How is insomnia treated?

Diagnosing insomnia is a very detail-intensive process, and for good reason. Effective treatment measures depend on the comprehensive detail which is acquired during the evaluation and / or testing process.

The effective management of insomnia may involve various other challenges which could impact treatment. Challenges may not only relate to the patient alone. Many physicians have only basic knowledge and training regarding certain sleep disorders and the overall impact they have on a person’s quality of life. Knowledge of treatment efficacy may also be basic. Thus, a doctor may prefer to refer a patient to another physician or specialist with more experience in diagnosing and treating sleep disorders or sleep-related conditions, like insomnia.

Once insomnia is diagnosed, the primary goals of treatment will be to:

• Improve a person’s quality of sleep (and thus help to create more sustainably healthy sleep patterns).
• Improve a person’s ability to function sufficiently during the day.

A doctor may not implement much medical treatment for acute insomnia. If the condition is mild, sometimes all that is needed is an adjustment of sleeping habits. If underlying stressors contribute to poor daily functioning, medical interventions, even during the short-term, may be beneficial. For the most part, treatment plans are dependent on the patient’s underlying issues, challenges or conditions.

Typically, insomnia becomes a little trickier when it co-exists with other medical or psychiatric conditions. The general rule of thumb is that if a person presents comorbid results, specifically related to a medical, psychiatric, neurological or other sleep disorder, a diagnosing doctor will generally direct primary care treatment at the co-existing condition. For instance, if physical pain is determined as the primary reason for sleep disturbance, this condition will be treated first to see if insomnia resolves thereafter.

If a psychiatric disorder is identified as an underlying or comorbid condition, treatment is likely to involve pharmacological interventions, as well as psychotherapy (and the affected person will be referred to an appropriate mental health specialist).

Variable degrees of insomnia can still occur even when a co-existing disorder receives effective treatment. Additional treatment measures will then be implemented to further reduce the persistency of insomnia symptoms, thus treating all related health problems.

Insomnia that is primarily triggered by a substance can be alleviated over the long term by initiating a withdrawal or tapering off of any medication, drug or other substance responsible for the condition in a controlled manner. While insomnia may remain a challenge during the initial stages of withdrawal and recovery from substance abuse and continue for a few months once the process is complete, it will generally resolve in the long term. ^{(21)  (22)} Professionally prescribed, medical management of insomnia during this process is therefore helpful in achieving recovery and a long-term resolution of the condition.

The general guideline in treating insomnia is that behavioural, psychological and pharmacological (medication) interventions are the most beneficial, particularly if insomnia is chronic. Such medical interventions are considered the correct initial therapeutic approach, along with educating an affected person about their sleep problem and what kinds of sleep hygiene methods are likely to help contribute to achieving better quality sleep.

Behavioural / psychological (non-pharmacological) intervention does have highly beneficial long-term treatment results for insomnia and is considered a very well suited first-line treatment for insomnia, particularly primary insomnia – due to the combination of physiological, cognitive arousal and conditioning, and emotional influences on the condition.

1. Medical treatment

Options which are available include cognitive and behavioural therapies, as well as pharmacological treatments:

Cognitive behavioural therapy (CBT)

This therapy approach is tailored to help alleviate the perpetuating factors of chronic insomnia – like poor sleep habits and hygiene, irregular sleep routines or schedules, and hyperarousal, as well as address any notable sleep misconceptions a patient may have.

Considered most effective in the treatment of primary, a doctor may still recommend CBT as adjunctive therapy where co-existing conditions are present too.

It has been shown through clinical study that CBT has significantly positive effects on:

• Sleep latency (i.e. the time it takes to transition from wakefulness to a sleep state)
• Sleep duration (total time spent asleep)
• The duration of wakefulness (i.e. total time spent awake)
• Overall quality of sleep.

With CBT treatment, many patients also display sustained sleep quality improvement within a 6-month period and thereafter.

CBT involves the following techniques and practices which can be initiated in combination during a treatment period:

1. Sleep hygiene education:

This type of therapy addresses any and all notable behaviours a person may have that do not help to promote ideal sleep quality. Factors associated with these behaviours involve the use of caffeine or alcohol, environmental noise or uncomfortable room temperatures, as well as engaging in disruptive practices like electronic device use and television watching directly before bed. Elimination of these triggers can significantly impact sleep quality and lead to noticeable improvements.

