First Glance

Whenever a specific cause for insomnia is found, that cause is treated first. If restless legs are the culprit, appropriate drug may be prescribed. If marital discord maintains insomnia, counseling may be the treatment of choice, and so on.
The treatment depends on the type of insomnia.

Acute Insomnia

If the insomnia has lasted only a few days or weeks, one determines its cause to prevent the acute insomnia from developing into a chronic one. Once that cause is dealt with, hypnotic agents are the treatment of choice. Acute insomniacs are expected to sleep well again within a few days or weeks, making questions of drug tolerance and withdrawal less salient. In addition, behavioral techniques often take weeks to become effective-- too slow for acute insomnia. It even seems reasonable to consider the prophylactic use of sleep restoring agents--e.g., if a patient typically has insomnia before important meetings or associated with jet lag.

Chronic Insomnia

The longer the insomnia lasts, the more important the behavioral therapies become. The more chronic the insomnia, the more important are the various learned perpetuating factors. Issues of drug tolerance and rebound may also become important. Sleep restoring agents are generally I prescribed. Sleeping pills are less appropriate in chronic insomnia than in acute insomnia.

Treatment of insomnia includes

Pharmacological treatment

A number of agents are available for the pharmacological treatment of insomnia.
The ideal sleep restoring agent should:

The pharmacological agents used in therapy include

Benzodiazepines: Benzodiazepines until recently, were the only sleep restoring agents of choice for insomnia. They differ mainly by the speed of absorption and their elimination half-life. The main worry when prescribing benzodiazepines is the development of tolerance and the possibility of rebound insomnia when the agent is withdrawn. That involves physical dependence, laboratory-documented withdrawal phenomena, and psychological issues.
The following benzodiazepines are approved as sleep restoring agents:

The commonly used bezodiazepines include: nitrazepam, diazepam, alprazolapam.

Newer, nonbenzodiazepine sleep restoring agents: Because of the concern about habituation to benzodiazepines, there is a new search for nonbenzodiazepine sleep restoring agents. These include:
Zopiclone - a cyclopyrralone derivative, which acts on the GABAa-benzodiazepine receptors and produces conformational changes different from benzodiazepines. It is rapidly absorbed with peak plasma levels occurring at 0.5 to 2 hours.
Zolpidem, - an imidazopyridine with a mean elimination half-life of about 2.5 hours. That makes it an ideal drug for problems with sleep onset.

Antidepressants as sleep restoring agents: Antidepressants with sedative side effects have increasingly been used as sleep restoring agents. They appear to habituate to a much lesser degree than benzodiazepines. Typically, they are prescribed in very low doses. Unfortunately, very little research on their sleep restoring efficacy is available.
Among the antidepressants, amitriptyline is often used because of its very strong sedating effects. Doses of 10 or 25 mg are often sufficient to improve sleep. A recent study documents that doxepin, in doses of 25 mg or less, may also be effective. In about one fifth of the 43 patients studied, even doses of fewer than 3 mg seemed effective. Especially with the amitriptyline, however, daytime sedation may be severe during the first 2 or 3 days following nighttime administration. In addition, tricyclics are known to aggravate periodic limb movements and restless legs, even at very low doses. As a result, trazodone, in doses of 25 or 50 mg, is frequently prescribed. This medication seems to have sleep-inducing properties similar to many of the tricyclics without aggravating periodic limb movements and restless legs.

Antihistamines: (e.g., diphenhydramine) are rarely indicated in the treatment of insomnia, mainly because their benefit -to-side-effect ratio is much worse than that of either benzodiazepines or antidepressants.

Melatonin: Melatonin is an indole-amine secreted by the pineal gland at night. It is clearly implicated in the regulation of the sleep/wake cycle and therefore is useful in treating jet lag. It is frequently suggested in the lay press as a sleep restoring agent.

Non Pharmacological treatment

The treatment of insomnia with non pharmacological methods include:

Behavioral Therapy
Behavioral therapy is the treatment of choice for psychophysiologic insomnia,idiopathic insomnia and patients with inadequate sleep hygiene. It serves as adjunctive therapy in most other chronic insomnias, such as those secondary to psychiatric or medical illness. Behavioral therapies work about equally well for difficulties in falling asleep, mid sleep awakenings, and early morning awakenings.
Some behavioral techniques, such as sleep hygiene, exposure to bright light, can be undertaken concomitantly with drug treatment for insomnia.

Sleep hygine: compromises techniques that promote good sleep architecture. These include

Bright Light Therapy: Bright light changes the timing of the sleep/wake (circadian) rhythm. Bright light traditionally has been used mainly to treat patients with delayed or advanced sleep phase syndrome.

Relaxation Therapy There are different kinds of tension--anxiety (psychological tension), muscular tension, and sympathetic arousal. Relaxation techniques need to be tailored to the specific type of tension the patient experiences. Relaxation techniques such as yoga can be tried to relieve tension, mental and physical.

Sleep Curtailment This treatment is based on the fact that, even in insomniacs, sleep become more “robust” as a result of sleep deprivation. That means that even insomniacs fall asleep faster and show fewer awakenings, more stage 3 and 4 sleep , and longer total sleep time after a night of no sleep at all. The improvement is short lived, however-- one or two nights. Sleep restriction therapy was designed to exploit the consequences of sleep loss for enhancing natural sleep while temporarily accepting daytime sleepiness as a side effect.

The following six steps are explained to the patient:

Conclusion

Understanding and treating insomnia is clearly more complex than initially assumed. In the hands of a skilled clinician, however, many causes of insomnia can be determined with confidence.

Treatment is considerably more sophisticated now than it was 20 years ago, and involves both improved hypnotic agents and a discussion of sleep hygiene and the use of behavioral therapies. These therapies have demonstrated clinically significant effects in a majority of insomniacs.