Instruct: Given a question, retrieve passages that can help answer the question.
Query: How is insomnia treated?
It is important to identify or rule out medical and psychological causes before deciding on the treatment for insomnia.[67] Cognitive behavioral therapy has been found to be as effective as medications for the short-term treatment of chronic insomnia.[12] The beneficial effects, in contrast to those produced by medications, may last well beyond the stopping of therapy.[68] Medications have been used mainly to reduce symptoms in insomnia of short duration; their role in the management of chronic insomnia remains unclear.[8] Several different types of medications are also effective for treating insomnia.[64] However, many doctors do not recommend relying on prescription sleeping pills for long-term use.[65] It is also important to identify and treat other medical conditions that may be contributing to insomnia, such as depression, breathing problems, and chronic pain.[65][69]
Insomnia is a general term for difficulty falling asleep and/or staying asleep. Insomnia is the most common sleep problem, with many adults reporting occasional insomnia, and 10–15% reporting a chronic condition. Insomnia can have many different causes, including psychological stress, a poor sleep environment, an inconsistent sleep schedule, or excessive mental or physical stimulation in the hours before bedtime. Insomnia is often treated through behavioral changes like keeping a regular sleep schedule, avoiding stimulating or stressful activities before bedtime, and cutting down on stimulants such as caffeine. The sleep environment may be improved by installing heavy drapes to shut out all sunlight, and keeping computers, televisions and work materials out of the sleeping area.
Some cases of insomnia are not really insomnia in the traditional sense, because people experiencing sleep state misperception often sleep for a normal amount of time.[21] The problem is that, despite sleeping for multiple hours each night and typically not experiencing significant daytime sleepiness or other symptoms of sleep loss, they do not feel like they have slept very much, if at all.[21] Because their perception of their sleep is incomplete, they incorrectly believe it takes them an abnormally long time to fall asleep, and they underestimate how long they remain asleep.[21]
Side effects observed in fluoxetine-treated persons in clinical trials with an incidence >5% and at least twice as common in fluoxetine-treated persons compared to those who received a placebo pill include abnormal dreams, abnormal ejaculation, anorexia, anxiety, asthenia, diarrhea, dry mouth, dyspepsia, flu syndrome, impotence, insomnia, decreased libido, nausea, nervousness, pharyngitis, rash, sinusitis, somnolence, sweating, tremor, vasodilatation, and yawning. Fluoxetine is considered the most stimulating of the SSRIs (that is, it is most prone to causing insomnia and agitation). It also appears to be the most prone of the SSRIs for producing dermatologic reactions (e.g. urticaria (hives), rash, itchiness, etc.).
Pharmacological treatments are used to chemically treat sleep disturbances such as insomnia or excessive daytime sleepiness. The kinds of drugs used to treat sleep disorders include: anticonvulsants, anti-narcoleptics, anti-Parkinsonian drugs, benzodiazepines, non-benzodiazepine hypnotics, and opiates as well as the hormone melatonin and melatonin receptor stimulators. Anticonvulsants, opiates, and anti-Parkinsonian drugs are often used to treat restless legs syndrome. Furthermore, melatonin, benzodiazepines hypnotics, and non-benzodiazepine hypnotics may be used to treat insomnia. Finally, anti-narcoleptics help treat narcolepsy and excessive daytime sleepiness.
At doses used to treat depression, doxepin appears to inhibit the reuptake of serotonin and norepinephrine and to have antihistamine, adrenergic and serotonin receptor antagonistic, and anticholinergic activities; at low doses used to treat insomnia it appears to be selective for the histamine H receptor.
Sleep restriction therapy and stimulus control therapy as described in insomnia have shown significance in treating middle of night insomnia.
Some studies have shown that zaleplon, which has a short elimination half-life, may be suitable for middle-of-the-night administration because it does not impair next day performance.
In 2016 the American College of Physicians advised that insomnia be treated first by treating comorbid conditions, then with cognitive behavioral therapy and behavioral changes, and then with drugs; doxepin was among those recommended for short-term help maintaining sleep, on the basis of weak evidence. The 2017 American Academy of Sleep Medicine recommendations focused on treatment with drugs were similar. A 2015 AHRQ review of treatments for insomnia had similar findings.
Workers who complain of insomnia should not routinely have polysomnography to screen for sleep disorders.[55] This test may be indicated for patients with symptoms in addition to insomnia, including sleep apnea, obesity, a thick neck diameter, or high-risk fullness of the flesh in the oropharynx.[55] Usually, the test is not needed to make a diagnosis, and insomnia especially for working people can often be treated by changing a job schedule to make time for sufficient sleep and by improving sleep hygiene.[55]
They are used to treat insomnia.
Other uses are pre- and postoperative states with anxiety and insomnia, severe nausea / emesis (in hospitalized patients), the amelioration of anxiety and agitation due to use of selective serotonin reuptake inhibitors for depression and, off-label, the amelioration of alcohol and opioid withdrawal. It may also be used cautiously to treat nonpsychotic irritability, aggression, and insomnia in pediatric patients.
Psychiatric mood disorders, such as major depressive disorder (MDD) and bipolar disorder, are intertwined with sleep disorders. This is evident in the high rate of comorbidity with psychiatric disorders and insomnia and other sleep disorders. Most people with psychiatric diagnoses have significantly reduced sleep efficiency and total sleep time compared to controls. Thus it is not surprising that treating insomnia with CBT-I can help to improve mood disorders. A study in 2008 showed that augmenting antidepressant medication with CBT-I in patients with MDD and comorbid insomnia helped to alleviate symptoms for both disorders. The overlap between mood- and sleep disorders is just starting to be rigorously explored, but the efficacy of CBT-I for MDD and bipolar disorder looks promising.
