Insomnia

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Treatment

The huge range of insomnia causes dictates an equally vast range of treatment and therapy. Often, therapy is directed at the underlying cause of sleep disruption. For instance, therapy for insomnia caused by asthma would include intensification of asthma therapy and elimination of drugs that may cause insomnia. Insomnia due to DSPS may include chronotherapy, or bright light therapy.

Insomnia due to depression or anxiety would include treatment of those underlying disorders. The reality is that the recognition of conditions like depression and anxiety often includes a diagnosis of disordered sleep, so treatment for depression may be tailored to address abnormal sleep. Often times, along with the specific therapy directed at a specific sleep condition, general symptomatic therapy is provided. This may include good sleep hygiene, behavioral therapy, and often medications. All three of these are discussed below.

Sleep Hygiene
Sleep hygiene refers to activities or practices that either promote sleep or hinder it. Many people with normal sleep habits have poor sleep hygiene, but it does not appear to affect them. People with insomnia, on the other hand, may be very susceptible to poor sleep hygiene. Good sleep hygiene practices include:

• Standard wake-up time
  It is tempting to sleep in on weekends, especially if one has had poor sleep during the week. This should be avoided with patients with insomnia in order to train the body to wake at a consistent time.

• Eliminate nicotine, caffeine, alcohol, and other stimulants
  This includes theophylline, beta agonists (usually as inhalers), and steroids, especially prior to bedtime. Nicotine and caffeine are stimulants that provoke arousal. The effects of caffeine can last for several hours, perhaps up to 24 hours, so the chances of it affecting sleep are significant. Caffeine may not only cause difficulty initiating sleep, but may also cause frequent awakenings. Alcohol may have a sedative effect for the first four hours following consumption, but it can then lead to frequent arousals and non-restful sleep.

• Avoid napping
  While napping seems like a proper way to catch up on missed sleep, it is not. Napping can by looked at as good sleep at a bad time. Typically, proper sleep hygiene practice involves establishing and maintaining a regular sleep pattern and training oneself to associate sleep with cues like darkness and a consistent bedtime. Napping may prove temporarily rewarding, but it diminishes the effects of long-term therapies.

• Exercise
  Regular exercise can promote sleep quality and duration. However, exercising immediately before bedtime can have a stimulant effect on the body and should be avoided.

• Limit activities in bed
  People suffering from insomnia should avoid working in bed, such as balancing the checkbook, studying, making phone calls, and other distractions, like watching television or listening to the radio. All these activities can increase alertness and make it difficult to fall asleep. Also, these habits may lead a person to associate wakefulness with bedtime and may counteract the body’s preparation for sleep.

• Avoid food and drink before bed
  Eating a late dinner or snacking before going to bed can activate the digestive system and cause arousal and should be avoided. Excessive drinking prior to bed can overwhelm the bladder, causing wakefulness and the need to use the restroom. Avoiding both liquids and food before bedtime can reduce the incidence of gastroesophageal reflux and curtail its effects, like heartburn, that make sleep difficult.

• Ensure an adequate sleep environment
  Temperature and lighting should be controlled to make the bedroom conducive to falling asleep. A comfortable or uncomfortable bed can affect a person significantly, though it may not be immediately noticeable. Isolation from loud noise or pets is also a sensible way of ensuring sound sleep.

• Worry time
  It can be very helpful to set aside a period of time at night to review the day and to make plans for the next day. The goal is to avoid doing these things while trying to fall asleep. It is also useful to make a list of, say, work-related tasks for the next day before leaving work.

• Relaxation therapy
  Relaxation therapy and stress reduction methods may consist of a variety of techniques, including progressive relaxation (perhaps with audio tapes), meditation, and biofeedback. The goal of all these interventions is to improve relaxation and relieve anxiety and arousal at bedtime. Calming the body often helps prepare it for sleep.

Sleep restriction and stimulus control
Sleep restriction therapy is used to limit the amount of time spent in bed to time actually sleeping. Being in the bed while awake causes increased anxiety and prohibits sleep. Therefore, in sleep restriction therapy, a person is encouraged to get out of bed if sleep is not possible. Also, sleep restriction therapy uses stimulus control to promote consolidated and restful sleep after sleep onset.

For example: A person who spends eight hours in bed estimates their total sleep time to be five hours. Upon going to bed, this person would set their alarm to go off five hours later. If he or she were not asleep within 20 minutes, then he or she would get out of bed and wait until tired again (stimulus control). The person will then return to bed and reset the alarm clock for five hours later. Once he or she is sleeping about 90 percent of the time spent in bed (sleep efficiency) for five consecutive days, then he or she increases the amount of time spent in bed by small amounts. If sleep efficiency of 90 percent is maintained, then therapy is successful. Behavior modification stimulus control of this nature is intended to establish a connection between the bed, bedtime, and rapid sleep onset. However, it does not work for everyone.

Medications

Current pharmacological therapy may include over-the-counter sleep medications, antidepressants with sedative effects, and benzodiazepines. Treatments specific to the conditions for which they are indicated are discussed in their respective sections. A general description follows.

Over-the-counter sleep medications
The vast majority of over-the-counter sleep aids contain antihistamines, which are associated with drowsiness. Unfortunately, they also tend to cause decreased memory and concentration, dry mouth, morning sickness, blurred vision, extended sedation, and constipation. They are generally not recommended for the treatment of insomnia that is severe enough to require attention of a physician. And they should be avoided, especially, in cases of chronic insomnia. Over-the-counter medications, including the subvarieties of legal uppers and stimulants that are typically available in gas stations and truck stops, only provide temporary relief, if any, and may further disrupt sleep over the long term.

Antidepressants
Many antidepressants have sedative side effects. These side effects may be utilized in patients with depression and insomnia. In fact, many widely used antidepressants, like Prozac®, actually regulate sleep onset and duration for those who take them. Some antidepressants may cause significant sedation in the morning. Others, however, may affect rapid eye movement sleep (REM) and disrupt sleep quality. Generally, they are used to treat the depression causing insomnia; the side effect of causing drowsiness is used to an advantage in helping with the insomnia. See more on antidepressants.

Benzodiazepines
Benzodiazepines have been the most popularly prescribed hypnotic (sleeping pill) for some time. There are a variety of them currently available. The main difference among benzodiazepines is length of effectiveness, or half life, in the body. Longer-acting benzodiazepines cause a lot of carry-over morning sedation, and shorter-acting benzodiazepines cause a higher incidence of rebound insomnia after discontinuation. There is a risk for developing drug dependency with long-term use in some patients. Benzodiazepines can cause fatigue, dizziness, confusion, falls, and blurred vision, especially in older people. Operating a motor vehicle or heavy machinery may be hazardous when using this type of medication.

There are new drugs such as zaleplon and zolpidem which interact with one of the benzodiazepine receptors on cells that induce sleep. These two drugs are increasingly being used to treat insomnia because of their rapid onset, decreased residual effect the next morning, and low number and severity of side effects. See more on benzodiazepines.

Insomnia, Treatment, Medications reprinted with permission from sleepdisorderchannel.com
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