Ms. H, age 53, has a 20-year history of recurrent major depressive disorder. She seeks treatment for insomnia; her primary complaint is that “no medicine has really ever helped me to sleep for very long.” She reports that every night she experiences a 2-hour sleep onset delay and an average of 5 awakenings that last 10 to 60 minutes each. Her mood is stable.
After failed trials of zolpidem, mirtazapine, amitriptyline, and sertraline plus trazodone, she improves with quetiapine, 50 mg at bedtime, plus sertraline, 150 mg at bedtime. Unfortunately, over the next 6 months Ms. H gains 20 pounds and her physician becomes concerned about her fasting serum glucose levels, which suggest borderline diabetes.
After Ms. H discontinues quetiapine, onset and maintenance insomnia remain clinically significant. Polysomnography reveals moderately loud snoring, a normal respiratory disturbance index of 4.5 per hour, no periodic leg movements of sleep, 32-minute sleep onset, total sleep time of 389 minutes (6.5 hours), and a sleep efficiency of 72%. Ms. H estimates that it took her 120 minutes to fall asleep and that she slept only 270 minutes (4.5 hours) of the 540 minutes (9 hours) in bed. The sleep specialist recommends cognitive-behavioral therapy for insomnia.
For some chronic insomnia patients—such as Ms. H—pharmacotherapy is ineffective or causes intolerable side effects. In any year, >50% of adults in the general population report experiencing difficulty falling asleep, staying asleep, early awakening, or poorly restorative sleep, but these symptoms are usually time-limited and have only a small impact on daytime alertness and function. Chronic insomnia, on the other hand, lasts ≥1 month and has substantial impact on daytime alertness and attention, cognitive function, depressed and anxious mood, and focused performance (Box).1
Medications used to treat insomnia include FDA-approved drugs such as eszopiclone and zolpidem and off-label agents such as mirtazapine and trazodone. The cognitive, behavioral, and other nonpharmacologic therapies described below can be effective options, either alone or in combination with medication.
Chronic insomnia: Clock watching by the numbers
One in 10 adults in industrialized nations experiences chronic insomnia. Women are affected twice as often as men, with higher rates also reported in older patients and those in lower socioeconomic groups.
Among adults with chronic insomnia, 35% to 45% have psychiatric comorbidities, such as anxiety or mood disorders, and 15% have primary insomnia—sleep disturbance with no identifiable cause, which traditional medical literature described as conditioned or psychophysiologic insomnia.
In the remaining cases, chronic insomnia is associated with:
- medical and sleep disorders (restless legs syndrome, periodic leg movements of sleep, and sleep apnea)
- general medical disorders, particularly those that cause pain
- use of medications that disrupt normal CNS sleep mechanisms.
Source: Reference 1
Assessing insomnia
Start by performing a thorough assessment and history. I have described this process in previous reviews,1,2 as has Neubauer in Current Psychiatry.3
Before initiating therapy for insomnia, assess and address the following:
- significant ongoing depression, mania, hypomania, generalized anxiety, panic, or obsessive-compulsive symptoms that impact sleep
- primary medical disorders of sleep, including restless legs syndrome, increased motor activity during sleep such as periodic leg movements of sleep, and the snoring/snorting of sleep apnea
- prescribed or self-administered medications or substances that can disrupt sleep, such as alcohol, caffeine, stimulants, corticosteroids, or beta blockers.
Recommended nondrug therapies
In 2006, the Standards of Practice Committee of the American Academy of Sleep Medicine (AASM) updated a comprehensive literature review of psychological and behavioral treatments of primary and secondary insomnia. On the basis of this peer-reviewed, graded evidence, the AASM recommended:
- stimulus control therapy
- relaxation training
- cognitive-behavioral therapy for insomnia (CBTi).4
The AASM also offered guidelines for sleep restriction therapy, multi-component therapy without cognitive therapy, paradoxical intention, and biofeedback. Evidence for sleep hygiene, imaging training, or cognitive therapy alone was insufficient, and the AASM neither recommended nor excluded these methods. Psychological and behavioral interventions were considered effective for treating insomnia in older adults and patients withdrawing from hypnotics.
Stimulus control therapy. Bootzin et al5 first evaluated stimulus control therapy for conditioned insomnia (subsequently identified as primary insomnia). This therapy’s goal is to interrupt the conditioned activation that occurs at bedtime. Patients are instructed to:
- go to bed when sleepy
- remain in bed for no more than 10 minutes (20 minutes if elderly) without sleeping
- if unable to sleep, get up, do something boring, and return to bed only when sleepy
- repeat getting up and returning as frequently as necessary until sleep onset.
For the first 2 weeks of stimulus control therapy, patients are required to self-monitor their sleep behaviors using a sleep diary. Stimulus control therapy is beneficial for primary insomnia and insomnia related to anxious preoccupation. About 70% of patients with conditioned insomnia will improve using stimulus control therapy,4 but it is not clear whether the primary effective intervention is: