Doctor Interview

An Interview with Dr S Nambi on "Medical Management of Insomnia"

Q1. What guidelines would you give for selection of therapy for insomnia?

Ans. Guidelines for selection of therapy for insomnia -

The choice of treatment depends on -

Diagnosis and duration of insomnia
Co morbid conditions including physical and psychiatric
Age of the Patient
Patient wish

Pharmacotherapy, psychological therapy and light therapy are among the important choices of treatment for insomnia. Pharmacotherapy is generally preferred in treating transient insomnia in non-substance-abusing young and middle-aged adults. In elderly with chronic insomnia, use of hypnotics, is a subject of considerable debate and there is no consensus at present. It is preferable to focus mainly on psychological therapy methods in this group of patients.

Q2. What are the different options in the medical management of insomnia?

Ans. One can choose from -

Benzodiazepines:They comprise the majority of all hypnotics currently prescribed. They have significant advantages over older drugs like barbiturates in that they are safer in overdose, less likely to cause tolerance, dependence, and withdrawal and have less abuse potential. Commonly encountered problems with benzodiazepines that are long acting, are day time drowsiness, memory impairment and interaction with other medicines (e.g.: Cyclic antidepressants, diuretics) Hence the shorter acting the drug the better. But abrupt discontinuation or if the patient forgets to take his dose, it can cause rebound insomnia and elevated daytime anxiety.
Imidazopyridines: (e.g.: Zolpidem) They bind selectively to a subset of benzodiazepine receptors named omega₁. They are less likely to produce tolerance and have less abuse potential. They are safe in overdose. Common side effects are drowsiness, dizziness, headache and gastrointestinal upset. Contraindicated in patients who have sleep apnea.
A3. Chloral hydrate: Used In the dose of 0.5mg to 2mg, common side effect is gastric irritation. Tolerance occurs rapidly and the dosage range is limited by its low therapeutic index. Contraindicated in those with known gastrointestinal inflammation and hepatic or renal disease.
Antidepressants and antipsychotics: Their use is discouraged in primary insomnia. They can be used only when insomnia is resulting from major depression or psychosis. They have anticholinergic side effects and have adverse effects on cardiac conduction. They also cause orthostatic hypotension and are extremely toxic in overdose. Trazodone is one exception and can be used in doses of 25-100mg to assist in sleep, especially at the beginning of treatment for major depression.
Over the counter sleep agents: The active ingredient in most OTC sleep agents is an antihistamine. They cause a sense of mental clouding and heavy headedness the next morning. They also have anticholinergic side effects.
Melatonin: It is not as efficacious as other hypnotics in the management of insomnia. The use of melatonin is controversial, and at best it may be useful for reducing sleep latency and to overcome jet lag.

Q3. When would you initiate therapy with sleep restoring agents?

Ans. The use of hypnotics should be restricted to managing short-term insomnia in relatively young individuals who do not have any contra-indicating conditions. It is wise to initiate drug therapy along with psychological therapy and to gradually taper and stop drugs.

Q4. While prescribing therapy for insomnia to the elderly patients what are the precautions to be taken?

Ans. Precaution to be taken while prescribing treatment for insomnia to elderly patients:

Start at a low dose.
Short acting agents without active metabolites to be preferred.
During initial assessment, history about use of over the counter drugs should be carefully enquired into because these drugs have additive effects when combined with other hypnotics.
A long-term use of sedative hypnotic agent would adversely affect sleep; the approach in treatment is to discontinue the medication.
If the sleep problem is secondary to a medical problem, the medical problem should be adequately controlled to improve sleep.

Q5. What are the principles of treatment of insomnia caused by co-morbid conditions?

Ans. The first step to be taken in the management of insomnia caused by co-morbid conditions is to accurately diagnose and manage the underlying disorder. Sleep hygiene measures should be initiated and hypnotics can be judiciously used for transient or short-term insomnia.

Hypnotics should not be used for patient with sleep apnea syndrome and drugs should be cautiously used in patients with renal/hepatic/pulmonary disease.

Q6. What are the guidelines for management of insomnia associated with psychiatric disorders?

Ans. Guidelines for management of insomnia associated with psychiatric disorders:

Patients with psychiatric disorders presenting with sleep problems should be evaluated carefully for primary sleep disorders or other medical causes of sleep problems since it should not be assumed that sleep disturbance only due to the underlying psychiatric illness.
If the sleep disturbance is due to the underlying psychiatric disorder, the following guidelines should be followed:

These patients could have poor sleep habits or lack social support or structure and they could be abusing substances, which further interfere with sleep.
Good sleep hygiene should be discussed with the patient.
Anxious patients/those with insomnia may benefit from relaxation training or stimulus control.
If there is co-morbid major depression it is preferable to use tricyclic antidepressant or trazodone, which have sedative effects.
In patients with psychotic symptoms, sedating antipsychotic drugs like phenothiazines could be used judiciously. But they should be carefully monitored for other side effects.

During initial assessment, history about use of over the counter drugs should be carefully enquired into because these drugs have additive effects when combined with other hypnotics.
A long-term use of sedative hypnotic agent would adversely affect sleep; the approach in treatment is to discontinue the medication.
If the sleep problem is secondary to a medical problem, the medical problem should be adequately controlled to improve sleep.

Q7. What is the general duration of medical therapy for insomnia? Does this therapy require tapering off of dose?

Ans. There is no specific guideline available for deciding on the exact duration of medical therapy for insomnia but it is preferable to keep the drugs for only a short duration. (About 4-6 weeks only)

When an individual is on medical therapy for insomnia the drugs should be tapered when deciding to stop. This is so because abrupt discontinuation leads to rebound insomnia and anxiety.

Q8. How can we compare pharmacologic therapy with psychotropic therapy in the management of insomnia?

Ans. Hypnotics, especially benzodiazepines are safe and effective in treating insomnia in non-substance-abusing young and middle-aged adults. But their use in chronic insomnia is controversial. Though the psychotherapeutic techniques are not immediately beneficial, are quite satisfactory in the long run. And those who succeed in learning these techniques effectively remain happy with maintenance treatment than when on chronic hypnotics. The benefits with these techniques are also sustained after 6 months.

Q9. What is the role of "Behavioral therapy" in the medical management of insomnia?

Ans. On the efficacy of cognitive behavior therapy, two meta - analyses have reported effect sizes of 0.87 for reduction in sleep latency, and significant effects have been found for number and duration of wakening (0.53-0.65) and sleep quality (0.94). A recent study concludes that 70-80% of patients benefit from cognitive behavioral therapy. Moreover the effect is durable over time, a feature notably lacking in the pharmacological literature on insomnia. Commonly used behavioral procedures are 'Stimulus control' and 'Sleep restriction', and cognitive strategies are 'Paradoxical intention' and 'Thought restructuring'.

Q10. What are the advantages of non-benzodiazepines over benzodiazepines in the treatment of insomnia?

Ans. Even though benzodiazepines are the most often prescribed drugs in the management of insomnia, there is considerable debate over their long-term use. Non-benzodiazepines like imidazopyridines, tricyclic antidepressants, trazodone and antipsychotics have many advantages like lack of development of tolerance over long term use, minimal or no abuse potential, minimal cognitive disturbance and lack of rebound insomnia/increase daytime anxiety on stopping drugs. Non-benzodiazepines should be preferred in elderly and in these with concomitant physical or psychiatric illnesses.

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