Insomnia is a common condition which causes emotional and physical stress, and is also responsible for many workday losses and decreased productivity.
The management of insomnia starts with taking a detailed history to identify the exact nature of the sleep problem. The patient must also be evaluated for any past or present medical condition, for medication use, and for other psychiatric or psychological disorders which might cause or contribute to the insomnia. Each patient must be asked about sleep hygiene, to identify factors which may disrupt normal sleep onset.
Further testing may be done in a sleep lab, including polysomnography and multiple sleep latency testing.
Insomnia management requires personal recommendations to correct underlying etiological or contributory conditions. Proper sleep hygiene must always be taught to the patient and the family or those who share the sleep environment. This includes:
- Regular time set for going to bed
- Turning off all noise-producing gadgets and devices, including radio and television, around bedtime
- Exercising moderately a few hours before bedtime shortens the sleep latency, and improves the duration and depth of sleep in a manner comparable to benzodiazepines
- Avoiding caffeine, alcohol, and smoking shortly before bedtime
There are many modes of management of sleep-onset insomnia, and treatment should be tailored to specific needs. The effectiveness of each treatment is measured by whether it reduces the time to sleep onset, or increases sleep time by at least 30 minutes.
The non-pharmacologic treatment of sleep-onset insomnia includes a wide range of measures.
- Cognitive behavioral therapy
This is based on helping the patient to recognize and modify the pressuring and unpleasant thoughts associated with inability to go to sleep at once. This is accompanied by help in changing behavioral responses appropriately. CBT may be given in individual or group sessions, followed by reviews. CBT helps the patient calm down over the whole day rather than just help decrease the time to sleep onset at night. Even if the sleep time remains the same, the patient is satisfied and unworried which has the same or better effect on health. It is highly effective, surpasses the effects of drugs, and is even better alone than when combined with medications. It has the additional advantage of having minimal adverse effects. Self-administered CBT via written or audiovisual presentations is being explored, which will increase the availability of this mode of therapy. The only hindrance might be the need to standardize the distributed materials to conform to the principles of CBT.
The following components are involved:
- Cognitive recognition of the thought process which delays sleep onset, along with offering a truthful challenge to the negative thoughts, thus altering the thoughts and calming the mind
- Behavioral changes, such as sleep restriction and temporal control, stimulus control, and relaxation therapy. Sleep restriction is an intervention which limits time in bed to little more than the actual sleep time, so that the time spent sleepless in bed is shortened. However, the waking time is retained unchanged, thus bringing about a slight sleep deprivation and adjusting the circadian rhythm. It increases sleep efficiency and improves its restfulness.
- Some behavioral modifications include: stimulus control which is a means of establishing a conditioned reflex associating the sight and experiences of bedtime to sleep instead of wakefulness. The bedroom is reserved for sleep and physical intimacy alone. In addition, the patient is expected to leave the bed after 20 minutes if sleep does not supervene, and pursue any quiet restful activity until sleepy. Progressive relaxation is often combined with stimulus control and this might increase the breadth of response to the intervention.
- Relaxation training helps the patient get ready for sleep by ensuring relaxed muscles, deep quiet breathing, and focusing the mind, all of which calm down the mind.
- Paradoxical intention is the name for the process of helping the mind let go of the distress associated with sleeplessness by reversing the focus of attention from the inability to fall asleep to the need to stay awake. This reduces the anxiety of trying to fall asleep by distracting the mind in the opposite direction.
- Imagery training is a means of stopping futile thoughts or focusing on peaceful or neutral images to help reduce the arousal level.
Sleep restriction, stimulus control, and cognitive recognition, help more patients than other types of CBT techniques, though each may have its own role to play.
Other modes of treatment include psychotherapy, stress relieving techniques, chronotherapy and bright light therapy.
Medications are used as the first-line approach in many cases because of the limited availability of CBT-trained personnel and the need for personal interactive sessions. The sedation they cause reduces the arousal state, thus improving night sleep. They have adverse effects, however, which limits their long-term use in many cases. Ideally, they should be used to bring about a rapid improvement in sleep over the short term while the patient is learning to use CBT techniques.
Benzodiazepines are hypnotic drugs which have been used traditionally to induce sleep, because they reduce the sleep latency and increase sleep duration. Their long duration of action and significant residual sedation have been cause for concern. They may cause amnesia and respiratory depression in some cases, as well as having addiction potential. They also shorten REM sleep.
Nonbenzodiazepines include the sedative GABA-ergic agents such as zolpidem and the newer zaleplon which has a very short half-life (1.5 to 4 hours), as well as the melatonin receptor agonist trazodone. Zolpidem (especially in sublingual form) and zaleplon are given at bedtime to induce sleep in sleep onset insomnia because of their short duration of action.
Certain antidepressants which reduce the activity of the HPA axis have been used. These offer a better effect without rapid induction of tolerance, and have a better safety profile over the long term.
Patients with sleep-onset insomnia have traditionally taken sedating antihistamines (diphenhydramine and doxylamine) to hasten sleep onset, but they quickly induce tolerance, and often leave the patient sleepy or less alert the next morning as well. This is also a serious potential drawback of the benzodiazepines. The lingering effects of impaired muscular reflexes and coordination, with slowing of memory and a sense of fatigue, have dogged the use of most of these drugs.
Herbal preparations such as melatonin and valerian have been promoted for use in this condition primarily due to this concern. Melatonin is a hormone intimately concerned with the light-dark cycle and circadian rhythms, including sleep cycles. Its amount in the body is reduced due to the use of tobacco, alcohol, and many drugs. Its levels also go down with age. It is used to induce sleep by early evening administration, which advances the Circadian phase.
Valerian root, valeriana officinalis, is used for the central sedative action of its oil, which causes inhibition of GABA metabolism and induces sleep
Alcohol is used as an aid to sleep but in excess it may cause the nocturnal awakenings, besides its propensity to fill the bladder and cause the need to void. Moreover, it is very likely to cause addiction.
Pain relievers, such as anti-inflammatory drugs, may also help to treat chronic pain-related insomnia as well as reduce the hyper-arousal associated with insomnia.
Reviewed by Susha Cheriyedath, MSc