eMedicine Specialties > Psychiatry > Psychosomatic
Sleep Disorders: Treatment & Medication
Updated: May 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Evaluate patients for other primary sleep disorders (eg, sleep apnea); the impact of prescribed medication; and underlying medical, psychiatric, and substance abuse disorders. Teach good sleep hygiene. If necessary, consider medication.
- Educating the patient on good sleep hygiene is the center of treatment.
- Use the bed for sleep and sex only (no television watching or reading in bed).
- Avoid caffeine, especially late in the day. Avoid activities that will get you stimulated and upset late in the day. Practice relaxation techniques before bedtime.
- Exercise each day.
- Maintain a regular schedule for bedtime and wakening; avoid naps.
- Do not watch the clock while in bed. Avoid struggling to fall asleep in bed. Instead, get up and spend quiet time out of bed until sleep comes.
- Sleep apnea can be helped by losing weight, the use of continuous positive airway pressure, and sometimes surgery.
- If someone sleep walks you may need to take steps to prevent them from accidentally hurting themselves at night by walking into things or out of the house.
- Light-phase shift therapy is useful for sleep disturbances associated with circadian rhythm abnormalities. Patients may be exposed to bright light, from either a light box or natural sunlight, to help normalize the sleep schedule.
- Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. Morin et al studied 160 adults with persistent insomnia and demonstrated that CBT used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P <0.001). Combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P = .05). Long-term outcome was optimized when medication is discontinued during maintenance CBT.2
Surgical Care
Surgical referral may be indicated to correct some underlying medical conditions that cause insomnia, such as for palate surgery in some cases of sleep apnea.
Consultations
Consultation can help evaluate patients for medical (including psychiatric) causes of insomnia. The evaluation team optimally should include a psychiatrist, neurologist, pulmonologist, sleep medicine specialist, and dietitian.
Diet
- No special diet is needed to treat insomnia, but large meals and spicy foods should be avoided in the 3 hours before bedtime.
- Patients should avoid sleep-disturbing substances such as alcohol, nicotine, and caffeine. Alcohol creates the illusion of good sleep, but sleep architecture is affected adversely. Nicotine and caffeine are stimulating and should be avoided in the second half of the day, from late afternoon on.
- Consumption of tryptophan-containing foods may help induce sleep. The classic example is warm milk.
Activity
- Strenuous exercise during the day may promote better sleep, but this same exercise during the 3 hours before bedtime can cause initial insomnia.
- Stimulating activities should be avoided 3 hours before bedtime. Examples include tense movies, exciting novels, thrilling television shows, arguments, and vigorous physical exercise other than coitus.
Medication
Many agents are useful in treating insomnia. Short-term drug therapy is preferred to restore a normal sleep pattern. Generally, hypnotic drugs are approved for 2 weeks or less of continuous use. In chronic insomnia, longer courses may be indicated, which require long-term monitoring to ensure ongoing appropriate use of the medication.
Barbiturates and chloral hydrate are seldom used now because of safety concerns related to their undesirably low therapeutic indexes.
Drugs that block the histamine type 1 receptor are used primarily in over-the-counter preparations, are inexpensive, and are helpful to some patients. However, in view of the anticholinergic properties of these agents, caution should be exercised in their use with older patients and with those who have disorders such as prostatic hypertrophy, cognitive disorders, and constipation. In addition, most of these drugs have a long duration of action, and their sedative effects may persist well into the following day.
Zolpidem (Ambien) and zaleplon3 (Sonata) are the newest and, arguably, the safest agents that are US Food and Drug Administration (FDA) approved for short-term hypnotic use. Zolpidem (Ambien CR) has recently released an extended-release version that lasts slightly longer than the original preparation. In addition, the FDA recently approved the new agent eszopiclone (Lunesta) as the first agent for long-term use in the management of chronic insomnia.
Benzodiazepines
Benzodiazepine receptor agonists are the mainstay in treatment of insomnia. Flurazepam, temazepam, quazepam, estazolam, and triazolam are the benzodiazepines that are approved by the US Food and Drug Administration as hypnotics.
These drugs bind to a special benzodiazepine site on the GABA receptor complex, enhancing activity of this neurotransmitter. All have variable half-lives and different metabolites that affect their onset and duration of action. This class of drugs suppresses REM sleep and reduces stages 3 and 4 sleep while increasing stage 2 sleep. The drug described here, temazepam, is only one example of this class of medications. A more detailed discussion of the other agents in this class can be found elsewhere in the text.
