Treatment Options for Insomnia

Medication

There are effective and safe drug treatments for insomnia. Prescription medications such as zolpidem (Ambien®), zolpidem ER (Ambien CR®), eszopiclone (Lunesta®), and zaleplon (Sonata®) are effective in many cases of transient and chronic insomnia. These medications fall into a category of drugs known as “non-benzodiazepine benzodiazepine receptor agonists (BZRAs).” They have been extensively tested in healthy subjects and people with insomnia, and have been approved for the treatment of insomnia. These medications are effective and safe when used as directed. There is no limit on the term of use of either Ambien CR or Lunesta.

There are some hypnotics that do not act at the benzodiazepine receptor complex. Ramelteon (Rozerem®) is a hypnotic that acts at the MT1 and MT2 receptors in order to promote sleep. It appears to exert its greatest effects in promoting sleep onset, but also has been shown to increase total sleep time. Ramelteon is safe and well-tolerated, and it is not associated with risk of dependence.

Silenor (doxepin tablets) was developed to help people who have trouble staying asleep. It is believed that Silenor acts to help people sleep by blocking histamine, an important chemical messenger in the brain. Silenor is approved to treat adults and elderly who have sleep maintenance insomnia.

The most recently approved prescription sleep aid is Intermezzo, which is the first treatment indicated for middle-of-the-night awakenings followed by difficulty returning to sleep. This drug contains the same medicine found in Ambien (zolpidem), but in lower doses administered under the tongue following a middle-of-the-night awakening.

Prior to the newer classes of sleep aids, medications known as the benzodiazepines were widely used. The first of these medications was discovered in the late 1950s, leading to the synthesis of more than 300 benzodiazepine drugs. Drugs in this class, used for sleep induction and maintenance, include triazolam (Halcion®), temazepam (Restoril®), estazolam (Prosom®), and flurazepam (Dalmane®). Other medications in this class, not approved as sleep aids, have also been commonly used to treat insomnia. These medications include drugs such as diazepam (Valium®), clonazepam (Klonopin®), and lorazepam (Ativan®). While physicians continue to use these medications, and a number of people find them to be effective and safe, they are used much less commonly than in the past. This is primarily due to reports of dependence, tolerance, and adverse effects (e.g., increased risk of falling, memory impairment) of these drugs.

Behavioral Therapies

There are many effective non-drug treatments for insomnia. These treatments include sleep hygiene therapy, behavioral therapy, relaxation therapy, and cognitive-behavioral therapy. Such treatments may be delivered by a primary care physician or family doctor, but commonly are performed by a sleep specialist or psychologist with special training in the field. Scientific evidence supports the use of many of these techniques, and sleep specialists commonly use them alone or in combination with medication therapy.

Sleep Hygiene

The term “sleep hygiene” refers to one’s sleep habits. People who experience problems falling asleep, staying asleep, or getting good quality sleep may benefit from practicing good sleep hygiene. However, many people aren’t aware of the good sleep hygiene principles advocated by most sleep specialists. The list to the right provides an overview.

Stimulus Control Therapy

Stimulus control therapy is based on the idea that people with insomnia develop negative associations between the sleep environment and sleep. This idea, essentially, is that people who lie awake in bed for extended periods begin to associate the bed and bedroom with “hyperarousal,” rather than comfort and relaxation. So getting into bed is thought to be a stimulus that provokes insomnia. Many people with insomnia can attest to this phenomenon, and describe their ability to fall asleep easily on their sofas or in their favorite recliners, but not in their own beds.

A protocol for stimulus control therapy was developed several years ago. This protocol is followed under the supervision of a professional who can tailor it to a specific patient’s needs. However, the basic outline of the protocol is provided below:

1. Go to bed only when sleepy
2. Allow yourself 15 – 20 minutes to fall asleep
3. If not asleep within 15 – 20 minutes, get out of bed, go to another room, and engage in a sedentary activity (e.g., reading) until you feel sleepy
4. Repeat steps 1 – 3 as often as necessary
5. Get up at the same time each morning, even if you had a difficult night
6. Avoid hazardous activity if you are sleepy during the day

Sleep Hygiene Do’s and Don’ts

DO:
> Establish a regular bedtime and rise time
> Exercise in the late afternoon or early evening
> Take a hot bath a couple of hours before bedtime
> Establish a comfortable sleep environment (e.g., bed, and bedding)
> Sleep in a dark, quiet area that is temperature and humidity controlled > Establish a relaxing pre-sleep routine that you use every night before sleep, such as washing your face, getting into pajamas, reading or listening to soft music before turning the lights out.

DON’T:
> Take daytime naps
> Use stimulants such as caffeine and nicotine
> Drink alcohol before bedtime
> Go to bed too hungry or too full
> Eat offensive foods, such as spicy or acidic foods (e.g., orange juice) before bed > Try too hard to fall asleep
> “Watch the clock”
> Take prescription and over-the-counter medications that might be stimulating (check with your doctor)

Sleep Restriction Therapy

Sleep restriction therapy is a treatment that is based on the idea that people with insomnia spend too much time in bed. Time spent awake in bed is thought to contribute to subsequent nights of wakefulness, sleep fragmentation, or poor quality sleep. Therefore, treatment is the process of reducing the sleeper’s time in bed to be roughly equivalent to his or her reported sleep time. For example, if a person reports lying in bed for eight hours per night, but sleeps only six hours per night, the sleep restriction therapist might recommend that the sleeper remain in bed for only six hours per night.

Sleep restriction therapy is usually administered by a healthcare professional who can tailor the therapy to a patient’s individual needs. However, the basic sleep restriction protocol is provided below.

1. Determine your usual rise time (e.g., 6:00 AM)
2. Determine the average number of hours that you spend asleep in bed (e.g., 5.5 hours) each night. This can be done using a sleep log.
3. Work backwards to determine what your bedtime should be. For example if you normally rise at 6:00 AM and you sleep 5.5 hours each night, your bedtime should be 12:30 AM.
4. Go to bed at your new “prescribed” time each night for one week.
5. If you do not fill your night with sleep, repeat steps 1 – 3 to identify an appropriate, later bedtime.
6. Continue this plan until your time in bed is mostly filled with sleep, or until you reduce your time in bed to 4 hours
7. If you fill your time in bed with sleep, wait for several days and then begin increasing your time in bed each night by 15 minutes. Do this as long as you can continue to fill your time in bed with sleep
8. Avoid hazardous activity if your are sleepy during the day

Over-the-Counter Medications

There are many over-the-counter (OTC) medications that are available to treat insomnia. These medications include drugs such as Sominex®, SleepEze®, and Unisom® that contain antihistamines such as diphenhydramine or doxylamine as the active ingredient. They also include pain-reliever/sleep-aid combinations such as Tylenol PM®. Such medications may be appropriate for the relief of short-term insomnia. However, patients should be aware that OTCs may fail to produce the desired result, and also may be associated with some unwanted adverse effects (e.g., dry eyes, dry mouth, next day “hangover”).

Melatonin

There is little scientific evidence to suggest that melatonin is valuable as a sleep aid in people with insomnia. Prolonged release melatonin has been approved for the treatment of elderly people with insomnia in European countries, but it has not been approved in the United States.

Herbal Remedies

There is little scientific evidence to suggest that herbal remedies are valuable as sleep aids in people with insomnia.

For more information about insomnia, please download the Insomnia Fact Sheet, which you can print and take to your doctor.