Insomnia is the most common sleep complaint among people. Insomnia is defined as difficultly falling asleep, staying asleep, or both, resulting in inadequate length of sleep and/or poor quality of sleep, which may affect a person's ability to function during the day. Insomnia also may affect quality of life, work performance, and overall health. Insomnia is not a disease, but a symptom associated with a variety of medical, psychiatric, or sleep disorders.
Insomnia is usually a transient or short-term condition (lasting less than 3 months). In some cases insomnia can become chronic (more than 6 months).
Transient insomnia specifically lasts up to 1 week and is associated with acute situational stress factors such as a job interview or exam. It usually resolves once the person has adjusted to stress factor, or it is no longer a concern. It can however reemerge when new or similar stressors occur. Causes of short-term (acute) insomnia are typically related to more significant or persistent stress sources, which may be environmental factors such as too much noise, light, temperature extremes, or an uncomfortable bed ,or situational factors including relationship concerns or losses (for example, death of a family member).
Causes of chronic insomnia are more variable and are associated with underlying causes.
Medical disorders
Neurologic disorders
Psychiatric disorders
Drug-related insomnia
Primary insomnia may be diagnosed when all other disorders have been excluded. Primary insomnia is often referred to as psychophysiologic insomnia. This disorder often results from a period of stress in a person's life. Normally, this condition resolves over time, but for some, insomnia results in ongoing tension and an inability to sleep. Bad sleep habits develop, and the person begins to worry about his or her sleep, worsening the symptoms of insomnia. The bad habits must be "unlearned," and the person educated regarding good sleep hygiene practices.
The management and treatment of insomnia depends on the underlining cause or causes. If a person has a medical or neurological problem, treatment directed at the primary disorder may improve insomnia. Also if insomnia is caused by taking certain medications, tapering or withdrawal of those medications should be considered.
Psychological and behavioral treatments can help many people who suffer from insomnia. It is important to discuss options and administration with your physician/Sleep Specialist. Behavioral treatments for insomnia include:
Sleeping pills (sedative-hypnotic drugs) do not cure insomnia, but they may relieve symptoms. Short-term use (2-3 weeks) of sleeping pills may be warranted for chronic insomnia while other treatments or behavioral therapies are being started.
The choice of sedative-hypnotic depends on the type of sleep problem. If an individual has trouble falling asleep, a quick-acting but short-lasting drug such as zolpidem (Ambien) may be prescribed. Zolpidem tartrate (Intermezzo), a lower dose formulation of Ambien, can be used to treat insomnia characterized by middle-of-the-night waking followed by difficulty returning to sleep. In general, these types of drugs are useful because they may be taken after several hours of trying to fall asleep, yet the effects do not last long enough to cause difficulty waking in the morning.
Drugs that have longer-lasting actions are more useful for individuals who wake up after initially falling asleep. For example
Benzodiazepine hypnotic drugs include
How do benzodiazepine hypnotic drugs work?
These drugs bind to benzodiazepine receptors (omega-1 and omega-2) in the brain, thereby inducing sleep.
Who should not use these medications?
People with the following conditions should not use benzodiazepines:
Uses: Take the prescribed dose 30 minutes before bedtime. Elderly individuals are prescribed smaller doses.
Drug or food interactions: Certain drugs, such as cimetidine (Tagamet), azole antifungal medications, antibiotics (for example, erythromycin [E-Mycin, Ery-Tab]), or drugs used to treat AIDS, lessen the body's ability to eliminate benzodiazepines, thereby increasing the risk of toxicity. Some drugs, such as rifampin (Rifadin) or St. John's Wort, may speed the metabolism (breakdown for use in the body) of sedative-hypnotics, thereby decreasing their effectiveness.
Side effects: Benzodiazepines may impair coordination, balance, or mental alertness and are more likely to disrupt REM sleep, causing less restful sleep.
Pregnancy and breastfeeding safety: Benzodiazepines are Pregnancy Category X. This means benzodiazepines are contraindicated in women who are or may become pregnant as they may cause fetal harm when administered to a pregnant woman. Because many drugs are excreted in human milk, caution should be exercised when administered to a woman breastfeeding, as the effect on a nursing infant is not known.
Nonbenzodiazepine hypnotic drugs include
How do sedative hypnotic drugs work?
Although these drugs are not chemically like benzodiazepines, they bind to a specific benzodiazepine receptor in the brain called omega-1, thereby inducing sleep. They may be less likely than benzodiazepine medications to disrupt natural sleep rhythm patterns (called the rapid eye movement [REM] ratio). Disruption of REM sleep may make sleep less restful. How Lunesta works is not fully understood. Lunesta is thought to promote sedation and to affect brain receptor sites that are close to gamma-aminobutyric acid (GABA).
TThe extended-release product (Ambien CR) consists of a coated 2-layer tablet and is useful for insomnia characterized by difficulties with sleep onset and/or sleep maintenance. The first layer releases drug content immediately to induce sleep, whereas the second layer gradually releases additional drug to provide continuous sleep.
People with an allergy to sedative hypnotics should not take them.
Uses: Take the prescribed dose 30 minutes before bedtime. Elderly individuals are prescribed smaller doses. If taking an extended-release product, such as Ambien CR, it must be swallowed whole (do not divide, chew, or crush). If taking Intermezzo sublingual tablet, it must be placed under the tongue and allow it to break apart completely, then swallow. It also must be taken only if you have at least 4 hours of sleep time left.
