Evidence-based approaches to treating insomnia with Dr. Karl Doghramji

Karl 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 patient.
• 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.

Treating insomnia

• 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).

Behavioral techniques

• 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 insomnia.

Pharmacologic interventions

• 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 Administration

• 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.
• "Z-drugs" 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 period.
• 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.

References

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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