Insomnia

What is the DSM-5 criteria for insomnia?

Dissatisfaction with sleep quantity or quality, associated with one or more of the following:

-Difficulty initiating sleep

-Difficulty maintaining sleep

-Early-morning awakening

Sleep difficulty occurs despite adequate opportunity for sleep

How often do symptoms of insomnia have to occur to be deemed insomnia?

Occurs at least 3 night/week

Lasting at least 3 months

What is insomnia associated with?

Social, occupational, academic, educational, behavioral or functional impairment

What are sleep difficulties as a result of insomnia NOT associated with?

Another sleep-wake disorder, medication, illicit substance use, psychiatric illness or medical condition

Describe the relationship between coexisting mental disorders and insomnia

Coexisting mental disorders and medical conditions do not adequately explain the dominant complaint of insomnia

What are the four types of insomnia?

Transient

Episodic

Persistent

Recurrent

Define transient insomnia

Lasts several days

Acute stress or environmental changes

Define episodic insomnia

Lasts at least 1 month, no more than 3 months

Often due to major life stressors

Define persistent insomnia

Lasts ≥ 3 months

Define recurrent insomnia

2+ episodes within 1 year timeframe

How can sleep be measured?

Sleep onset latency (SOL)

Total sleep time (TST)

Wake after sleep onset (WASO)

Sleep efficiency

Define sleep onset latency (SOL)

Time from wakefulness to sleep

Goal < 30 minutes

Define total sleep time (TST)

Total time in bed - total time awake

Goal > 6 hours

Define wake after sleep onset (WASO)

Total time in bed - time spent asleep

Goal < 30 minutes

Define sleep efficiency

TST / total time in bed

Goal > 80-85%

What medical illnesses can cause sleep disorders?

Angina

Arthritis or chronic pain

Asthma or COPD

GERD

PUD

Head injury

Hepatic or renal failure

Hypoglycemia

Malignancy

Parkinson disease

Seizure disorders

Sleep apnea

What psychiatric disorders can cause sleep disorders?

Anxiety disorders

Depression

Manic episodes

Mood disorders

Psychotic disorders

Substance use or abuse

What drugs can cause drug-induced insomnia?

Alcohol

Antidepressants

Antihypertensives

Antiparkinsonism drugs

Antipsychotics

Caffeine

Cocaine

Corticosteroids

Decongestants

Nicotine

Stimulants

Sympathomimetics

Theophylline

Thyroid preparations

Which antidepressants can cause drug-induced insomnia?

TCAs

SSRIs, SNRIs

Bupropion

Which antihypertensives can cause drug-induced insomnia?

B-blockers

Diuretics

Which antiparkinsoniam drug can cause drug-induced insomnia?

Levodopa

Which stimulants can cause drug-induced insomnia?

Amphetamines

What drugs can cause withdrawal insomnia?

Alcohol

Antidepressants

Antihistamines

Barbiturates

Benzodiazepines

Nicotine

Opioids

Other drugs of abuse

What are the treatment goals when treating insomnia?

Correct underlying sleep complaint

Improve sleep quality and quantity

Improve daytime functioning and impairment

Avoid adverse effects from selected therapies

What is recommendation 1 for insomnia according to the ACP?

Recommends that all adult patients receive CBT-I as the initial treatment for chronic insomnia disorder

What is recommendation 2 for insomnia according to the ACP?

Recommends that clinicians use a shared decision-making approach to decide whether to add pharmacological therapy in adults with chronic insomnia in whole CBT-I alone was unsuccessful

What are behavioral interventions for insomnia?

Relaxation training

Sleep restrictions

Stimulus control

Sleep hygiene techniques

Cognitive behavioral therapy (CBT)

Define cognitive behavioral therapy

Cognitive and behavioral therapy that identifies maladaptive behaviors and thoughts, then CHANGES THEM

What are examples of sleep hygiene?

Go to bed and wake up at the same time each day

Exercise routinely, but not directly before bedtime

Avoid caffeine, nicotine, and alcohol before bedtime

Avoid heavy meals close to bedtime

Improve sleeping environment

Do something relaxing to wind down before bed

Try relaxation therapy

What are first line agents for insomnia?

BZDs, NBRAs, melatonin agonists, orexin receptor antagonists, sedating antidepressants

What are alternative agents for insomnia?

Sedating antipsychotics, OTC antihistamines, herbal products

What drug is an OTC pharmacologic sleep aid?

Diphenhydramine (Benadryl)

What are OTC herbal supplements for insomnia?

