Southeast Houston Sleep Medicine

INSOMNIA

Insomnia is one of the most common medical conditions seen in the
United States. According to a recent survey of Americans, 19% comp-
lain of chronic insomnia and 50% complain of occasional insomnia
. As many as 10% of patients seen in primary care offices list insomnia as one of their complaints.

The American Academy of Sleep Medicine defines insomnia when three specific criteria are met:

  • Difficulty initiating sleep, maintaining sleep, or waking up too early.
  • Daytime fatigue, abnormalities of mood, sleepiness, tension, or poor concentration.
  • Adequate opportunity to sleep.

Primary insomnia is sleeplessness that cannot be attributed to an existing medical or psychiatric cause. Secondary insomnia results from medical conditions such as respiratory or neurological disease. Insomnia can also be related to psychiatric conditions, such as anxiety, depression, or bipolar disorder.

The treatment of insomnia involves more than just medications. If the insomnia is secondary to a medical illness or a psychiatric condition, addressing the underlying cause may correct it. Physicians also use cognitive behavioral therapy as a method of treatment. This approach requires decreasing any disturbing stimuli at night such as loud noises or bright lights. In addition, doctors will ask patients to stay on a regular schedule by going to bed at the same time every night and waking up at the same time every morning. It is important to avoid daytime naps and to go to bed only when feeling sleepy.

Patients prone to insomnia should use the bed only for sleep or sex. They should avoid using the bed for activities such as reading, studying, playing video games, eating or watching television. In this way, the mind will learn to associate the bed mainly with sleep.

Cognitive behavioral therapy can require some sleep restriction. In general, patients will be instructed to set the alarm clock and force themselves to wake up at a certain time each day. As a result, they will feel ready to fall asleep at bedtime.

If behavioral management fails, medications can be used to treat insomnia. A hormone naturally produced by the pineal gland called melatonin can help regulate the sleep-wake cycle. By taking a small amount about an hour before scheduled sleep, insomnia can be treated without risking many of the side effects of addictive medicines. Other possible medications include benzodiazepines such as Restoril, Klonopin, or Ativan. Another class of medications called nonbenzodiazepine receptor antagonists acts at the same sites in the brain as benzodiazepines, but have different chemical structures and side effects. These medications include Ambien, Lunesta, and Sonata.

In general, Sonata is probably the best choice among these medications. The effects of Lunesta last a long time, and patients are often groggy and sleepy the next day. Ambien has been associated with adverse side effects such as sleepwalking, making phone calls or eating with no memory of doing so. Ambien has some addictive potential as well.

Many psychiatrists and sleep specialists use an antidepressant called trazodone to treat insomnia, as it does not suppress REM sleep the way benzodiazepines and barbiturates do. Although barbiturates such as phenobarbital were used as sleep aids in the 1960s and 1970s, they are no longer commonly prescribed because of their addictive potential. In addition, they can be lethal if mixed with alcohol and antidepressants.

Alcohol should be avoided as a sleep aid. Although patients may be tempted to use it as a “nightcap,” because it is readily available, the effects of alcohol do not last long enough to keep people asleep throughout the entire night. Consequently, patients trying to use alcohol to help them sleep often wake up very early in the morning without adequate rest. In addition, alcohol suppresses REM sleep which contributes to daytime drowsiness and fatigue.