Updates in insomnia diagnosis and treatment

Abstract

Introduction Insomnia is the most commonly reported sleep disorder and remains undertreated in many patients. New changes to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, have changed the way insomnia is diagnosed. In patients who suffer from insomnia, a number of available treatment options exist including both behavioral therapy and medications. Literature Review: First line therapy for insomnia should always include behavioral modifications such as sleep hygiene and insomnia-oriented cognitive behavioral therapy. In patients deemed to need pharmacotherapy, first line medications include nonbenzodiazepine hypnotics (i.e., z-drugs) and antidepressants depending on the patients’ needs and comorbidities. The risk of next day impairment, parasomnias, and central nervous system depression are some of the most feared side effects with z-drugs. Second line drug therapy includes melatonin and suvorexant. Several concerns exist for suvorexant similar to other insomnia medications, but melatonin remains one of the safest medication alternatives. Other medication options such as benzodiazepines, antihistamines, and antipsychotics should rarely be used because of weak effectiveness data or serious safety concerns. Discussion The most appropriate treatment plan needs to be tailored to meet the needs of individual patients. Many patient factors (e.g., age, other comorbidities, specific problems with sleep) need to be considered before prescribing drug therapy for patients suffering from insomnia. Medications with the best evidence and fewest safety concerns should be prioritized when clinicians work with patients to determine the most appropriate treatment plan. Conclusions Nondrug treatment should be the emphasis for managing insomnia, but several options exist for patients needing multimodal therapy to improve their symptoms and maximize their quality of life. Z-drugs and antidepressants are first line medications options, but other options may be considered when tailored to individual patients. Medications should only be used intermittently and short term until nondrug treatments help to change a patient’s sleep routine.

Zolpidem: Efficacy and Side Effects for Insomnia

“…In addition, it is essential for those with chronic insomnia to maintain a consistent sleep-wake cycle with circumvention of daytime napping; this is referred to as temporal control therapy. 9,11 Stimulus control therapy can be used to help the patient associate the bedroom with sleep and is characterized by lying down only when ready to sleep, getting out of bed after 20 minutes of lying down if unable to fall asleep, using the bed strictly for sleep and sex, and waking at a similar time each day regardless of the time of sleep onset. Patients without a history of bipolar disorder or epilepsy who spend prolonged times in bed trying to fall asleep may benefit from sleep restriction therapy (minimum of five hours) until homeostatic sleep drive increases and improve sleep efficiency.…”

“…RCTs have demonstrated that these drugs significantly decreased sleep latency compared to placebo by an average of 20 minutes (P<0.0001) and sustained those results long-term. 11,19 Zolpidem immediate release is superior at reducing sleep latency and increasing TST out of all the z-drugs, making it a frequent first choice medication in this group. Zolpidem extended-release does not offer any additional benefit for treating insomnia but may increase the risk of next-day impairment.…”

“…Zolpidem extended-release does not offer any additional benefit for treating insomnia but may increase the risk of next-day impairment. 11 Sublingual zolpidem is faster acting and more effective at SOL reduction than the oral formulation. 10 Alternatively, zaleplon has a shorter half-life.…”

“…Eszopiclone has a longer half-life and is frequently associated with subsequent day impairment, making it the least favorable of the group. 11…”

“…Many patients with mood disorders experience insomnia, and an antidepressant can be a valid option for some patients in combination with cognitive-behavioral therapy. 11 Doxepin, a histamine H 1 receptor antagonist, can be used at low doses to decrease WASO (3mg and 6mg: P<0.0001), decrease SOL (3mg: P = 0.0047; 6mg: P = 0.0007), and increase TST (3mg and 6mg: P<0.0001). 10,11 At these lower doses, the associated anticholinergic and antiadrenergic blockades of doxepin are less significant, making the side effect profile favorable.…”