Melatonin

Valerian Root

Chamomile

How long can BZDs and NBRAs be used for?

Long-term use is not recommended

If used, should only be for 1-12 weeks

What is the biggest concern with BZDs and NBRAs?

Concern for dependence

Which 5 BZDs are FDA-approved for insomnia?

Flurazepam (Dalmane)

Temazepam (Restoril)

Triazolam (Triazolam)

Quazepam (Doral)

Estazolam (ProSom)

Which BZDs are not FDA-approved for insomnia, but still used for it?

Alprazolam (Xanax)

Lorazepam (Ativan)

Clonazepam (Klonopin)

Diazepam (Valium)

Chlordiazepoxide (Librium)

Oxazepam (Serax)

What does it mean if a BZD has a fast onset of action?

It works quickly, meaning that is it good for sleep latency

Which BZDs are good for sleep latency?

Flurazepam

Triazolam

Quazepam

Alprazolam

What does it mean if a BZD has a long half-life?

It stays in the body for longer, meaning that it is good for sleep maintenance

Which BZDs are good for sleep maintenance?

Quazepam

Clonazepam

Diazepam

Chlordiazepoxide

Which BZDs undergo phase I metabolism through CYP3A4?

Diazepam

Triazolam

Alprazolam

Not good in patients with liver impairment or in those taking CYP3A4 inhibitors

Which BZDs undergo phase II metabolism through glucuronidation?

Lorazepam

Temazepam

Oxazepam

LOT

What are adverse effects of BZDs?

Drowsiness and sedation

Impaired memory

Ataxia and incoordination

Disinhibition

Anterograde amnesia

Dysphoria

Tolerance and dependence

When should BZDs be avoided?

In those with active substance abuse history

With other CNS depressants

With alcohol

What are other warnings/precautions of BZDs?

Caution risk of respiratory depression

Caution in elderly patients

Withdrawal risk

What drugs are non-BZD receptor agonists (NBRAs)?

Eszopiclone (Lunesta)

Zaleplon (Sonata)

Zolpidem (Ambien)

Which NBRA is good for both sleep latency and sleep maintenance?

Eszopiclone

Has a LONG half life (unique compared to other NBRAs)

Which NBRAs are metabolized by CYP3A4?

Zolpidem

Eszopiclone

Which NBRA is metabolized by aldehyde oxidase?

Zaleplon

Good for hepatic impairment

What are adverse effects of NBRAs?

Similar to BZDs = sedation, dizziness, disinhibition

Headache

Parasomnia and complex sleep effects = hallucinations, sleep-eating, sleep-driving

What are warnings and precautions of NBRAs?

Next day sedation and impairment

Caution in patients with hepatic impairment

Caution in those with substance abuse history

Caution in elderly patients = lower doses used

Caution concomitant CNS depressants

Ramelteon

Rozeram

What is ramelteon effective for?

Sleep latency

What is ramelteon metabolized by?

CYP3A4 and CYP1A2

What are adverse effects of ramelteon?

Dizziness, daytime sedation

Which drugs are orexin receptor antagonists?

Suvorexant (Belsomra)

Daridorexant (Quviviq)

Lemborexant (Dayvigo)

What are orexin receptor antagonists effective for?

Sleep latency AND sleep maintenance

What can decrease the absorption of orexin receptor antagonists?

Food delays absorption

Sleep onset will be delayed if taken with food

What are warnings of orexin receptor antagonists?

Avoid alcohol consumption

Caution in hepatic impairment

What are adverse effects of orexin receptor antagonists?

Sleep paralysis

Worsened depression

Complex sleep problems

What should be monitored when taking orexin receptor antagonists?

Monitor respiratory function

What are orexin receptor antagonists metabolized by?

CYP3A4

What are sedating antidepressants most helpful for?

Sleep maintenance

Which drugs are sedating antidepressants used for insomnia?

Trazodone (Desyrel)

Mirtazepine (Remeron)

Doxepin (Silenor)

What are adverse effects of trazodone?

Priapism

Orthostatic hypotension

What are adverse effects of mirtazepine?

Weight gain

Sedation

What are adverse effects of doxepin?

Anticholinergic

Next day sedation

Behavioral changes

Complex sleep problems

Which sedating antidepressants may also help with sleep latency?

Trazodone

Doxepin

Which sedating antidepressant is a CYP3A4 substrate?

Trazodone

Which sedating antidepressant should be used with caution in renal or hepatic impairment?

Mirtazepine

Which sedating antidepressant should be taken on an empty stomach?

Doxepin