor agonist.
  • If the patient has a comorbid medical, neurologic, or sleep disorder, treatment should be directed at that disorder.
  • In the case of a psychiatric disorder (eg, depression or anxiety), treatment should be directed at the disorder. This may involve medications, psychotherapy, and, if possible, referral to a psychiatrist, psychologist, or therapist. A short-term sedative-hypnotic in conjunction with an antidepressant can be beneficial.
  • If the insomnia is related to medication or drug abuse, the offending medication or drug must be slowly tapered and withdrawn.
• The treatment of primary insomnia begins with education about the sleep problem and appropriate sleep hygiene measures (elements of good sleep hygiene are described in Patient Education).
• Before instituting therapy, most patients are asked to maintain a sleep diary for 2-4 weeks (see Sleep diary). This gives the physician a clearer picture of the degree of sleep disturbance and allows him or her to better tailor the treatment.

Cognitive behavior therapy (CBT)

CBT is a group of techniques that regardless of predisposing or precipitating factors is used to ameliorate factors that perpetuate or exacerbate chronic insomnia, such as poor sleep habits, hyperarousal, irregular sleep schedules, inadequate sleep hygiene, and misconceptions about sleep and the consequences of insomnia. While CBT is most effective for primary insomnia, it can also be effective for comorbid insomnia as adjunctive therapy.

CBT consists of the following components:

• Sleep hygiene education addresses behaviors that are incompatible with sleep (eg, caffeine or alcohol use, environmental noise, room temperature, watching TV in bed) (see Patient Education).
• Cognitive therapy: The patient is educated to correct inaccurate beliefs about sleep and to reduce catastrophic thinking and excessive worrying about the consequences of failing to obtain adequate sleep.
• Relaxation therapy: In progressive relaxation, the patient is taught to recognize and control tension through a series of exercises that consist of first tensing and then relaxing each muscle group in a systematic way.
  • Guided imagery and meditation teach the patient how to focus on neutral or pleasant targets in place of racing thoughts.
  • Biofeedback techniques can also be used. These techniques have the advantages of providing the patient with immediate feedback regarding his or her level of tension and rapidly teaching the patient how to relax.
• Stimulus control therapy: This works to reassociate the bed with sleepiness instead of arousal. Rules for its use include the following:
  • Use the bed only for sleeping and sexual activity (no reading, TV, eating, or working in bed)
  • Go to bed only when sleepy.
  • If unable to fall asleep in 15-30 minutes, get out of bed to do something relaxing until sleepy; this can be repeated as often as needed.
  • Do not spend more time in bed than is needed by establishing a standard wake-up time.
  • Refrain from daytime napping.
• Sleep-restriction therapy: This is based upon the fact that excessive time in bed often perpetuates the insomnia. Limiting time in bed leads to more efficient sleep that is both consolidated and more regular and predictable. Time in bed is allowed to increase as the patient demonstrates a continuing ability to sleep in an efficient and consolidated manner. This treatment plan consists of limiting time in bed to the patient's estimated total sleep time (not less than 5 h) and increasing it by 20 minutes for a given week when the patient estimates that their sleep efficiency (SE; ratio of time asleep to time in bed) has reached greater than 85%. The amount of time in bed remains the same when the SE falls between 80 and 85%, and is decreased by 20 minutes for a given week when the SE is less than 85%. Periodic (weekly) adjustments are made until the optimal sleep duration is achieved.

Multiple, randomized, controlled trials have demonstrated the efficacy of CBT. Sleep latency, total sleep time, duration of wakefulness, and sleep quality improve compared with placebo treatment. 50-75% of patients attain clinically significant improvement. CBT also improves the absolute amount of slow-wave sleep by 30%. Six-month follow-up has shown sustained efficacy for this treatment modality. The AASM evidence-based practice parameter found that CBT (all components), as well as individual components of stimulus-control, paradoxical intention, relaxation training, and biofeedback were effective.⁷ CBT has also been shown to be better in weaning patients from hypnotics compared with tapering medications alone. Most studies of CBT used trained psychologists to work with patients over an average of 5.7 sessions over 6.5 weeks. At this time, how practical or effective this treatment can be when administered by a healthcare provider is not known.