Other healthy hygiene tips which may be offered during consultations include:

• Trying to sleep only as long as is necessary to achieve restfulness.
• Maintaining a regular routine for bedtime and waking time on a daily basis.
• Not trying to ‘force’ sleep – this will aggravate insomnia.
• Avoiding the consumption of caffeinated beverages post-lunch.
• Avoiding the consumption of alcoholic beverages in the evenings, close to bedtime.
• Refraining from or quit smoking, especially during the evenings.
• Consuming regular and nutritious meals at the appropriate times and do not go to bed on an empty stomach.
• If stress factors are promoting anxiety or worry, before retiring to bed make a list of ‘things to do’ the following day in order to alleviate apprehension and restlessness which will disrupt sleep.
• Ensuring that any exercise is performed at least 4 hours before bedtime.

2. Cognitive and relaxation therapy:

Excessive worrying can create misconceptions or beliefs about sleep, and thus impact sleep quality by altering thought processes in a negative manner. Often, people with a tendency to worry about sleep become highly anxious about being able to function during the day and thus initiate a cycle of poor quality sleep and impaired function the following day. Anxiety levels increase during the night as a result, making the following day increasingly unproductive. This negative cycle promotes a pattern of blaming all negative life aspects or events on a lack of quality sleep.

Cognitive therapy works to eradicate anxiety by dealing with it in a more appropriate manner. A patient will learn that poor sleep is not solely responsible for the problems which arise in their life and finding better ways to cope with the various relevant factors will be encouraged. Therapeutic techniques will thus specifically look at how to assist the affected person in being able to better deal with stress factors which stimulate anxiety, thereby working to avoid their impacts on sleep quality.

In correcting their thought patterns, a patient will also be taught relaxation therapy in order to help re-condition their negative behaviour. In this process, a patient is taught to gain the upper hand over their condition by recognising the initial behavioural triggers and exercising better control over the tension these create. Several techniques may be taught involving tensing and then relaxing each muscle group in a sequential manner – starting with the muscles in the face, down to the neck and shoulders, upper arms, lower arms, fingers, chest and torso, back etc. right down to the toes. These techniques promote restfulness which will aid in improved sleep quality. 

Others include practices of meditation and guided imagery which adopt similar techniques to assist a patient with learning how to focus the mind on more neutral or pleasing aspects, and thus reduce the allowance of racing or erratic thoughts.

Biofeedback is another handy technique (sometimes used in conjunction with relaxation therapy), which can help a patient to achieve better awareness of various physiological functions. The technique makes use of certain instruments as they relate to an activity using specific physiological systems and provides immediate feedback information. Feedback helps with determining the levels of tension being experienced and enables therapy to adapt techniques that assist in manipulating the bodily systems at will and promote relaxation. Techniques also involve a slowing down of breathing, practicing deep breathing, and relaxing muscle groups to ease tension.

3. Stimulus-control therapy:

This method is useful in assisting a patient with re-associating the bed / bedroom as a place for sleep and not for other wakeful-related activities which do not promote quality sleep. Reading, eating habits, working on an electronic device (like a laptop) or television watching are some examples of activities which will be discouraged. Such activities can often provide a person with some form of a ‘reward’ for staying awake and thus discourage sleepiness. A therapist will also recommend that the bed be thought of as a place to retire to when a person feels sleepy and be used for no other purpose.

A therapist will also address problems with initiating sleep. If a patient is unable to fall asleep within a 15 to 20-minute period, he or she will likely be advised to get out of bed and engage in something that will help them to relax and feel sleepy, returning to bed when this has been achieved. The practice can be repeated as many times as is necessary.

Therapy will not likely produce an instant result. A person with insomnia may not achieve the desired night’s sleep they’d like during the first night following the commencement of treatment. However, over time, along with the discouragement of naps, a person will be able to ‘retrain’ the body, in a sense, to sleep and feel sleepy at the appropriate time of day. In this way he/she will soon begin to achieve more restful sleep on subsequent nights.