Insomnia is a common protracted withdrawal symptom that persists after the acute withdrawal phase of alcohol. Insomnia has also been found to influence relapse rate. Studies have found that magnesium or trazodone can help treat the persisting withdrawal symptom of insomnia in recovering alcoholics. Insomnia can be difficult to treat in alcoholics because many of the traditional sleep aids (e.g., benzodiazepine receptor agonists and barbiturate receptor agonists) work via a GABAA receptor mechanism and are cross-tolerant with alcohol. However, trazodone is not cross-tolerant with alcohol.[12][13][14] The acute phase of the alcohol withdrawal syndrome can occasionally be protracted. Protracted delirium tremens has been reported in the medical literature as a possible but unusual feature of alcohol withdrawal.[15]
While insomnia is a common symptom of depression, antidepressants are effective for treating sleep problems whether or not they are associated with depression. While all antidepressants help regulate sleep, some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can have an immediate sedative effect, and are prescribed to treat insomnia.[100] Amitriptyline and doxepin both have antihistaminergic, anticholinergic, and antiadrenergic properties, which contribute to both their therapeutic effects and side effect profiles, while mirtazapine's side effects are primarily antihistaminergic, and trazodone's side-effects are primarily antiadrenergic. Mirtazapine is known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep efficiency and increasing the total amount of sleeping time in people with both depression and insomnia.[101][102]
Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and the relaxation therapies. Hypnotic medications are equally effective in the short-term treatment of insomnia, but their effects wear off over time due to tolerance. The effects of CBT-I have sustained and lasting effects on treating insomnia long after therapy has been discontinued.[79][80] The addition of hypnotic medications with CBT-I adds no benefit in insomnia. The long lasting benefits of a course of CBT-I shows superiority over pharmacological hypnotic drugs. Even in the short term when compared to short-term hypnotic medication such as zolpidem (Ambien), CBT-I still shows significant superiority. Thus CBT-I is recommended as a first line treatment for insomnia.[81]
In 1909, a military manual from the Mounted Service School in Fort Riley recommended cannabis indica for treating abdominal pains in horses, or to supplement ether for treating spasms. During World War I, military doctors recommended that the American Expeditionary Force carry cannabis indica tablets to treat headaches, insomnia, and cramps.
The combined actions of 5-HT and 5HT receptor antagonism with serotonin reuptake inhibition only occur at moderate to high doses of trazodone. Doses of trazodone lower than those effective for antidepressant action are frequently used for the effective treatment of insomnia. Low doses exploit trazodone's potent actions as a 5-HT receptor antagonist, and its properties as an antagonist of H and α-adrenergic receptors, but do not adequately exploit its SERT or 5-HT inhibition properties, which are weaker. Since insomnia is one of the most frequent residual symptoms of depression after treatment with an SSRI, a hypnotic is often necessary for patients with a major depressive episode. Not only can a hypnotic potentially relieve the insomnia itself, but treating insomnia in patients with major depression may also increase remission rates due to improvement of other symptoms such as loss of energy and depressed mood. Thus, the ability of low doses of trazodone to improve sleep in depressed patients may be an important mechanism whereby trazodone can augment the efficacy of other antidepressants.
Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children, as well as insomnia. Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls. CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety and insomnia. "Sparx" is a video game to help young persons, using the CBT method to teach them how to resolve their own issues.
Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without (or alongside) medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.
Clinically, H antagonists are used to treat certain allergies. Sedation is a common side-effect, and some H antagonists, such as diphenhydramine (Benadryl) and doxylamine, are also used to treat insomnia.
Middle-of-the-night insomnia is often treated with medication, although currently Intermezzo (zolpidem tartrate sublingual tablets) is the only Food and Drug Administration-approved medication specifically for treating MOTN awakening. Because most medications usually require 6–8 hours of sleep to avoid lingering effects the next day, these are often used every night at bedtime to prevent awakenings. Medication may not be prescribed in some cases, especially if the cause turns out to be the patient ingesting too much fluid during the day or just before they go to sleep.
Rebound insomnia is insomnia that occurs following discontinuation of sedative substances taken to relieve primary insomnia. Regular use of these substances can cause a person to become dependent on its effects in order to fall asleep. Therefore, when a person has stopped taking the medication and is 'rebounding' from its effects, he or she may experience insomnia as a symptom of withdrawal. Occasionally, this insomnia may be worse than the insomnia the drug was intended to treat.
A quantitative review published in 2015 found that for the pooled results of the pivotal trials, the number needed to treat (a sign of effect size, so a low number is better) for the patch for symptom reduction was 11, and for remission, was 9. The number needed to harm (inverse of the NNT, a high number here is better) ranged from 387 for sexual side effects to 7 for application site reaction. With regard to the likelihood to be helped or harmed (LHH), the analysis showed that the selegiline patch was 3.6 times as likely to lead to a remission vs. a discontinuation due to side effects; the LHH for remission vs. incidence of insomnia was 2.1; the LHH for remission vs. discontinuation due to insomnia was 32.7. The LHH for remission vs insomnia and sexual dysfunction were both very low.
As of 2004, doxylamine and diphenhydramine were the agents most commonly used to treat short-term insomnia. As of 2008, antihistamines were not recommended by the American Academy of Sleep Medicine for treatment of chronic insomnia "due to the relative lack of efficacy and safety data".
Epilepsy and insomnia can both be treated with medication.