Management of Chronic Insomnia

SUMMARY

Insomnia is defined as a self-reported dissatisfaction with sleep quality or quantity. Insomnia disorder occurs when insomnia symptoms cause daytime impairment, physical or psychological distress. Billions of dollars are spent each year in the United States on insomnia treatment, with additional billions of dollars lost in workplace productivity because of daytime impairment and disability. The American College of Physicians and the American Academy of Sleep Medicine have issued guidelines to assist with the management of chronic insomnia. For information on the diagnosis and evaluation of chronic insomnia, please see related topics below.

Definitions
Treatment
Follow up

DEFINITIONS

Insomnia

Difficulty with sleep latency (falling asleep)
Difficulty maintaining sleep
Poor sleep quality or quantity

Insomnia Disorder

– Insomnia symptoms that causes daytime impairment or distress

Short-term Insomnia Disorder

Typically in response to a stressor
Symptoms last over days to weeks before resolving
For many patients, treatment is unnecessary and symptoms resolve when stressor is removed

Chronic Insomnia Disorder

Insomnia symptoms that occur at least three nights a week and last for at least 3 months AND
Symptoms must cause clinically significant functional distress or impairment AND
Symptoms cannot be linked to other psychiatric or medical conditions

TREATMENT

General principles

Treatment is recommended whenever chronic insomnia has a significant negative impact on patient’s physical or psychological wellbeing
Prior to beginning treatment
- Sleep should be objectively evaluated via a sleep log and sleep scale (see Related Topics below for more information)
- Objective and realistic goals for improvement in sleep should be set with patient (e.g., improved sleep latency, decreased nighttime awakenings, improved daytime concentration and energy)
Comorbid conditions that commonly occur with insomnia should be evaluated and treated
- Psychiatric conditions that may worsen insomnia (anxiety, PTSD, depression, mania) | BPH | RLS | OSA | Medications (e.g., stimulants, diuretics)
Behaviors and substance use that may be affecting sleep should be identified and modified
The FDA has approved pharmacologic therapy for short term use, and patients should not remain on these drugs for extended periods of time (> 4 weeks)

Non-pharmacologic treatment

Cognitive behavioral therapy – Insomnia
- Recommended as first line therapy for adults by the ACP (High Value Care)
- Behavioral component consists of improving sleep hygiene practices: Consistent time in and out of bed | Avoiding stimulating substances | Using bed only for sleep or sex | Leaving bed when awakened and unable to sleep to minimize total time in bed not spent sleeping | Maintaining healthy diet and exercise pattern | Keeping a quiet sleep environment
- Cognitive component deals with identifying negative beliefs regarding sleep and replacing them with positive concepts about sleep
- May include instruction on relaxation techniques
- Can be cost prohibitive or inaccessible for many patients
- Takes several sessions spaced over several weeks for efficacy

Pharmacologic treatment

Benzodiazepine Receptor Agonistic Modulators – Non-Benzodiazepine (Hypnotics)

All hypnotics come with a box warning about adverse effect of complex sleep behaviors including: Sleep-walking | Sleep-driving | Engaging in complex behaviors while not fully awake
Discontinue the drug immediately if a patient experiences a complex sleep behavior
Eszopiclone (Lunesta)
- Used for insomnia due to sleep onset or sleep maintenance difficulties
- 2 to 3 mg qhs
  - 1 mg qhs: Elderly | Debilitated | Hepatic impairment
Zaleplon (Sonata)
- Approved for sleep onset insomnia
- 10mg qhs
- 5mg qhs in the: Elderly | Debilitated | Hepatic impairment
Zolpidem (Ambien)
- Available in extended-release and instant release formulations
- Evidence of benefit when taken as needed as well as scheduled
- Extended release
  - Preferred for sleep maintenance insomnia
  - 12.5 mg qhs
  - 6.25mg qhs in the: Elderly | Debilitated | Hepatic impairment
  - Extended release cannot be crushed
- Immediate release
  - Preferred for delayed sleep latency
  - 10mg qhs
  - 5mg qhs in the: Elderly | Debilitated | Hepatic impairment

Benzodiazepines

Not addressed in ACP guidelines
Includes: Temazepam | Triazolam | Estalozam | Flurazepam
Other benzodiazepines sometimes used off label
Longer acting benzos (e.g., Flurazepam)
- Help with total sleep time and early/frequent awakenings, but can cause daytime drowsiness
Shorter acting benzos (e.g., Temazepam, Triazolam, Estalozam)
- More helpful in cases of insomnia due to prolonged sleep latency
Caution when using in the elderly or patients with prior substance abuse histories

Orexin Receptor Antagonist

Suvorexant (Belsomra)
- Used for insomnia due to sleep onset or sleep maintenance difficulties
- Side effects include: Somnolence |Cognitive and behavioral changes | Neuropsychiatric symptoms |Complex behaviors (such as “sleep-driving”) stop treatment if this occurs
- Contraindicated in narcolepsy
Daridorexant (Quviviq) not included in guidelines due recent FDA approval in 2023
- Used for insomnia due to sleep onset or sleep maintenance difficulties
- Side effects include: Somnolence |Cognitive and behavioral changes | Neuropsychiatric symptoms |Complex behaviors (such as “sleep-driving”) stop treatment if this occurs
- Contraindicated in narcolepsy

Melatonin receptor agonists

Ramelteon (Rozerem)
- Approved for insomnia due to prolonged sleep latency
- Side effects include: Dizziness | Fatigue | Headache |Cognitive and behavioral changes | Complex behaviors (such as “sleep-driving”)

Anti-depressants

Doxepin (Silenor)
- Found to improve total sleep time
- Only anti-depressant recommended by ACP for insomnia due to poor sleep maintenance
- Watch for anticholinergic side effects and drug interactions
Amitriptyline (Elavil) | Mirtazapine (Remeron) | Paroxetine (Paxil) | Trazodone
- Insufficient evidence on efficacy and not FDA approved for this usage
- Not recommended by ACP, but frequently used off label for insomnia
- Used at dosages below the necessary dose to treat depressive symptoms

OTCs

Typically have an antihistamine component to give a sedating effect
Can have significant anti-cholinergic effects
Efficacy not well established, especially for long term use
Not recommended by the ACP or the American Academy of Sleep Medicine

Follow up

Goals of treatment include:
- Improvement of insomnia symptoms: Sleep latency | Number of awakenings | Early morning awakenings | Improved sleep efficiency
- Improvement of insomnia related daytime impairments: Fatigue | Anxiety or worry over lost sleep | Poor concentration | Impaired ability to complete complex tasks | Changes in mood | Irritability | Memory difficulties
Patients should repeat sleep logs and a sleep scale to assess for improvement at regular intervals
In the event of pharmacologic treatment failure, a different drug or drug class may be tried

KEY POINTS

The cornerstone of treatment for chronic insomnia is CBT-I (cognitive behavioral therapy – insomnia), which includes sleep hygiene practices (behavioral component) and therapy (cognitive component)
If CBT-I is unsuccessful or inaccessible, then pharmacologic treatments can be used both in addition to CBT-I or on their own
Objective data on the patient’s sleep, including a sleep log and sleep scale, should be obtained prior to initiating treatment and at periodic follow ups to assess trajectory
Co-morbid psychiatric conditions can both worsen insomnia and be exacerbated by insomnia, and should be treated aggressively