4. Sleep restriction therapy:

A therapist will recommend that a patient try to maintain routine times of sleeping and waking on a daily basis, thus developing healthier sleep habits and schedules. He/she will also discourage a person from spending more time in bed than is actually needed (including daytime napping which can result in partial sleep deprivation).

It is common for people to think that ‘sleeping in’ the following morning will ‘make up for’ a night of lost sleep. The effect is normally counteractive, making it more difficult to achieve quality sleep by nightfall on the same day, and instead creating a negative cycle.

Excessive time spent in bed thus tends to worsen insomnia. By avoiding such behaviour, insomnia sufferers learn how to achieve better quality sleep that is more consolidated and regular, breaking negative patterns.  

Time spent in bed typically starts by being limited according to an estimated total sleep time (i.e. the time a person is a normally able to sleep) and will not likely be less than 5 consecutive hours. A therapist may even begin to allow more time spent in bed, increasing it by between 15 and 30 minutes at a time, should a more regular sleeping pattern be established.

Incremental increases are thus dependant on a patient’s ability to achieve sleep efficacy (i.e. the ratio of time spent asleep in bed, which is aimed at achieving at least 85% of the target). If this ratio falls below 80 – 85%, time added may be decreased by 15 to 30 minutes, thus returning to the original time target.  It’s like using building blocks to achieve an ultimate goal. Building on unstable foundations isn’t likely to achieve the desired effect, and a step back must be taken in order to move forward appropriately. Time adjustments will continuously be made until a more pleasing sleep duration can be achieved.

A doctor will take a patient’s occupation into careful consideration before implementing sleep-restriction therapy, especially when dealing with those who are involved in night-shift work (e.g. pilots, commercial truck drivers, medical personnel or heavy machinery operators).

The process of this therapy will take some time to get used to. A person may still feel fatigued during the day and struggle to maintain concentration and focus during the initial few days or weeks following the commencement of treatment. A doctor may recommend that a patient increases their activity levels during the day when they begin to feel tired instead of adopting more sedentary behaviours. Insomnia sufferers undergoing medical treatment should take care to work closely with their treating doctor, especially when it comes to the restriction therapy process, and only tweak sleeping schedules where necessary, so as to avoid placing themselves in compromising or potentially dangerous positions (such as at increased risk of road accidents if not competent enough to drive).

CBT has been found to benefit people with insomnia by enabling them to better control the negative stimuli or triggers that disrupt their sleeping capability. The practice is also very effective for helping to wean patients off of medications and hypnotics. Tapering medications without CBT can sometimes prove difficult or less effective for insomnia sufferers.

CBT can be a time-consuming process, but it helps considerably if a medical provider is specifically trained in using the aforementioned techniques for effective adjustment therapies. Behavioural medicine specialists at sleep centres also run effective CBT programmes with well trained personnel. Trained psychologists may recommend an average of 5 to 6 sessions over a 6 to 7-week period, for a duration of 20 to 40 minutes each. In the long-run, it has been effectively shown that insomnia patients (with and without coexisting medical conditions) treated with CBT as part of their treatment plan showed continued or sustained efficacy with much improved sleep schedules and quality of life. ⁽²³⁾ 

Other therapies available

1. Phototherapy / light therapy:

For a patient with insomnia as a result of delayed sleep phase syndrome, phototherapy may be beneficial. Such individuals typically struggle with falling asleep much later in the night, and thus generally rise late in the mornings. This therapy makes use of a light box, which a person will be exposed to for a period of 30 to 40 minutes at a time.

Light exposure is normally used in the morning once a person as awoken with the aim of helping to realign a person’s ‘sleep clock’. This helps the person in question to ‘train their internal clock’ to initiate sleep earlier in the evenings by being exposed to light earlier in the day. If a patient’s condition is relatively mild, light exposure (i.e. bright sunlight) and physical activity in the mornings may be enough to help initiate a healthier sleep routine.

2. Chronotherapy:

Insomnia due to circadian rhythm sleep disorders can be retrained with the use of this therapeutic technique, which involves a short period of intentionally delaying sleep (bedtime) by at least 2 or 3 hours on several successive days. The objective is to force new bedtime habits at more appropriate times. The technique can be difficult initially but achieving sleep at a more desirable bedtime can be accomplished. Once this occurs, a person must maintain this sleep-wake schedule as far as possible to avoid possible relapses.

Medications (or pharmacologic therapies)

Did you know? During the early 19^th century insomnia was generally treated with alcohol and opioids. Towards the end of the century, popular treatment included the use (and often misuse) of chloral hydrate, a germinal diol or sedative. When misused (i.e. when taken with alcohol), the ‘treatment’ was often referred to as ‘knockout drops’ or a ‘Mickey Finn’ or simply ‘a Mickey’.

Central nervous system depressants, known as Barbiturates were popularly used from the early 20^th century and into the 1960s. At this time the FDA (the U.S. Food and Drug Administration) approved flurazepam and quazepam (long-acting benzodiazepines) for the treatment of insomnia. These medications continued to be prescribed for insomnia patients until the 1980s.

Benzodiazepine medications assist with sedation, reduced anxiety levels and muscle relaxation. These medications do carry risk of side-effects such as:

• Drowsiness (which can cause daytime impairments concerning decision-making and overall activity performance)
• Withdrawal
• Abuse
• A developed tolerance
• Problems with rebound insomnia

These medications are typically only recommended for short-term use as a result.

During the 1990s, antidepressants became more widely used for patients with primary insomnia and continue to be used as a treatment option today.

During 2017, however, pharmacological guidelines were amended for the treatment of insomnia, and particularly chronic insomnia in adults. Benzodiazepines now include intermediate-acting forms and short-acting forms as well (temazepam, estazolam and triazolam). The longer-acting forms are thus not in as regular use as they were previously, due to the nature of side-effects including daytime sedation, cognitive problems and an increased risk of falls, particularly for senior patients. 

Currently sedative-hypnotics are the most commonly prescribed pharmacologic treatment for insomnia patients.

Here is a breakdown of the various prescription / non-prescription medication options for the treatment of insomnia:

Sedative-hypnotic medications

These prescription drugs are not necessarily intended to ‘cure insomnia’ conditions, but do provide patients with adequate symptomatic relief. These medications may be prescribed as a primary treatment for insomnia (whether mild or acute) or in combination with Cognitive Behavioural Therapy (CBT). These medications in combination with CBT are most effective for transient or short-term variations of insomnia and should be used sparingly as the sole treatment in those with chronic insomnia.

Insomnia sufferers who have difficulty achieving the desired results with CBT can, however, be considered as candidates for these medications as a sole treatment.

These medications include non-benzodiazepine receptor agonists (zolpidem, eszopiclone or zaleplon) and are preferred as they are generally less habit-forming than previously used benzodiazepines. Non-benzodiazepine medications do have fewer adverse effects than benzodiazepines as they target sleep centre regions of the brain, more so than other areas. These medications are also short-acting and thus typically do not result in as much residual next-day sedation.

Non-benzodiazepine medications are available in dissolvable tablet form, as well as an oral liquid spray. These medications can have negative interactions when taken with other sedating drugs or alcohol. Such behaviours will thus be discouraged by a doctor.

A doctor is likely to prescribe these medications (in controlled dosages) in order to achieve efficacy between 6 and 12 months, improving symptoms of patients with both sleep initiation and sleep maintenance difficulties, without the development of tolerance to the drug, or side-effects like ‘next-morning mental or cognitive impairment’.

The medications work by binding to the alpha-1 subunit of the GABAa (gamma-aminobutyric acid-A) receptor, which is associated with the natural processes or sedation in the body.

