Session Discusses Effective Insomnia Management

San Diego—Insomnia is prevalent in the general population and quite common among people with mental health disorders. Approximately 50 to 70 million Americans suffer from chronic sleep disorders that adversely affect daily functioning, health, and longevity.

During a scientific session at the Psych Congress meeting, David Neubauer, MD, associate professor, Johns Hopkins University School of Medicine, Baltimore, Maryland, discussed insomnia during his presentation titled Implementing Effective Insomnia Management: Important Issues in Evaluation and Treatment. The session focused on diagnosing insomnia, common challenges in evaluating patients with sleep disturbances, key advantages and disadvantages of the major treatment options, and consensus on clinical guidelines.

Understanding that the primary factors that regulate the sleep/wake cycle are homeostatic and circadian will help clinicians assess sleep problems in patients, explained Dr. Neubauer. Furthermore, clinicians should consider comorbid psychiatric conditions, comorbid obstructive sleep apnea, and comorbid circadian rhythm sleep disorders when evaluating insomnia in patients. Possible factors that may cause insomnia include situational disturbances, psychological conditioning, poor sleep habits, psychiatric disorders, medication effects, and genetics.

Dr. Neubauer continued his presentation with a review of insomnia treatment options. In addition to education and sleep hygiene measures, behavioral and cognitive therapy techniques and pharmacotherapy are options for insomnia management. Cognitive behavioral therapy for insomnia (CBT-I) involves a cognitive approach and at least one behavioral strategy. CBT-I components include: (1) cognitive behavioral strategies; (2) sleep restriction therapy; (3) stimulus control therapy; (4) relaxation therapy; and (5) sleep hygiene education and rules.

Dr. Neubauer addressed 3 of the components during his presentation. Developed in the 1980s by Arthur Spielman, sleep restriction therapy promotes rapid sleep onset, sustained and deeper sleep, and circadian rhythm reinforcement. Stimulus control therapy, developed by Richard Bootzin in the 1970s, addresses the reinforced association between the bed, bedroom, and attempts to fall asleep in relation to excessive arousal, prolonged wakefulness, and frustration.

The goal of relaxation therapy is to decrease somatic and cognitive arousal that may interfere with sleep. Progressive muscle relaxation, guided imagery, and abdominal breathing are techniques patients can practice at other times before using them at bedtime.

FDA-approved insomnia treatment medications include benzodiazepine receptor agonist hypnotics, selective melatonin receptor agonists, and selective histamine H1 receptor agonists. “Make prescribing decisions based on pharmacodynamics and pharmacokinetics,” Dr. Neubauer said.

Examples of off-label prescription medications include antidepressants, antipsychotics, antihypertensives, and anticonvulsants/mood stabilizers. Dr. Neubauer said one of the issues associated with these medications is the efficacy and safety profile for insomnia patients. Over-the-counter (OTC) sleep aids are regulated by the FDA and include antihistamines. These medications are available alone or combined with analgesics. Potential adverse effects with antihistamines include next day residual sedation and anticholinergic effects.

Dr. Neubauer concluded the presentation by highlighting the American Academy of Sleep Medicine chronic insomnia clinical guideline recommendations: (1) short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible; (2) OTC antihistamine as well as herbal and nutritional substances are not recommended in the treatment of chronic insomnia due to the relative lack of efficacy and safety data; (3) older approved drugs for insomnia including barbiturates, barbiturate-type drugs, and chloral hydrate are not recommended for the treatment of insomnia; (4) patients should be followed on a regular basis, every few weeks in the initial period of treatment when possible; (5) efforts should be made to employ the lowest effective maintenance dosage of medication and to taper medication when conditions allow; (6) chronic hypnotic medication may be indicated for long-term use in those with severe or refractory insomnia or chronic comorbid illness; and (7) long-term use may be nightly, intermittent, or as needed.