Susan M. Harding, MD
Professor of Medicine
Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine
The University of Alabama at Birmingham
Birmingham, Alabama

Dr. Harding does not have any commercial affiliation to disclose.

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 0.25 AMA PRA Category 1 credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Insomnia is a common and vexing problem. A 2003 National Sleep Foundation poll found 48% to 73% of adults have transient insomnia, and 20% to 30% have chronic problems with the disorder (Sleep. 2005;28:1049-1057). Chronic insomnia is associated with a host of harmful medical conditions including mood disturbances, hypertension, and diabetes. Insomnia also is a cause of serious accidents and falls in the elderly.

“The brain is very active during sleep,” says UAB pulmonologist Susan M. Harding, MD, medical director of the UAB Sleep/Wake Disorders Center. “Moreover, a lack of sleep affects daily functioning and physical and mental health in ways we are just beginning to understand.”

Female gender and older age are significant risk factors for insomnia. Although the cause of increased prevalence in older individuals is not well understood, scientists believe the presence of age-related comorbid disorders and the partial decline in functionality of sleep control systems are important contributors.

Medical and psychiatric disorders and working night or rotating shifts increase risk for insomnia. While not independent causes, these factors may precipitate insomnia in individuals who are predisposed to it, Harding says.

In many individuals, chronic insomnia reduces quality of life to levels comparable to that seen in other chronic medical conditions. The high levels of morbidity associated with insomnia also contribute to its direct cost to society, which investigators estimate at more than $13 billion per year in the United States (Sleep. 1999;22[suppl2]:S386-393).

National Sleep Foundation's 2007 "Sleep in America" Poll

“Insomnia — the inability to obtain enough sleep or the feeling that sleep is not restorative — is a symptom, not a disease,” Harding says. “However, recently developed diagnostic criteria have led to the acknowledgment that insomnia is a disorder with important nocturnal and diurnal symptoms.”

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders separates insomnia into categories, defining primary insomnia as that in which the central feature is the inability to sleep. The diagnosis requires difficulty initiating or maintaining sleep or nonrestorative sleep for at least 1 month and clinically significant distress or impairment in daytime functioning (difficulty concentrating, irritability, or fatigue). Clinicians also need to rule out psychiatric, medical, and other sleep disorders as the cause of inadequate sleep. As many as 75% of depressed patients have sleep complaints, and depression is the most common disorder associated with insomnia characterized by early morning awakenings.

Behavioral insomnias include adjustment sleep disorder, inadequate sleep hygiene, limit-setting sleep disorder, and sleep-onset association.

Symptoms of insomnia come in different forms. “When patients first present they often just say, ‘I can’t sleep.’ So clinicians must tease out symptoms, triggers, sleep hygiene, and other sleep behaviors,” Harding says. “A sleep log, or some form of diary, is useful to begin looking at patterns of sleeplessness. Often patients have had insomnia for more than 10 years, and physicians have tried numerous medications before referral to a sleep medicine specialist.

“The disorder is diagnosed primarily by clinical evaluation, including a detailed medical, psychiatric, and sleep history, which includes assessment of sleep patterns and waking processes,” she says, noting polysomnography has limited use in diagnosing insomnia.

Newer therapeutic approaches aim to reverse various biologic and psychophysiologic aspects of insomnia, Harding says. “The key to successful management is discovering the underlying cause and contributory factors for an individual patient’s insomnia. This allows specific goal-directed therapy,” she says. “Management is often divided into behavioral and pharmacologic therapy, but these approaches are complementary, not mutually exclusive.”

Behavioral therapy can correct the maintaining factors that are so critical in insomnia and is an important intervention because the efficacy of medications often decreases over time.

Elements of behavioral therapy include stimulus control, sleep restriction, sleep hygiene, relaxation training, and cognitive therapy. Stimulus-control therapy restricts time in bed to sleep and sexual activity. Sleep-restriction therapy attempts to align the time in bed to the time the patient spends sleeping. Sleep hygiene refers to a variety of techniques based on knowledge of sleep homeostasis (no napping or oversleeping), sleep pharmacology (no alcohol or caffeine consumption in the evening), and circadian rhythm physiology (regular bedtime and waketime and no bright light exposure before bedtime).

Patients should be counseled to address environmental factors, including not allowing pets in the bedroom, refraining from stimulating activities in the bedroom (eg, working on a computer or watching television), and controlling noise, light, and temperature.

All patients with insomnia should practice behavioral therapy, Harding says. Several studies attest to its efficacy in insomnia management (J Clin Psychiatry. 2004;65[suppl16]:33-40). “Although behavioral modifications may be insufficient to resolve all sleep difficulties, they create a favorable environment for improving sleep,” she says.

There are many pharmacologic approaches for insomnia therapy. Patients often self-medicate with alcohol or over-the-counter sleep aids, such as diphenhydramine.

Diphenhydramine blocks release of histamine, a major neurotransmitter involved in maintaining wakefulness. Unfortunately the drug is relatively long acting, can produce daytime drowsiness, and loses its sleep-promoting properties with repeated use. Because diphenhydramine can result in anticholinergic side effects and mental confusion, it is contraindicated in elderly patients.

Although alcohol may help induce sleep, once metabolized it produces significant sleep disruption, including a decrease in REM sleep. “Avoiding alcohol, especially in the evening, is critical,” Harding says.

Prescription drugs used for insomnia include those with specific Food and Drug Administration (FDA) indications, and those used off label. FDA-approved insomnia medications include the benzodiazepines (estazolam, flurazepam, quazepam, temazepam, and triazolam), benzodiazepine receptor agonists (zaleplon, eszopiclone, and zolpidem), a nonbenzodiazepine hypnotic (zolpidem extended release), and a selective melatonin receptor agonist (ramelteon).

Benzodiazepines have significant potential for dependency. Benzodiazepine receptor agonists are costly and may not be covered by insurance. In April 2007 the FDA approved the first generic versions of immediate-release Ambien (zolpidem). All of these medications can be useful for short-term use while patients undergo behavioral therapy, Harding says.

Until 2005, all FDA-approved medications for insomnia came with indications for short-term use. Three newer options, eszopiclone, ramelteon, and zolpidem extended release, have no duration limit and may be appropriate for selected patients with chronic insomnia. “Such patients require regular monitoring and evaluation for continued benefit from the drugs,” Harding says.

Off-label pharmacological treatments include low-dose sedating antidepressants such as doxepin, mirtazapine, trazodone, and amitriptyline. “We know neither the minimally effective dose of various sedating antidepressants nor how long they retain their sleep-promoting effects,” she says.

In patients with chronic insomnia physicians should emphasize the importance of behavioral modifications; optimize treatment of comorbid conditions; and evaluate patients’ use of medications with potentially stimulating effects, including paradoxical stimulation from sedating drugs, an effect that is more common among the elderly.

“Insomnia is often a chronic sleep disorder. Effective behavioral and pharmacological treatments are available,” Harding says. “As we learn more about cellular and molecular mechanisms of wakefulness and sleep, we will have more to offer our patients.”

For more information:

Dr. Susan Harding
1-800-UAB-MIST
mist@uabmc.edu

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