Prescription Meds: In general the most studied and effective medications for short term and/or intermittent treatment of insomnia are the benzodiazepines and the hypnotic “Z” drugs (zolpidem, zaleplon, eszopiclone). Risks include dependency, excessive sedation, cognitive impairment and complex sleep related behaviors. Sleep onset insomnia will typically benefit more from short acting medications such as zolpidem, zaleplon, or triazolam. If there are issues with maintenance of sleep a longer acting choice such as eszopiclone, zolpidem ER, lorazepam, or temazepam may be more beneficial, but these may carry an additional risk of morning sedation.

Other options that could be used when there are concerns about abuse of these medications or addictive risk, include low doses of sedating antidepressants such as trazodone, mirtazapine, amitriptyline and doxepin. These agents are not infrequently used as long-term agents, when effective. Use of quetiapine (Seroquel) or clonidine may also be an option.

OTC: Over the counter options for insomnia typically have antihistamines as their active ingredient. Generally these are fairly safe and a viable option though the research has not supported their use for treatment of primary insomnia. Nonetheless, these agents are popular and readily accessible.

Herbals: Herbal products are also frequently used even though studies of effectiveness are limited or inconclusive. It is important to inform patients of possible negative effects of these substances along with information about their potential benefits. The most common alternative remedies used for insomnia include melatonin, valerian, kava, chamomile, St. John’s wort, and 5-Hydroxytryptophan (5-HTP).

Melatonin has some of the best research supporting its use in sleep disorders, mainly for disorders of the circadian rhythm. There are few side effects associated with melatonin and it may help with both sleep onset and maintenance. Research only supports the use of doses between 0.3-0.6 mg, higher doses will raise blood levels of melatonin throughout the day with risk of daytime sedation as well the potential of hyperprolactinemia. A melatonin agonist (ramelteon) is also now available.

St. John’s wort has been used for depression, anxiety and sleep. It is believed to work on the GABA and serotonin systems. In general it is probably safe to use for insomnia but the patients should be warned about various interactions with other medications as St. John’s wort affects the p450 system and thus can increase the risk of serotonin syndrome if taken along with an SSRI medication.

Other Herbals: Valerian appears to work on the GABA system through benzodiazepine-like activity. It should not be used by pregnant or breast feeding women and there has been some reports of possible liver failure. Three or more weeks of daily use may be required for efficacy to become apparent. Kava has also been frequently used for insomnia and it too appears to work through the GABA system. There have also been some reports of liver failure with its use. Chamomile is generally used in a tea for insomnia. It has very little research supporting its use in insomnia but has very few potential adverse effects so there is no reason to discourage its use if the patient desires. Finally 5-HTP is a serotonin precursor that may have some benefit for insomnia, though the evidence is weak. It may take 6-12 weeks of use to see any benefit and because it raises serotonin levels use with other serotonergic medications may increase the risk of serotonin syndrome.

In summary behavioral treatments for insomnia should always be used first but if ineffective then use of a medication or herbal supplement could be tried. First line treatment for short term use should probably be a benzodiazepine or a “Z” drug. Use of herbal supplements while lacking rigorous studies, do seem to have some benefit and in general low side effects profiles so they could be recommended as possible treatment options. Patients should be advised that these substance are not intrinsically safe because they are “natural” and that they can have side effects and drug interactions. Additionally, they are unregulated and can be subject to contaminates that may be harmful. Patients should try to obtain these substances from reputable sources. If the patient does not respond to sleep aid options or they are unable to be tapered off the prescription meds after 1-2 months, then it would be recommended refer to a sleep clinic for further evaluation and treatment.

Insomnia Defined: ―trouble with either falling asleep, staying asleep or early awakenings at least 3 nights a week for at least a month associated with significant functional impairment or distress.

The major causes of insomnia include medical conditions and psychiatric disorders, yet about 6% of adults will present with a primary insomnia for which no underlying illness or condition can be identified.

Both physical and psychiatric causes of poor sleep should be evaluated when a patients presents with complaints of insomnia.

– Common medical issues to assess include problems with pain, restless leg syndrome, sleep apnea, thyroid or other endocrine/metabolic disorders and any drug/medication use that could be affecting sleep.

– Psychiatric conditions can affect sleep as well and treatment of the underlying psychiatric issues, particularly anxiety and mood disorders, will frequently lead to improved sleep.

Assessment of the sleep problem should include a history of what the sleep problem is like– is it mainly trouble initiating sleep, staying asleep, early awakening or a combination of these. Sleep onset insomnia is the most common complaint but each case has its own profile and determining when a patient goes to bed, how long it takes to fall asleep, the number of times they awaken at night, when and how they finally arise and if they take naps during the day is important.

Additional information to review includes any routines the patient has prior to going to bed, any other activities they do in bed (eating, TV, reading, etc), use of caffeine, alcohol, or other substances and what they do when they are not falling asleep (toss and turn, trying to force the sleep to come, watching TV, reading, etc.

The first step in treating the insomnia should be to address issues of sleep hygiene. This includes having a set bed time, minimizing napping during the day, avoiding caffeine, alcohol or other stimulating substances at night, not eating large meals close to bed time, and having a sleep routine.

Establishing a nightly sleep routine of sleep preparation can be suggested, with the goal of winding things down—this may include terminating ―screen time (TV, computers, phones) and using relaxation techniques (deep breathing, muscle relaxation) for 30 – 60 minutes prior to the chosen and established bedtime.

A problem arises for many people when the bed and bedroom becomes paired with behaviors that are not conducive or compatible with sleep– such as watching TV in bed, eating in bed, and/or discussing the day’s anxieties and frustrations. Good sleep hygiene limits activities such as these.

Patients who have not fallen asleep within 15-30 min of going to bed should be advised to get up rather than to toss and turn restlessly. For some, efforts to relax, listening to quiet music, reading with limited light exposure may be more helpful than staying in bed tossing and turning or worrying as these behaviors can become paired to being in the bed.

If serious efforts to implement sleep hygiene do not prove helpful, use of a medication may be appropriate. Next week’s e-Weekly will discuss the various pharmacologic approaches including both OTC and prescription medication options.