"Treatment Options for Insomnia" (My Synopsis)

Treatment Options for Insomnia
KALYANAKRISHNAN RAMAKRISHNAN, MD, and DEWEY C. SCHEID, MD, MPH, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
Am Fam Physician. 2007 Aug 15;76(4):517-526.
http://www.aafp.org/afp/2007/0815/p517.pdf

     Insomnia is defined as poor sleep that affects daytime performance. It affects over 33% of adults in some shape or form. Risk factors include being female, increasing age, unemployment, medical comorbidities, low socioeconomic status, and psychiatric illness. Criteria for insomnia includes having at least one of the following:
problems initiating or maintaining sleep, poor sleep quality, or waking up too early;
AND one of these daytime problems:
impairment in attention, concentration, or memory; daytime sleepiness, fatigue, malaise, mood disturbances, tension headaches, or errors/accidents during the day.
     Acute insomnia occurs for less than 30 days. Causes of acute insomnia include stress (environmental or situational) or death/illness of a loved one. Chronic insomnia lasts for more than 30 days. Causes include medical disorders (CHF, COPD, HIV, ESRD, GERD, cancer, chronic pain), medications (mostly those that are anticholinergic or have anticholinergic side effects, including CNS stimulants, MAOIs, steroids, antidepressants), psychiatric disorders, sleep-wake schedule disorders, substance abuse and primary sleep disorders.
     When evaluating a patient with insomnia, the clinician should first rule out any coexisting medical or psychiatric conditions. A sleep history should be taken, with attention given to Sleep habits, substance abuse, daytime functioning, and nighttime limb movements. Additional information should be ascertained from their partner or caregiver. Patients will also get a mini-mental status exam, a neurologic exam, and a medication review with their physical exam.  Patients will need to keep a sleep diary for at least two weeks. A polysomnography can be done if the patient has sleep apnea or a limb movement disorder. An actigraphy is used to monitor a patient's' activity and movement during sleep.
     Treatments starts with nonpharmacologic therapy. Examples include CBT, exercise, relaxation therapy (tensing and flexing certain muscle groups), stimulus control therapy (no bright lights, no noise, no coffee, etc), and temporal control measures (waking up at the same time and no naps during the day). When these techniques are ineffective, a low dose of hypnotics can be given for a few weeks. They have abuse and tolerant potential, so caution should be exercised. OTC antihistamines are not very effective and are not recommended. There are many herbal supplements on the market, but they have no benefit, other than melatonin and valerian root. Melatonin can stabilize the circadian rhythm. Valerian root causes sedation because it is a GABA inhibitor.
     Barbiturates are a GABA-a agonist. and are effective for short term insomnia. Opiates may be helpful in certain patients, like those who cannot sleep because of pain. Of the antidepressants available, trazodone is the one most often prescribed for insomnia. Benzodiazepines have less risk of abuse and overdose than barbiturates. Shorter acting benzos (estazolam, triazolam, and temazepam) are preferred because of their rapid action. These medications should not be used beyond four weeks due to the risk of dependence, withdrawal and rebound insomnia.
     Nonbenzodiazepine hypnotics (zolpidem, zaleplon, eszopiclone) are similarly effective as benzos with less adverse drug risk, abuse, and dependence. They do not affect the sleep stages like the benzos do. Zaleplon causes less memory and psychomotor impairment than benzos and zolpidem. It does cause changes in color perception.  Eszopiclone is approved for use longer than 35 days. Non-benzos are more expensive, but do not show better efficacy than traditional benzos.
     Ramelteon is a melatonin receptor agonist. it has low likelihood of abuse and dependence. Side effects are rare. It is the only non scheduled medication approved for insomnia.