Commonly used variants of sedative-hypnotic medications include:

• Zaleplon (Sonata): Effective for the treatment of sleep initiation problems (due to rapid action onset and short duration period before taking effect).
• Zolpidem (Zolpimist, Ambien, Ambien CR, Intermezzo and Edluar): Effective for sleep initiation problems with little residual next-day sedation. Ambien CR is a good option for those with sleep initiation and maintenance difficulties (it is available as a two-layer coated tablet), as is Zolpimist (available in tablet or spray form).
• Eszopiclone (Lunesta): This non-benzodiazepine hypnotic binds with GABA receptors and helps to reduce sleep latency (the time it takes to fall asleep), as well as improve sleep duration.
• Triazolam (Halcion): Most effective for short-term insomnia (it is a short-acting benzodiazepine).
• Estazolam: An intermediate-acting benzodiazepine, it is most effective for those with sleep maintenance problems.
• Temazepam (Restoril): Patients who experience more trouble maintaining sleep than initiating it may benefit more from this short-to-intermediate-acting benzodiazepine medication, which has a longer onset latency.

General precautions and factors to take note of when using these medications:

• A doctor is likely to prescribe the lowest effective dosage of these medications so as to avoid too many unwanted side-effects which could impair a person’s ability to function normally after taking them, and thereby impact their quality of life.
• A doctor may caution against continued nightly use of medications, and patients will rather be encouraged for use these medications as and when they are actually needed.
• If nightly use is required, a doctor will prescribe dosages for no longer than a 2 to 4-week period after which a follow-up consultation will usually be required.
• Patients who have trouble initiating sleep may be prescribed medications with a rapid onset effect (like zolpidem and zaleplon).
• Patients with trouble maintaining sleep may be prescribed medications with a slower onset rate (like temazepam, estazolam or flurazepam).
• A doctor will recommend that a patient should aim for up to 8 hours of sleep a night when using these medications but will often caution that he/she may experience impairment side-effects even if feeling awake and rested (while on the medication) and should never use the medication in combination with alcohol.

A doctor will not likely prescribe these medications to patients with diagnosed obstructive sleep apnoea, kidney, liver or lung conditions or women who are pregnant. Those with a history of alcoholism or drug abuse / misuse may also not be considered as candidates for these medications.

A doctor will exercise caution when assessing the potential benefits over risks with regards to patients who have an occupation requiring accurate decision-making during the night, like medical personnel, or those who are a sole caregivers or parents.

The lowest possible dosages will be prescribed for older adults (seniors). If a patient presents depressive symptoms, a doctor may forego prescribing these medications and opt for antidepressants with sedative properties instead. These can include mirtazapine, trazodone or amitriptyline.

A doctor is likely to require regular follow-ups for assessment of medication efficacy and any potentially adverse side-effects a patient may be experiencing. In most instances, the risk of dependency on these medications is very low.

Side-effects of sedative-hypnotic medications can include:

• Impaired cognitive and motor function due to residual sedation experienced the following day – this can impact one’s ability to drive or perform various day-to-day tasks requiring concentration.
• Impaired memory function – some individuals have experienced memory concerns whereby they have little to no recollection of tasks or activities they have actively been involved in (such as driving from one place to another, sleep walking or eating a meal). This side-effect can be amplified if medications have been taken with alcohol or other medications like pain narcotics.
• Risk of severe allergic reactions – Although rare, an allergic reaction is most typical following an initial dosage. Reactions include anaphylaxis (an overreaction of the immune system) and angioedema (severe swelling).
• Risk of substance addiction – normally applicable with long-term use or poor dosage control. 

Discontinuation of these types of medications will need to be tapered to as to avoid rebound insomnia and withdrawal side-effects. 

Suvorexant (Belsomra)

This orexin receptor antagonist first came into use for insomnia treatment during 2014 and has proven beneficial in alleviating problems with initiating sleep and maintaining a sleep state. The drug works with the orexin neuropeptide signalling system which contributes to wakefulness, and blocks neuropeptides orexin A and orexin B from binding to OX1R and OX2r receptors (which normally help a person to stay awake).

In this way the drug helps to suppress the wakefulness drive, at a recommended dosage of 10 mg.  Higher dosages increase the risk for next-day impairment (due to residual drowsiness).

The medication is typically more effective for treating problems with achieving sleep onset (initiation), and or / maintaining a sleep state. The medication has also been shown to work well when taken in combination with cognitive, behavioural and psychological therapy treatments.

A doctor is less likely to prescribe this medication should a patient have obstructive sleep apnoea as a coexisting condition. This is because the medication does carry risk for the development of breathing problems during sleep.

