Insomnia: Bad Sleep is Bad

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Quick facts!

Most well-rested adults fall asleep within 10-20 min of attempting to sleep and spend less than 30 min awake at night. 

Insomnia = persistent sleep difficulty and associated daytime dysfunction despite adequate sleep opportunity. 

What is persistent sleep difficulty? 

  • Adult patients with insomnia take more than 30 minutes to fall asleep (sleep initiation difficulty), or spend more than 30 minutes awake (sleep maintenance difficulty), or wake up 30 minutes before desired wake up time (early morning awakening).
  • Short term insomnia (adjustment insomnia) lasts a few days or weeks in the setting of an identifiable stressor. 
  • Per DSM-V, (persistent) insomnia occurs 3x per week and persists for at least 3 months, and is not better explained by a coexisting sleep, mental, or physical disorder. 

What is daytime dysfunction? 

  • Fatigue or malaise
  • Poor attention or concentration
  • Social, vocational, or educational dysfunction
  • Mood disturbances, irritability
  • Daytime sleepiness
  • Reduced motivation
  • Increased errors or accidents
  • Hyperactivity, impulsivity, or aggression
  • Ongoing worry about sleep

What is adequate sleep opportunity? 

  • The American Academy of Sleep Medicine (AASM) and Sleep Research Society (SRS) offer a consensus recommendation:
    • Adults should sleep 7 or more hours per night on a regular basis to promote optimal health.

General facts: 

  • 30% of the general population reports symptoms of insomnia.
  • 10% meet clinical criteria for insomnia including daytime distress.
  • 6% meet the full DSM-V criteria for insomnia. 

Bad Sleep is Bad…

Sleeping less than 7 hours per night on a regular basis is associated with adverse health outcomes:

  • weight gain and obesity
  • diabetes
  • hypertension
  • heart disease and stroke
  • depression
  • increased risk of death
  • impaired immune function
  • increased pain
  • impaired performance
  • increased errors
  • greater risk of accidents

Insomnia with short sleep duration is associated with other adverse effects: 

  • dysfunctional beliefs about sleep
  • anxious-ruminative traits
  • poor coping skills
  • impaired HR variability
  • cardiometabolic mortality

A series of studies at Penn State looked at a cohort of over 1,700 men and women, finding a variety of conclusions: 

  • insomnia with objective short sleep duration in men is associated with increased mortality
  • insomnia with short sleep duration is associated with increased odds of diabetes
  • insomnia with short sleep duration is associated with an increased risk for incident hypertension in a degree comparable to sleep-disordered breathing

Is insomnia becoming more prevalent?

Google Trends reveals increases in internet searches for insomnia during the COVID-19 global pandemic: 

  • The number of internet searches for insomnia in the US increased by 58% during the first 5 months of 2020 compared with the same months from the previous 3 years
  • There is a robust diurnal pattern in insomnia search queries in the US, with the number of queries peaking around 3 AM and the overall pattern remaining stable during the pandemic

Approach to Management

Cognitive Behavioral Therapy

Behavioral Approaches:

  • Establishment of a stable sleep and wake times 7d per week
  • Using bed only for sleep and sex
  • Going to bed only when sleepy, getting out of bed if having prolonged anxiety optimizing sleep hygiene

Cognitive Approaches:

  • Identifying and addressing anxious thoughts associated with sleeplessness
  • Identifying inappropriate expectations about hours of sleep
  • Incorporating mindfulness and meditation techniques into pre-sleep routine

Pharmacotherapy

General goal: Use pharmacotherapy only for short-term insomnia or as a short-term supplement to non-pharmacological management. 

  • Despite the above, the rate of prescription sleep aid use (particularly non-benzodiazepines and off-label use of antidepressants) has risen significantly over the last 20 years, in some cases outpacing the diagnosis of sleep disorders among the general population
  • A large prospective study of former and current insomnia sufferers found that 70% of patients using a prescription sleep aid continued to do so at 1-year follow-up but did not demonstrate significant improvements in sleep compared to non-users

FDA-approved medications for insomnia: 

  • Antidepressants: doxepin
  • Antihistamines: diphenhydramine, doxylamine
  • Barbiturates: butabarbital, secobarbital
    • rarely used because of multiple ADE
  • Benzodiazepines: estazolam, flurazepam, quazepam, temazepam, triazolam
  • Melatonin agonists: ramelteon, tasimelteon
    • Sleep effects: modest effect on sleep latency and duration in adults (up to 15 min for both), longer in children (up to 40 min)
    • ADE: nightmares, headaches
  • Nonbenzodiazepine ligands (aka Z drugs): eszopiclone, zaleplon, zolpidem, zopiclone
    • Sleep effects: decreases sleep latency
      • Eszopiclone has a longer half-life, which may help with sleep maintenance as well
    • ADE: memory loss, dizziness, hallucinations, dependence formation
  • Orexin receptor antagonists: suvorexant
    • Sleep effects: regulates the sleep-arousal cycle

Off-label medications commonly used for insomnia: 

  • Alpha agonists: clonidine, guanfacine
  • Anticonvulsants: carbamazepine, gabapentin, tiagabine
  • Antidepressants: amitriptyline, mirtazapine, trazodone
  • Antihistamines: hydroxyzine
  • Antipsychotics: olanzapine, quetiapine, risperidone
    • Only consider in presence of psychiatric comorbidities (e.g., bipolar disorder)
  • Benzodiazepines: alprazolam, clonazepam, diazepam, lorazepam
  • Herbals: melatonin, valerian

CBT-I vs Pharmacotherapy

  • Methods: Randomized, placebo-controlled clinical trial that involved 63 young and middle-aged adults with chronic sleep-onset insomnia. Interventions were CBT, pharmacotherapy, or combination therapy compared with placebo. 
    • Primary outcome measure: sleep-onset latency as measured by sleep diaries
    • Secondary outcome measures: sleep diary measures of sleep efficiency and total sleep time, objective measures of sleep variables, and measures of daytime functioning. 
  • Results: CBT was the most sleep effective intervention in most measures; it produced the greatest changes in sleep-onset latency and sleep efficiency, yielded the largest number of normal sleepers after treatment, and maintained therapeutic gains at long-term follow-up.
    • The combined treatment provided no advantage over CBT alone, whereas pharmacotherapy produced only moderate improvements during drug administration and returned measures toward baseline after drug use discontinuation. 
  • Conclusions: These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia. 

Take-Home Points!

  • Insomnia is common, as is prescribing medication for it
  • CBT in combination with sleep hygiene is first line and more effective (and longer-lasting!) than pharmacotherapy
  • If starting pharmacotherapy consider type of insomnia (sleep onset vs sleep maintenance vs mixed)
  • If requiring > 1 month of pharmacotherapy, consider readdressing non-pharm approaches and further evaluating for co-morbid factors (OSA, chronic pain, mood disorders, etc)

Blog post based on Med-Peds Forum talk by Chelsea Boyd, PGY2, and Fritz Siegert, PGY2

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