Sep 25, 2019
Doghramji, MD, is professor of psychiatry with secondary
appointments in neurology and medicine at Thomas Jefferson
University in Philadelphia. He also directs the Sleep Disorders
Center at Thomas Jefferson.
Show notes by Jacqueline Posada, MD, consultation-liaison
psychiatry fellow with the Inova Fairfax Hospital/George Washington
University program in Falls Church, Va.
Classification and consequences
- Insomnia is defined by the DSM-5 as dissatisfaction with sleep
quantity or quality, difficulty falling asleep or staying asleep,
or both. The symptoms need to occur at least three times per week
for more than 3 months and cause dysfunction or distress in the
- 20%-30% of the population reports insomnia; within inpatient
psychiatry populations, the rates rise to up to 80%.
- Insomnia is thought to be caused by central nervous system
hyperarousal or hyperactivity of unclear etiology, and there is
evidence of genetic vulnerability.
- Insomnia is associated with significant impairments, such as
diminished ability to enjoy life and sleep during inappropriate
times (i.e., while driving or in occupational settings). In
addition, insomnia confers increased risk for chronic illnesses
such as major depressive disorder, substance use disorder, as well
as diabetes, hypertension, and dementia.
- It is best to first treat the
comorbidities of insomnia, such as mood disorders and anxiety, and
then target insomnia with both behavioral modifications and
medications. When prescribing medications, choose a pharmacologic
agent that targets the period of sleep difficulty.
- Evaluation of insomnia must examine the dimensions of sleep,
including falling asleep (sleep initiation), compared with staying
asleep (sleep maintenance).
- Stimulus control therapy: If a person is unable to fall asleep
within 20-30 minutes, either at initiation or in the middle of
sleep cycle, he/she should get out of bed and do something outside
of the room and return to bed only when feeling sleepy.
- Relaxation therapies, such as progressive muscle relaxation,
can improve sleep if performed once a week for 12 weeks.
- Sleep hygiene improvements, such as addressing late caffeine
consumption, room brightness, and daytime napping can mitigate
- Over-the-counter options include valerian root and
histamine1 antagonists, such as diphenhydramine and
melatonin. Melatonin is modestly effective at low doses, though the
effects have not panned out in meta-analyses. At low doses,
melatonin may increase total sleep time or improve sleep initiation
by a few minutes. Watch out for adverse effects with long-term use
of melatonin, such as disruption of other receptors, decreased
fertility, and altered efficacy of chemotherapeutic agents.
Prescription drugs approved by the Food and Drug
- Benzodiazepines approved for insomnia include flurazepam
(Dalmane), temazepam (Restoril), estazolam (Prosom), and triazolam
(Halcion). However, those medications have long half-lives and tend
to contribute to excessive daytime sedation.
are the selective benzodiazepine receptor agonists. Zaleplon
(Sonata) and zolpidem are useful for sleep initiation but might not
help with sleep maintenance through the entire night. Eszopiclone
(Lunesta) and zolpidem extended release (Ambien CR) can help with
sleep initiation and sleep maintenance through the entire sleep
- Z-drugs, especially if mixed with alcohol, can contribute to
parasomnias such as sleep walking and sleep driving. The FDA
counsels that if patients develop parasomnias, they should not be
rechallenged with those drugs.
- Nonscheduled medications include ramelteon (Rozerem), a
melatonin receptor agonist that is effective for sleep initiation,
and low-dose doxepin (Sinequan), which is effective for middle to
late portions of the night.
Pavlova MK and Latreille V. Sleep disorders. Am J
Med. 2019 Mar 132(3):292-9.
Clark J. Slumber
Camp. Conquer insomnia. For clinicians. Slumber Camp is an
award-winning, 28-day, online course that teaches the principles of
cognitive-behavioral therapy for insomnia.
Cui R and Fiske A. Predictors of treatment attendance and
adherence to treatment recommended among individuals receiving
cognitive behavioral therapy for insomnia.
Cogn Behav Ther. 2019 Mar 14:1-7.
Christensen MA et al. Direct measurements of smartphone
screen-time: Relationships with demographics and sleep. PLoS One.
2016 Nov 9;11(11):e0165331.
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