Antidepressants (with sedation properties)

Antidepressant medications with sedating components are sometimes prescribed for insomnia patients, although this treatment option is not usually the first choice. Most drugs in use are not officially approved by the FDA as first-line treatments for insomnia. There is very little clinical data to support the use of sedating antidepressants for patients with primary insomnia and no coexisting mood disorder.

Prescribing doctors have found some benefit, however, when recommending these drugs to patients with insomnia who have also been diagnosed with depression or anxiety.

Those which have been, and are still, used include tricyclic medications (nortriptyline, amitriptyline and doxepin at a low dose) or tetracyclic drugs (like mirtazapine).

• Doxepin (Silenor): At low dosages (3 mg and 6 mg tablets), this medication is FDA approved for insomnia treatment, particularly where maintaining sleep is concerned.

Non-FDA approved for insomnia, but commonly used medications are:

• Amitriptyline: This medication with sedative properties inhibits the reuptake of norepinephrine and serotonin and helps to improve concentration.
• Nortriptyline (Pamelor): This medication is reasonably effective for helping to control chronic pain by inhibiting the reuptake of norepinephrine and serotonin.
• Mirtazapine (Remeron and Remeron SolTab): This non-FDA approved medication has shown beneficial effects for persistent insomnia associated with anxiety disorders or depression. The medication helps those with sleep difficulties to better enable sleep initiation.
• Trazodone (Oleptro): This medication can help insomnia sufferers to consolidate sleep as it displays a short action onset.
• Nefazodone: A potent antagonist, this medication effectively inhibits serotonin reuptake, but does carry a black box warning for possible liver failure. 

Antidepressant medications do carry a risk of daytime sedation side-effects (i.e. drowsiness), as well as other adverse reactions like postural hypotension (decreased systolic blood pressure), weight gain, dry mouth, dry eyes and cardiac arrhythmias.

Sedating antidepressants has been shown to improve the initiation and maintenance of sleep, and thus contribute to better sleep quality. Early morning awakenings are usually few, if any at all. Low dosages can be recommended in order to achieve sustainable improvements to overall sleep. 

Antihistamines

These medications are another option for doctors to consider. As an ingredient, antihistamine is often found in many over-the-counter sleep medications and is fairly common in those used to treat sinus trouble and the common cold too. Dosages of these types of medications are often taken during the night and do have a sedative effect.

These medications are not considered primary choices for the treatment of insomnia, but have been used for their sedating properties, and include diphenhydramine, doxylamine and hydroxyzine (first-generation H1-receptor antagonists).

Antihistamines do carry some residual sedation effects into the following day, and are mostly considered to have some subjective benefit when it comes to improving sleep quality. A medical doctor is not likely to prescribe the use of antihistamines for the treatment of insomnia on a regular or long-term basis.

In general, the taking of over-the-counter antihistamines which are intended for the treatment of conditions such as allergies is not advisable when attempting to treat insomnia. Many of these medications contain pain relieving agents, which are not safe for daily use, and especially so if the drug being used is not primarily being taken for such symptoms.

Along with residual next-day drowsiness, antihistamines do result in other side-effects including blurred vision, dry mouth and problems with effective bladder emptying.

Melatonin

Based on the natural hormone, melatonin, which is released by the pineal gland in the brain, medications containing synthetic versions of this can be used for the treatment of insomnia. These medications are structured in such a way that the concentration of the ingredient is highest in a person’s system during normal sleep times and lowest when they are usually awake. This is done to mimic the natural process that takes place in healthy individuals as closely as possible.

It should be noted that many melatonin containing drugs are not regulated by the FDA even though they have shown some positive benefit for patients with sleep initiation difficulties. As such, these medications are generally marked as dietary supplements. On the plus side, melatonin does not carry many adverse side-effects (other than residual sedation), and appears to be most helpful in patients with delayed sleep phase syndrome.

A doctor will recommend very specific evening dosages as timing is important in order for the medication to be effective. If the medication must be taken during the early evening, the likely effect is that sleep time (duration) will be increased. If dosages are prescribed about 30 minutes before a scheduled bedtime, the medication will generally influence a person’s ability to fall asleep.

Melatonin does appear to have a hypnotic effect when taken during wakeful hours, but studies do not seem to have achieved a precise prescription recommendation for the treatment of insomnia, especially in those with chronic sleep disturbances. For the most part, it appears agreeable that fairly accurate dosages of melatonin can help to decrease the time it takes a person to fall asleep, improve their overall sleep duration (and thus quality of sleep), as well as help to better stabilise problems with irregular circadian rhythms.

Due to a lack of sufficient findings during clinical study focussed on chronic insomnia, it is not likely that a doctor will recommend melatonin for the treatment of persistent or long-term sleep disturbances. Melatonin can be used for senior patients and is usually prescribed in prolonged-release dosages. It has proven to improve sleep in those with difficulty falling asleep with few indications of a tolerance being developed over a six-month period. Visually impaired patients who suffer from cyclical episodes of sleep disruption as due to the lack of natural light information reaching the hypothalamus and disruption to circadian rhythms as a result can also benefit from supplemented melatonin. ⁽²⁴⁾ 

Where prescribed or recommended, melatonin can also be used in combination with dosages of magnesium and or/ zinc supplements (taken at night, often 1 hour before a scheduled bedtime) to help improve the overall quality of sleep.

Ramelteon (Rozerem) is a melatonin receptor agonist which is most often used, and is the only FDA approved medication for the treatment of insomnia. This medication is classified as a non-scheduled prescription drug as it has virtually no proven risk of dependency.

Ramelteon works by binding to melatonin MT1 and MT2 receptors, with a half-life of between 1 and 3 hours (i.e. it takes this medication 1 to 3 hours to reduce to half of the initial dose taken). The MT1 receptor constricts signals from the SCN (suprachiasmatic nucleus), and the MT2 receptor assists by advancing the SCN (suprachiasmatic nucleus) clock in order to encourage sleep. In other words, this medication helps to better promote sleep by assisting in the maintenance of circadian rhythms and a healthy sleep-wake cycle.

There are few, if any, residual next-morning side-effects while one is on this medication, and it is suitable for senior patients with virtually no impairment to memory function, balance and mobility.

A doctor is likely to prescribe this medication for problems to those with issues falling asleep (and not so much maintaining sleep), especially senior patients with gait-related conditions who are high risk for falls. Patients with a history of substance abuse are also better suited to this type of medication in order to treat symptoms of insomnia, due to the low risk of habit-forming dependency.

Melatonin is most useful for patients with disrupted circadian rhythms (i.e. due to shift work or jet lag) or with naturally low levels of the substance in their bodies (which is often the case for patients undergoing treatment for schizophrenia).

The most common side-effects include sleepiness, a sore throat and headache, although such reactions to the drug occur in very few patients. Precautionary factors include patients with liver disease actively taking fluvoxamine (Luvox), or those with hypertension, diabetes or who have a history of seizures – a doctor will likely not recommend this medication to these patients.  

The most typical starting dosage is 8 mg, taken before bedtime.

General medication considerations

Before prescribing or recommending any pharmacological product, a doctor will consider all potential benefits in relation to a patient’s overall condition and relevant risk factors. The goal in treating insomnia is to promote overall sleep quality while retaining (or improving) daytime function during wakeful hours. All potential risks must be assessed against the benefits of medication use, including side-effects and drug abuse factors where relevant. Some medications are more cost effective than others, and this will also be considered during the treatment recommendation process.

For all medications being taken, simultaneous alcohol use will be discouraged, and for very good reason. Alcohol has a tendency to disrupt sleep during the night and can thus worsen the symptoms of insomnia. If alcohol is consumed on a regular basis in conjunction with sleeping pills, a patient’s risk of developing a dependency on these substances is increased and this can lead to more severe or chronic problems with insomnia.

Periodic follow-ups while on medication will be required. A doctor will wish to assess pharmacological efficacy within a few days of treatment commencement in order to determine whether any improvements in sleep are experienced, or if alternative measures should be considered, such as a referral to a sleep centre for evaluation.

