Sleepless in Rockaway

By Peter Galvin, MD

Insomnia disorder is characterized by dissatisfaction with sleep quality or duration associated with falling or staying asleep and substantial distress or daytime impairments. The disorder is sleep disturbance that occurs three or more nights a week, persists for three or more months, and is not the result of inadequate opportunities for sleep. It frequently occurs with other medical conditions (e.g., pain) and psychiatric disorders (e.g., depression), as well as other sleep disorders like restless leg syndrome and sleep apnea. Insomnia is the most common sleep disorder in the general population and is among the most frequent issues raised by patients during primary care visits, although it often goes untreated. About 10% of adults meet the criteria for insomnia disorder and another 15 to 20% report occasional insomnia symptoms. It is more common in women and persons with mental or medical problems, and its incidence increases in middle age and later, as well as during perimenopause and menopause.

While the mechanisms of insomnia disorder are still poorly understood, its core features are recognized as psychological and physiological hyper-arousal. In more than 50% of patients, it follows a persistent course. The first episode typically arises from stressful life situations, health problems, atypical work schedules, or travel across several time zones (jet lag). While most people resume normal sleep following the precipitating event, those susceptible to the disorder may develop chronic insomnia. For example, sleeping late into the morning or napping during the day may initially help people to cope with sleep disturbances, however those same practices can exacerbate sleep disturbances over time. Chronic insomnia is associated with increased risks of major depression, hypertension, Alzheimer’s disease, and work disability.

Currently, treatment options for insomnia include prescribed and over-the-counter medications, psychological and behavioral therapies (cognitive behavioral therapy for insomnia [CBT-I]), and complementary and alternative therapies. While non-pharmaceutical CBT-I is the preferred method of treatment, medication is often used due to a lack of trained CBT-I therapists. CBT-I involves a combination of strategies aimed at changing the behavioral and psychological factors of patients and includes sleep scheduling, stimulus controls, relaxation methods, psychological and cognitive interventions, and sleep hygiene education. When faced with needing to begin medication for insomnia, clinicians usually prefer to start with OTC mediations, including melatonin and diphenhydramine (Benadryl, found in most OTC sleep aids).

Prescribing prescription medications for insomnia can often be a slippery slope, one many prescribers are wary of getting into. That is because medications have side effects, like daytime sleepiness (some prescriptions preclude next day driving and operating machinery), dependance (after using a prescribed sleep aid for a while, many people find that they cannot fall asleep without it), interactions with other medications, and the potential for abuse. Prescribed medications include benzodiazepines (Halcion, Restoril, Klonopin), non-benzodiazepines (Ambien, Sonata, Lunesta), dual orexin receptor agonists (Belsomra, Quviviq, Dayvigo), and sedating antidepressants (doxepin, trazodone, mirtazapine, and amitriptyline).

Many people with insomnia worry about falling asleep, which only exacerbates the situation. This is where CBT-I helps, if it is available, and is safer than medication. CBT-I focuses on maintaining regular sleep-wake times to strengthen circadian sleep regulation and cognitive exercises to lessen sleep-focused ruminations. Of course, if there is an underlying psychological or medical issue, that should be addressed as well.

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