Insomnia medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Insomnia is a sleep disorder characterized by an inability to sleep and/or inability to remain asleep for a reasonable period. Insomniacs typically complain of being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and nonorganic insomnia constitute a sleep disorder.[1][2].Insomnia is a medical term for a sleep disorder, in which a person have difficulty with falling asleep, staying asleep or feeling unfresh in the morning because of poor sleep[3]. Insomnia is one of the frequently reported complaints in adult population, it is reported that 30-40% of the adult population is the US have insomnia[4]. The DSM-V Diagnostic Criteria for Insomnia Disorder is, difficulty with sleep for at least three days per week for consecutive three months.
Medical Therapy
Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.
In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was insignificantly more than for antidepressants.[1] Benzodiazepines had an insignificant tendency for more adverse drug reactions.[1]
Benzodiazepines
The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABAA receptor.[1] This includes drugs such as temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long periods of time.
Non-benzodiazepines
Nonbenzodiazepine prescription drugs, including the nonbenzodiazepines zolpidem(Stilnoct) and zopiclone(Imovane), are more selective for the GABAA receptor[1] and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence, and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.
| Treatment | Outcome at 6 months | |
|---|---|---|
| Responders | Remitters | |
| 6 weeks of CBT | 55% | 40% |
| 6 months of CBT | 63% | 44% |
| 6 months of CBT 6 weeks of zolpidem |
81% | 68% |
| 6 months of CBT 6 months of zolpidem |
65% | 42% |
| Adapted from Table 4 of Morin et al.[2] | ||
Antidepressants
Some antidepressants such as mirtazapine, trazodone and doxepin have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture.
Melatonin
Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation.
Antihistamines
The antihistamine diphenhydramine is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.
Atypical antipsychotics
Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.
Herbal medicines
Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.[3][4][5]
Other substances
Cannabis has also been suggested as a very effective treatment for insomnia. [6]
Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.
Insomnia may be a symptom of magnesium deficiency, or lower magnesium levels. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.[7]
Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal. [8]
References
- ↑ 1.0 1.1 1.2 1.3 Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007 Sep;22(9):1335-50. Epub 2007 Jul 10. PMID 17619935
- ↑ 2.0 2.1 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C; et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial". JAMA. 301 (19): 2005–15. doi:10.1001/jama.2009.682. PMID 19454639.
- ↑ Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I (2000). "Critical evaluation of the effect of valerian extract on sleep structure and sleep quality". Pharmacopsychiatry. 33 (2): 47–53. PMID 10761819.
- ↑ Morin CM, Koetter U, Bastien C, Ware JC, Wooten V (2005). "Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial". Sleep. 28 (11): 1465–71. PMID 16335333.
- ↑ Meolie AL, Rosen C, Kristo D; et al. (2005). "Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence". Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 1 (2): 173–87. PMID 17561634.
- ↑ http://www.cannabis.net/medical-marijuana/pot-docs.html
- ↑ Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann D (1998). "Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study". Sleep. 21 (5): 501–5. PMID 9703590.
- ↑ "Cider Vinegar and Insomnia".