2. Alternative treatment

Many a study has been done but very few have offered conclusive results for the effective treatment of insomnia using alternative methods to combat sleep disruptions. Mild improvements may be noticeable in sufferers engaging in activities such as yoga or tai chi which adopt relaxation principles.

Another alternative measure for insomnia involves acupressure, a technique that involves manual pressure applied to various parts of the body and is rooted in helping to balance or restore a flow of energy in the body. Such practices do not appear to cause any direct harm in individuals battling insomnia. It is, however, advisable that patients discuss their interest in alternative treatments with their medical doctor before becoming actively involved, so as to ensure that no activity causes disruption (or interference) to a carefully prepared treatment plan.

Now available for use in treating insomnia (via prescription) is the Cerêve Sleep System, which is an FDA-approved sleeping aid. The device helps to reduce the time it takes to completely fall asleep by inducing a deeper and more restorative night’s sleep. To do this, the device actively keeps the forehead cool. The frontal cortex of those with ‘racing minds’ and who are plagued by intrusive thoughts typically remains active at night and thus has a direct influence on ability to achieve deep and more restorative sleep.

The Cerêve Sleep System is a bedside device which is controlled with the use of software. A user will need to wear a forehead pad connected to the bedside component, through which cool fluid is pumped through the night. The cool fluid has a calming effect and helps to stimulate sleep by reducing frontal cortex activity.

This device was FDA approved during June 2016 following three clinical studies evaluating more than 230 insomnia patients over at least 3 800 nights. ⁽²⁵⁾ 

The intention of this sleeping aid device has the potential to offer insomnia patients an alternative to the use of medications, should they not be effective, result in too many unsatisfactory side-effects or show little improvement in overall condition.

Outlook for insomnia

How long insomnia lasts is typically dependant on the root cause of sleep disruption. It may last as little as a few nights in a row, or persist for several weeks or months, even years, at a time. Ensuring that appropriate treatment is implemented also has a hand in how long it takes to correct a sleeping problem.

In short-term insomnia cases, quality sleep may be achieved in as little as a few days (depending on the underlying causes). Lifestyle issues, like eating habits, impacts of a situational stress, or a case of jet lag and the effects of a change in time zones, which are simple to correct can quickly alleviate a sleeping difficulty. Sometimes curing insomnia is merely about removing the aggravating factor in order to correct sleep disturbance factors.

When the cause of insomnia is more complex, and a person struggles with more persistent insomnia, once again, the outlook and duration will depend on the specifics relating to the underlying problem or condition. An effective treatment plan will be carefully monitored by a treating doctor or physician and altered where applicable in order to achieve the ultimate goal of quality sleep as soon as possible (while also treating an underlying root cause effectively).

Did you know? An annual day dedicated to important issues relating to sleep is celebrated every March (around mid-month). World Sleep Day usually takes place before the March or vernal equinox (in the northern hemisphere). The purpose of the day is to create better awareness around sleep disorders, such as insomnia, so as to lessen the burden its effects can have on society overall by educating people about appropriate prevention and management. Future dates for World Sleep Day are scheduled for 15 March 2019 and 14 March 2020.

 References:

^{21. US National Library of Medicine - National Institutes of Health. 2007. Treatment options for sleep disturbances during alcohol recovery: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936493/ [Accessed 04.08.2018]}

^{22. Journal of Addiction Research and Therapy. 11 March 2011. Insomnia: The Neglected Component of Alcohol Recovery: https://www.omicsonline.org/insomnia-the-neglected-component-of-alcohol-recovery-2155-6105.10000e2.php?aid=38691 [Accessed 04.08.2018]}

^{23. US National Library of Medicine - National Institutes of Health. January 2018. Insomnia and cognitive behavioural therapy—how to assess your patient and why it should be a standard part of care: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803038/ [Accessed 04.08.2018]}

^{24. US National Library of Medicine - National Institutes of Health. September 2007. Visual impairment and circadiam rhythm disorders: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202494/ [Accessed 04.08.2018]}

^{25. US Food and Drug Administration. October 2014. De Novo Classification Request for Cerêve Sleep System: https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN140032.pdf [Accessed 04.08.2018]}