Temazepam (Restoril)
Intermediate rate of absorption and duration of action make this drug useful for treating initial and middle insomnia. Has no active metabolite, which reduces cognitive impairment and grogginess the following day.
Adult
15-30 mg PO qhs
Pediatric
Not established
Cimetidine, disulfiram, isoniazid, and estrogen increase plasma levels of benzodiazepines; benzodiazepines may increase levels of digoxin and phenytoin; alcohol and other sedating drugs have additive effects with benzodiazepines
Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive sleep apnea; history of substance abuse; severe uncontrolled pain
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in chronic respiratory or hepatic disease and in elderly patients; avoid in individuals with history of substance abuse; effect of respiratory compromise more pronounced when ingested with alcohol; may have associated tolerance, dependence, daytime sedation/hangover effect, and withdrawal syndromes; long-term use may result in cognitive dysfunction and rebound insomnia when discontinued
Imidazopyridine
Zolpidem is the sole member of this class of medications. It binds at a benzodiazepine receptor subtype (omega I). Found more in CNS more than in peripheral nervous system, which helps to account for hypnotic effect with no significant muscle-relaxant properties. Unlike benzodiazepines, normal sleep architecture not suppressed.
Zolpidem (Ambien)
Rapidly absorbed, with fast onset (20-30 min) of action, which makes this a good drug for sleep induction. Decreases sleep latency and increases duration of sleep.
Adult
5-20 mg PO qhs
Pediatric
Not established
Increases toxicity of alcohol and other CNS depressants
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Decrease dose to 5 mg in patients who are elderly or debilitated because of greater possibility of impaired motor and/or cognitive difficulties; not recommended in breastfeeding mothers (drug excreted in milk)
Caution with pulmonary dysfunction
Pyrazolopyrimidine
Zaleplon is the sole agent in this class of nonbenzodiazepine hypnotics.
Zaleplon (Sonata)
Not structurally related to benzodiazepines, barbiturates, or other drugs with known hypnotic properties. Interacts with GABA-benzodiazepine receptor complex, causing effects in sedation. Should be taken immediately before bedtime.
Decreases time to sleep onset. Shorter onset of action means peak serum concentrations achieved within 1 h of administration. This may account for lower incidence of daytime grogginess and less withdrawal rebound insomnia.
Adult
10 mg PO qhs; dose may be halved or doubled depending on patient weight and/or response to drug
Pediatric
Not established
May interact with drugs metabolized by aldehyde oxidase and CYP3A4, including diphenhydramine and cimetidine; cimetidine significantly increases levels of zaleplon; may enhance response to alcohol, barbiturates, and other CNS depressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Taking drug while still awake and active may cause hallucination, short-term memory impairment, impaired coordination, light-headedness, and dizziness; failure of insomnia to remit after 7-10 d of treatment may indicate need for evaluation for primary psychiatric or medical illness; limit treatment to 7-10 d and reevaluate patient if drug to be taken for >2-3 wk (do not prescribe zaleplon in quantities exceeding 1-mo supply); in hepatic function impairment, reduce dose to 5 mg PO hs; caution in patients exhibiting signs or symptoms of depression
Pyrrolopyrazine
This is another nonbenzodiazepine sedative/hypnotic drug class indicated to improve sleep onset and maintenance.
Eszopiclone (Lunesta)
Nonbenzodiazepine hypnotic pyrrolopyrazine derivative of the cyclopyrrolone class. The precise mechanism of action is unknown but is believed to interact with GABA-receptor at binding domains close to or allosterically coupled to benzodiazepine receptors. Indicated for insomnia to decrease sleep latency and improve sleep maintenance. Short half-life of 6 h. Higher doses (ie, 2 mg for elderly adults and 3 mg for nonelderly adults) are more effective for sleep maintenance, whereas lower doses (ie, 1 mg for elderly adults and 2 mg for nonelderly adults) are suitable for difficulty in falling asleep.
Decreases sleep latency and improves sleep maintenance.
Adult
Nonelderly adults: 2 mg PO hs; may increase to 3 mg PO hs prn
Elderly adults: 1 mg PO hs initially; not to exceed 2 mg PO hs
Severe hepatic impairment: Do not exceed 2 mg PO hs
Pediatric
<18 years: Not established
>18 years: Administer as in adults
CYP3A4 and CYP2E1 substrate; potent CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin, nefazodone, ritonavir, nelfinavir) increase AUC, Cmax, and t1/2 and therefore potential toxicity (decrease dose); potent CYP3A4 inducers (eg, rifampicin) increase clearance; coadministration with alcohol or other CNS depressants may increase effect and toxicity (decrease dose); coadministration with olanzapine may decrease DSST scores; sleep onset may be delayed if taken with or immediately after a high-fat or heavy meal
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause dysgeusia, headache, or coldlike symptoms; rare adverse effects associated with hypnotics include short-term amnesia, confusion, agitation, hallucinations, worsened depression, or suicidal thoughts; high doses (ie, 6-12 mg) produce euphoric effects similar to those of diazepam 20 mg; anxiety, abnormal dreams, nausea, and upset stomach may occur within 48 h after discontinuing; alertness may be affected the following day, use caution while operating machinery or driving a car
Melatonin receptor agonist
Ramelteon is the first and only nonscheduled insomnia medication with a novel mechanism of action.
Ramelteon (Rozerem)
Melatonin receptor agonist with high selectivity for human melatonin MT1 and MT2 receptors. MT1 and MT2 are thought to promote sleep and be involved in maintenance of circadian rhythm and normal sleep-wake cycle. Indicated for insomnia characterized by difficulty with sleep onset.
Adult
8 mg PO 30 min before bedtime on empty stomach
Pediatric
Not established
Major substrate of cytochrome P450 CYP1A2 and minor substrate of CYP2C and CYP3A4; strong CYP1A2 inhibitors (eg, fluvoxamine) increase AUC up to 190-fold and Cmax 70-fold; strong CYP inducers (eg, rifampin) decrease total exposure by mean of 80%; strong CYP3A4 inhibitors (eg, ketoconazole) and strong CYP2C9 inhibitors (eg, fluconazole) may increase serum levels
Documented hypersensitivity; strong cytochrome P450 CYP1A2 inhibitors (eg, fluvoxamine); severe hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in mild hepatic impairment; adverse effects that led to discontinuation in clinical trials included dizziness, nausea, fatigue, headache, and worsening insomnia; has been associated with decreased testosterone levels and increased prolactin levels (changes related to these hormones should be carefully monitored)
Antidepressants
Although no antidepressants are approved specifically for use in the treatment of sleep disorders, a cyclic antidepressant, trazodone (Desyrel), is used routinely for this purpose.
Trazodone (Desyrel)
Mechanism of action not fully understood. Thought to selectively inhibit serotonin uptake by brain synaptosomes and potentiate behavioral changes induced by serotonin precursor, 5-HT. Major adverse effect is sedation.
Adult
Starting dose: 50 mg PO qhs
Usual dose range for insomnia: 50-100 mg, PO but up to 300 mg may be needed; not to exceed 400 mg
Pediatric
Not established
May enhance response to alcohol, barbiturates, and other CNS depressants; may decrease hypoprothrombinemic effects of warfarin; digoxin and phenytoin serum levels may increase with concomitant trazodone
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypotension has occurred, including orthostatic hypotension and syncope; may produce drowsiness, dizziness, or blurred vision; observe caution while driving or performing other tasks requiring alertness, coordination, or dexterity; priapism reported in patients taking trazodone; patients with prolonged or inappropriate penile erection should immediately seek emergency medical treatment and discontinue drug
More on Sleep Disorders |
| Overview: Sleep Disorders |
| Differential Diagnoses & Workup: Sleep Disorders |
 Treatment & Medication: Sleep Disorders |
| Follow-up: Sleep Disorders |
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References
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Further Reading
Keywords
sleep disorders, primary sleep disorders, disorders of initiating and maintaining sleep, DIMS, dyssomnias, insomnia, parasomnias, sleep-wake cycle disturbances, sleep apnea, obstructive sleep apnea, OSA, REM sleep, non-REM sleep, polysomnography, sleep maintenance, sleep onset, circadian rhythm, circadian cycle, nightmare, sleepwalk, sleepwalking, hypersomnia, narcolepsy, somnambulism
