Review Addresses Pharmacologic Treatments of Insomnia

August 17, 2007 — A review in the August 15 issue of American Family Physician discusses various treatment options for insomnia, including tips for appropriate times to prescribe hypnotics and other pharmacologic treatments.
"The American Academy of Sleep Medicine defines insomnia as unsatisfactory sleep that impacts daytime functioning," write Kalyanakrishnan Ramakrishnan, MD, and Dewey C. Scheid, MD, MPH, from the University of Oklahoma Health Sciences Center in Oklahoma City. "More than one third of adults report some degree of insomnia within any given year, and 2 to 6 percent use medications to aid sleep. Insomnia is associated with increased morbidity and mortality caused by cardiovascular disease and psychiatric disorders and has other major public health and social consequences, such as accidents and absenteeism."
The need to evaluate and treat insomnia depends in large measure on how often sleep is disrupted and on how much insomnia affects daytime functioning. Although treating insomnia on the first visit without further evaluation may be appropriate for patients experiencing grief or other clear acute stressor, severe or long-lasting insomnia mandates a complete workup. This evaluation should focus on underlying medical, neurologic, or psychiatric conditions.
Criteria for the diagnosis of insomnia should include 1 or more of the following symptoms: difficulty falling and staying asleep, poor quality of sleep, difficulty sleeping despite adequate opportunity and circumstances for sleep, and/or awakening too early.
In addition, patients diagnosed with insomnia should have 1 or more of the following types of daytime impairment caused by disturbances in sleep: impairment of attention, concentration, or memory; concerns or anxiety regarding sleep; daytime sleepiness; making errors or having motor crashes or mishaps while working; fatigue or malaise; gastrointestinal symptoms; absent motivation; irritability or disturbances in mood; poor performance in school, at work, or in social settings; and/or tension headaches.
"Ideally, treatment for insomnia would improve sleep quantity and quality, improve daytime function (greater alertness and concentration), and cause minimal adverse drug effects," the study authors write. "Most experts recommend starting with nonpharmacologic therapy.... Behavioral and cognitive interventions have minimal risk of adverse effects, but disadvantages include high initial cost, lack of insurance coverage, few trained therapists, and decreased effectiveness in older adults."
Initial treatment options should include nonpharmacologic therapy, education regarding sleep hygiene, and proper attention to exercise, which has been shown in some trials to improve sleep as effectively as do benzodiazepines. The efficacy of cognitive behavior therapy (CBT) for insomnia is well documented.
When hypnotics are needed, the frequency and duration of use should be individualized based on each patient's specific circumstances. As a general rule, they should be prescribed only for short periods. Over-the-counter antihistamine preparations should only be used on occasion and not routinely. Because of its potential for abuse, alcohol should not be used to treat insomnia.
Opiates may be helpful for insomnia caused by pain. For short-term treatment, benzodiazepines may be indicated, but long-term use may be associated with adverse effects and withdrawal symptoms. For long-term treatment of chronic insomnia, the newer-generation nonbenzodiazepines, such as zolpidem, zaleplon, eszopiclone, and ramelteon, have a better safety profile and therefore are more effective first-line treatment options.
Specific clinical recommendations are as follows:
Effective, nonpharmacologic treatments for chronic insomnia are exercise, CBT, and relaxation therapy (level of evidence, A).
In patients with sleep disorders that involve circadian rhythm, melatonin is effective and safe for short-term treatment (level of evidence, B).
Although benzodiazepines are effective for treating chronic insomnia, they have significant adverse effects as well as the risk for patients becoming dependent on their use (level of evidence, B).
Based on indirect comparisons, the nonbenzodiazepines are effective for chronic insomnia and seem to have fewer adverse effects than benzodiazepines. Examples of the nonbenzodiazepines include eszopiclone, zaleplon, and zolpidem (level of evidence, B).
Although little available evidence supports combining nonpharmacologic and pharmacologic treatments of insomnia, one study comparing benzodiazepine with CBT vs benzodiazepine alone showed that combination therapy minimally improved sleep efficiency, but not wakefulness after sleep onset or total sleep time.
"Although substance abusers may abuse benzodiazepines, they rarely abuse nonbenzodiazepines," the study authors conclude. "The cost of nonbenzodiazepines is considerably higher than benzodiazepines. An economic evaluation comparing the cost-effectiveness of nonpharmacologic treatment, benzodiazepines, eszopiclone, and no treatment in older adults found that, compared with benzodiazepines, nonpharmacologic therapy (ie, CBT) produced a net gain of 0.37 quality-adjusted life-years at a savings of $2,781 over 10 years."
The authors have disclosed no relevant financial relationships.
Am Fam Physician. 2007;76:517-526, 527-528.