Insomnia: An Overview

People who are unhappy with the amount or quality of their sleep often complain of insomnia. Research suggests that about 30% of adults report at least 1 symptom of an insomnia disorder, and about 6% meet diagnostic criteria. Along with emotional or alertness concerns, patients may also have a variety of medical and/or psychiatric illnesses. Those with long-term insomnia are at risk for substance abuse, personal and work difficulties, and accidents. Individuals with a higher probability of sleep problems include elderly people, women, and those who work shifts during normal sleep hours.

When diagnosing insomnia, clinicians must document 1 or more of the following criteria: difficulty falling asleep, numerous awakenings, early awakenings with inability to return to sleep, and distress or dysfunction. Insomnia must be present at least 3 nights per week for 3 months, despite sufficient opportunity for sleep, and must not be caused by a sleep disorder, substance abuse, or medical or psychiatric ailments.

Taking a history and conducting a physical examination are paramount. Evaluate patients not only for somatic or psychiatric disorders but also for substance use (eg, caffeine, cocaine), environmental or social stressors, and/or overt sleep pathologies (eg, obstructive or central sleep apnea, restless legs syndrome). Treatment for insomnia begins after such conditions are excluded, diagnosed, or have responded poorly to past therapy.

Intervention varies based on the specific etiology. After evaluation, treat the causative pathologies, whether somatic, emotional, or substance-related. In addition, sleep hygiene principles such as the following must be explained to patients:

• Avoid naps late in the day
• Avoid caffeine after lunch
• Avoid alcohol late in the day (alcohol shortens sleep latency but disturbs sleep quality)
• Avoid large meals in the evening; however, a bedtime snack promotes sleepiness
• Avoid exercising near bedtime
• If anxious about something before bedtime, make a list of tasks for the next day
• Avoid cellphones, TV or computer screens, and bright lights before bed, as they suppress melatonin production
• Avoid anxiety-producing activities at bedtime
• Regularize bed and arousal times
• Use the bed only for sleep and/or sex
• Make the bedroom quiet, dark, and comfortable
• Do relaxing activities before bed, eg, reading, listening to music
• Utilize anything calmative at bedtime, such as a fan or background noise

Nonpharmacologic strategies for insomnia besides sleep hygiene include the following:

• Cognitive-behavioral therapy for insomnia
• Psychotherapy focusing on reducing anxiety or depression
• Relaxation exercises such as progressive muscle relaxation, breathing exercises, or meditation

A variety of sleep aids, both over-the-counter and prescription medications, can be utilized. Nonbenzodiazepine medications include the so-called “z-drugs” (zolpidem, zaleplon, eszopiclone), and other medications include the melatonin agonist ramelteon, benzodiazepines, doxepin, and suvorexant. Antihistamines, antidepressants, antipsychotics, alpha-1 adrenergic blockers, and gabapentin and related medicines can mitigate insomnia and correct underlying disorders. Benzodiazepines are best prescribed on a short-term, intermittent, and well-monitored basis, if the above options are ineffective.

When selecting pharmacotherapies, clinicians should consider pharmacokinetic and pharmacodynamic changes that accompany illnesses, other pharmaceuticals, and/or aging. Clinicians should avoid polypharmacy, drugs with the potential for dependency, and medications that impair cognitive and psychomotor function. Diphenhydramine, for instance, has counterproductive anticholinergic properties and a prolonged half-life, which are undesirable, especially in older people. Dependence on benzodiazepines is a primary concern to address and/or avoid.

Financial disclosure:Drs Brar, Bache, and Lippmann had no relevant personal financial relationships to report.