Preliminary evidence by Morin indicated that providing written information about CBT can be helpful.⁸ In summary, CBT should be an integral component of therapy for any patient with insomnia, whether it be primary insomnia or comorbid insomnia.

Efficacy of CBT versus sedative hypnotics for primary insomnia

Several randomized trials comparing CBT against hypnotics for primary insomnia have been published. Morin and colleagues compared temazepam with CBT in older patients and found similar short-term effects, but continued efficacy after discontinuation of therapy in the CBT group only. Another study by Jacobs et al comparing zolpidem with CBT showed continued efficacy for the patients treated with CBT.⁹

A European study by Sivertsen and colleagues showed that CBT was superior to zopiclone. In fact, zopiclone was no different than placebo on 3 of 4 outcome measures.¹⁰ CBT, on the other hand, reduced total wake time by 52%, improved sleep efficiency, and increased slow-wave sleep. At 6 months, sleep efficiency was still improved with CBT. The limitation of this last study was that it only consisted of 44 older subjects using zolpicone (not available in the US). Zopiclone is a racemic mixture of an inactive and an active isomer with the active isomer equivalent to eszopiclone. Furthermore, the dose used was slightly higher than the maximal recommended dose of eszopiclone.

Efficacy of combined CBT and sedative hypnotics

Several studies have demonstrated that after 10-24 months follow-up, the CBT group demonstrated sustained benefit that wasn’t seen in the combined CBT-hypnotic group. This could be due to patients being less willing to practice CBT techniques during the initial phase if they have obtained rapid, short-term improvement of sleep with a sedative hypnotic.

In this regard, many sleep experts feel that CBT should be considered as initial therapy for primary insomnia and adjunctive therapy for secondary insomnia. A limitation of CBT is that it requires someone who is trained in CBT and requires approximately 6 sessions over 6 weeks with each session lasting at least 20-40 minutes. A study by Edinger et al showed that 4 biweekly individual treatments represents the optimal dosing of CBT. Obviously, this is not practical for most primary care or neurology specialists.¹¹ Some sleep centers have specialized behavioral medicine specialists who can administer CBT. Preliminary evidence suggests that the use of written information may be beneficial.⁸ An internet-based CBT learning program for patients is also available for a nominal cost (seeCBTforINSOMNIA.com).

[#CombinedTherapy]CBT and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. Morin et al studied 160 adults with persistent insomnia and demonstrated that CBT used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P <0.001). p =" .05)." style="font-size: 0.85em; line-height: 0; ">12

Surgical Care

No surgical intervention is warranted, unless the patient has another medical condition or sleep disorder contributing to insomnia that warrants surgical therapy.

Consultations

Primary care physicians should be able to diagnose and treat transient or short-term insomnia. Chronic insomnia is often more difficult to treat and when primary or associated with a sleep or psychiatric disorder, referral to an appropriate specialist may be indicated.

Patients should be referred to a sleep specialist in the following cases:

• If history suggests obstructive sleep apnea or restless legs syndrome/periodic leg movement disorder
• In cases of primary insomnia, particularly if it is psychophysiologic insomnia and of long duration.
• The patient requires daily or near-daily sedative-hypnotics for insomnia for 30 days or more.
• Many sleep centers have a staff psychologist who specializes in treating insomnia. The advantages include experience in cognitive-behavioral techniques and providing sleep education, greater available time for the often-frequent follow-up that is needed, and the ability to ascertain if other psychological factors are present that may need further evaluation by a psychiatrist.
• Patients with a history of depression should be treated with an antidepressant or referred to a psychiatrist based on the physician's comfort level in treating depression, the severity of depression, and the response to therapy. Furthermore, patients with a history of substance abuse or another major psychiatric disorder should also be referred to a psychiatrist.

Diet

• Avoid caffeinated beverages in the late afternoon or evening since the stimulant activity of adenosine antagonism can promote hyperarousal.
• Avoid alcohol in the evening since this can worsen sleep disordered breathing leading to frequent arousals. Furthermore, while alcohol promotes sleep early in the night, it leads to more sleep disruption later in the evening.
• Avoid large meals near bedtime, particularly in patients with gastroesophageal reflux disease or delayed gastric emptying.

Activity

Exercise in the late afternoon or early evening (at least 6 hours before bedtime) can promote sleep. However, vigorous physical activity in the late evening (<>