Drug or food interactions: Other drugs that depress the brain's functioning, such as alcohol or barbiturates may increase drowsiness and cause an increased risk of toxicity. Cimetidine (Tagamet) increases Sonata levels, thereby increasing the risk of toxicity. Antidepressant medications also can interact with sedative hypnotic medications by causing additive affects and dose adjustment of concomitant CNS depressants may be necessary. Ketoconazole (Nizoral), itraconazole (Sporanox), clarithromycin (Biaxin), nefazodone (Serzone), ritonavir (Norvir, Kaletra), and nelfinavir (Viracept) may increase blood levels of Lunesta, therefore increasing the risk for side effects. Zolpidem's effect may be delayed if taken with food or shortly after a meal.
Side effects: Common side effects include drowsiness and dizziness,, possibly impairing coordination, balance, and/or mental alertness. These drugs must be used with caution in individuals with a history of drug abuse or dependence. Ambien, Lunesta, and Sonata work very quickly and should only be taken just before going to bed. Proper dosing is important to minimize the likelihood of side effects and differs between men and women. Patients should allow for a full 8 hours after taking the medication before driving or operating equipment.
Pregnancy and breastfeeding safety: Nonbenzodiazepine hypnotics are Pregnancy Category C. This means there are no adequate and well-controlled studies in pregnant women for non-benzodiazepines. Consult a physician to determine if the potential benefit justifies the potential risk to the fetus. Because many drugs are excreted in human milk, caution should be exercised when administered to a nursing woman as the effect of on a nursing infant is not known.
This is a newer class of medications to treat insomnia that also does not fall into the benzodiazepine category. Currently, the only US Food and Drug Administration (FDA)-approved medication in this category is uvorexant (Belsomra).
The drug works by decreasing activity in the wake center of the brain and therefore promoting sleep. This particular type of insomnia medication works on orexin receptors in the lateral hypothalamus in the brain. It acts by decreasing activity in the wake centers of the brain and helping patients transition to sleep. This is in contrast to traditional insomnia medications, which attempt to increase activity in the sleep centers of the brain. The mechanism action of suvorexant (Belsomra) is completely unrelated to both the benzodiazepine and non-benzodiazepine sedative-hypnotic drugs.
People with the following conditions should not use orexin receptor antagonists:
Uses: Take the prescribed dose 30 minutes before bedtime.
Drug or food interactions: Other drugs that depress the brain's functioning, such as alcohol or barbiturates, may increase the likelihood of abnormal behaviors during sleep, drowsiness, and cause an increased risk of side effects.
Side effects: The most significant side effect noted in studies was increased daytime sleepiness. Caution is advised and it should be reported to your doctor if there is any incident of increased abnormal night-time activity such as activity out of bed while not fully awake, "sleep driving" increased symptoms of depression or suicidal thoughts, change in breathing function, sleep paralysis, or hallucinations.
Pregnancy and breastfeeding safety: The drug is classified as Pregnancy Class C since there are no established studies in humans. The drug should be avoided during pregnancy unless the benefits significantly outweigh the risks. Based on animal data, the drug may cause fetal harm when administered to a pregnant woman. Because many drugs are excreted in human milk, caution should be exercised when administered to a woman breastfeeding, as the effect on a nursing infant is not known.
Antidepressant drugs include, but are not limited to
Antidepressant drugs are believed to work by altering levels of brain chemicals known as neurotransmitters. Some antidepressant drugs cause drowsiness as a side effect. Because this side effect may last for a long time, it can benefit an individual whose problem is awakening after initially falling asleep. Antidepressant drugs may also be used for people who have insomnia caused by depression.
PPersons taking a monamineoxidase inhibitor (MAOI, another class of antidepressant drug) should not take these medications. Additionally, anyone with the following conditions should not take antidepressants:
Uses: Take the prescribed dose 30 minutes before bedtime. Elderly individuals are prescribed smaller doses.
Drug or food interactions: Do not use within 14 days of taking an MAOI. Other drugs that depress the brain's functioning, such as alcohol or barbiturates, may increase drowsiness, cause a hangover effect in the morning, and increase the risk of toxicity. Cimetidine (Tagamet) may increase blood levels of antidepressant drugs, thereby increasing the risk of toxicity.
Side effects: Common side effects include dry mouth, blurred vision, constipation,, urinary retention, and increased heart rate.
Pregnancy and breastfeeding: Antidepressants are Pregnancy Category C. This means there are no adequate and well-controlled studies in pregnant women for most antidepressants. Consult a physician to determine if the potential benefit justifies the potential risk to the fetus. Because many drugs are excreted in human milk, caution should be exercised when administered to a nursing woman as the effect of on a nursing infant is not known.
Pineal gland hormones include
Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon is a prescription drug that stimulates melatonin receptors. It promotes the onset of sleep and helps normalize circadian rhythm disorders. It is approved by the US FDA for insomnia characterized by difficulty falling asleep.
Uses: Swallow prescribed dose 30 minutes before bedtime on an empty stomach.
Drug or food interactions: Drugs that inhibit metabolism of melatonin and ramelteon, such as fluvoxamine (Luvox), may increase the risk for toxicity. Rifampin increases the metabolism of ramelteon, therefore decreasing its effectiveness. Melatonin has been reported to interfere with warfarin (Coumadin).
Side effects:
Pregnancy: Penal gland hormones are in Pregnancy Category C. This means there are no adequate and well-controlled studies in pregnant women for pineal gland hormones. Consult a physician to determine if the potential benefit justifies the potential risk to the fetus. Because many drugs are excreted in human milk, caution should be exercised when administered to a nursing woman as the effect of on a nursing infant is not known.
There are many psychiatric and medical conditions that cause insomnia. Some of the common symptoms of insomnia are:
