Ewha Med J.  2013 Sep;36(2):84-92. 10.12771/emj.2013.36.2.84.

Current Clinical Practice of Insomnia

• Choi HY
• Lim WJ

• KMID: 2171236
• DOI: http://doi.org/10.12771/emj.2013.36.2.84

Abstract

Insomnia is one of the most common sleep disorders, which is leading to significant clinical distress and impairment of daytime functioning and decreasing quality of life. This article reviews the current clinical treatment options of insomnia. Non-pharmacological treatment including stimulus control, sleep restriction, cognitive therapy, relaxation training, and education of sleep hygiene should be considered first for treatment of insomnia. Psychological and behavioral interventions tend to have longer-lasting treatment benefits, while drugs show immediate improvement of sleep disturbance. In pharmacotherapy, benzodiazepine receptor agonist, melatonin receptor antagonist, and 'off-label' drugs to treat insomnia are reviewed.

Keyword

Behavior therapy; Cognitive therapy; Drug therapy; Insomnia

MeSH Terms

Behavior Therapy
Cognitive Therapy
Drug Therapy
Quality of Life
Relaxation
Sleep Initiation and Maintenance Disorders*
Sleep Wake Disorders
Receptors, GABA-A
Receptors, Melatonin

Reference

1. Ellis JG, Perlis ML, Neale LF, Espie CA, Bastien CH. The natural history of insomnia: focus of prevalence and incidence of acute insomnia. J Psychiatr Res. 2012; 46:1278–1285.

2. Terzano MG, Parrino L, Cirignotta F, Ferini-Strambi L, Gigli G, Rudelli G, et al. Insomnia in primary care, a survey conducted on the Italian population. Sleep Med. 2004; 5:67–75.

3. Espie CA, Kyle SD, Hames P, Cyhlarova E, Benzeval M. The daytime impact of DSM-5 insomnia disorder: comparative analysis of insomnia subtypes from the Great British Sleep Survey. J Clin Psychiatry. 2012; 73:e1478–e1484.

4. Leger D, Morin CM, Uchiyama M, Hakimi Z, Cure S, Walsh JK. Chronic insomnia, quality-of-life, and utility scores: comparison with good sleepers in a cross-sectional international survey. Sleep Med. 2012; 13:43–51.

5. Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011; 135:10–19.

6. Phillips B, Mannino DM. Do insomnia complaints cause hypertension or cardiovascular disease? J Clin Sleep Med. 2007; 3:489–494.

7. Woo JM, Hyun SY, Lee SH, Kang SG, Lee JS, Kim L, et al. Productivity time lost by sleep disturbance among workers in Korea. J Korean Neuropsychiatr Assoc. 2011; 50:62–68.

8. Walsh JK. Clinical and socioeconomic correlates of insomnia. J Clin Psychiatry. 2004; 65:Suppl 8. 13–19.

9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association;2013.

10. American Academy of Sleep Medicine. The international classification of sleep disorders: diagnostic and coding manual. 2nd ed. Westchester: American Academy of Sleep Medicine;2005.

11. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008; 4:487–504.

12. Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update: an American Academy of Sleep Medicine. Sleep. 2006; 29:1415–1419.

13. Kopta SM, Howard KI, Lowry JL, Beutler LE. Patterns of symptomatic recovery in psychotherapy. J Consult Clin Psychol. 1994; 62:1009–1016.

14. Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systemic review. BMC Fam Pract. 2012; 13:40.

15. Edinger JD, Sampson WS. A primary care "friendly" cognitive behavioral insomnia therapy. Sleep. 2003; 26:177–182.

16. Siebern AT, Suh SY, Nowakowski S. Non-pharmacological treatment of insomnia. Neurotherapeutics. 2012; 9:717–727.

17. Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia: an American Academy of Sleep Medicine review. Sleep. 1999; 22:1134–1156.

18. Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock's comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lipppincott Williams and Wilkins;2009. p. 2150–2157.

19. Buysse DJ, Strollo PJ Jr, Black JE, Zee PG, Winkelman JW. Sleep disorders. Hales RE, Yodifsky SC, Gabbard GO. The American Psychiatric Publishing textbook of psychiatry. 5th ed. Arlington, VA: American Psychiatric Publishing;2008. p. 921–936.

20. Stepanski EJ, Wyatt JK. Use of sleep hygiene in the treatment of insomnia. Sleep Med Rev. 2003; 7:215–225.

21. Holbrook AM, Crowther R, Lotter A, Cheng C, King D. Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ. 2000; 162:225–233.

22. Roth T, Roehrs TA. A review of the safety profiles of benzodiazepine hypnotics. J Clin Psychiatry. 1991; 52:Suppl. 38–41.

23. Mendelson WB. Clinical distinctions between long-acting and short-acting benzodiazepines. J Clin Psychiatry. 1992; 53:Suppl. 4–7.

24. Roehrs T, Pedrosi B, Rosenthal L, Roth T. Hypnotic self administration and dose escalation. Psychopharmacology (Berl). 1996; 127:150–154.

25. Paterniti S, Dufouil C, Alperovitch A. Long-term benzodiazepine use and cognitive decline in the elderly: the Epidemiology of Vascular Aging Study. J Clin Psychopharmacol. 2002; 22:285–293.

26. Allain H, Bentue-Ferrer D, Polard E, Akwa Y, Patat A. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging. 2005; 22:749–765.

27. Cumming RG, Le Couteur DG. Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs. 2003; 17:825–837.

28. Wilson S, Nutt D. Drug treatment of chronic insomnia: dawn at the end of a long night? J Psychopharmacol. 2008; 22:703–706.

29. Walsh JK, Krystal AD, Amato DA, Rubens R, Caron J, Wessel TC, et al. Nightly treatment of primary insomnia with eszopiclone for 6 months: effect on sleep, quality of life, and work limitations. Sleep. 2007; 30:959–968.

30. Krystal AD, Erman M, Zammit GK, Soubrane C, Roth T. ZOLONG Study Group. Long-term efficacy and safety of zolpidem extended-release 12.5 mg, administered 3 to 7 nights per week for 24 weeks, in patients with chronic primary insomnia: a 6-month, randomized, double-blind, placebo-controlled, parallel-group, multicenter study. Sleep. 2008; 31:79–90.

31. Ancoli-Israel S, Richardson GS, Mangano RM, Jenkins L, Hall P, Jones WS. Long-term use of sedative hypnotics in older patients with insomnia. Sleep Med. 2005; 6:107–113.

32. Morgenthaler TI, Silber MH. Amnestic sleep-related eating disorder associated with zolpidem. Sleep Med. 2002; 3:323–327.

33. Ministry of Food and Safety. Drug safety communications: insomnia drugs containing zolpidem. Seoul: Ministry of Food and Safety;2013. cited 2013 Aug 10. Available from: http://www.mfds.go.kr/index.do?mid=57&seq=19505&cmd=v.

34. Hardeland R. New approaches in the management of insomnia: weighing the advantages of prolonged-release melatonin and synthetic melatoninergic agonists. Neuropsychiatr Dis Treat. 2009; 5:341–354.

35. Roth T, Zee PC, Wang-Weigand S, Zhang J, Zee P. Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia. Sleep Med. 2006; 7:312–318.

36. Pandi-Perumal SR, Srinivasan V, Poeggeler B, Hardeland R, Cardinali DP. Drug insight: the use of melatonergic agonists for the treatment of insomnia-focus on ramelteon. Nat Clin Pract Neurol. 2007; 3:221–228.

37. Roth T, Seiden D, Sainati S, Wang-Weigand S, Zhang J, Zee P. Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia. Sleep Med. 2006; 7:312–318.

38. Descamps A, Rousset C, Millan MJ, Spedding M, Delagrange P, Cespuglio R. Influence of the novel antidepressant and melatonin agonist/serotonin 2C receptor antagonist, agomelatine, on the rat sleep-wake cycle architecture. Psychopharmacology (Berl). 2009; 205:93–106.

39. Leproult R, Van Onderbergen A, L'hermite-Balériaux M, Van Cauter E, Copinschi G. Phase-shifts of 24-h rhythms of hormonal release and body temperature following early evening administration of the melatonin agonist agomelatine in healthy older men. Clin Endocrinol (Oxf). 2005; 63:298–304.

40. Krystal AD, Lankford A, Durrence HH, Ludington E, Jochelson P, Rogowski R, et al. Efficacy and safety of doxepin 3 and 6mg in a 35-day sleep laboratory trial in adults with chronic primary insomnia. Sleep. 2011; 34:1433–1442.

41. Walsh JK, Erman M, Erwin CW, Jamieson A, Mahowald M, Regestein Q, et al. Subjective hypnotic efficacy of trazodone and zolpidem in DSM-III-R primary insomnia. Hum Psychopharmacol. 1998; 13:191–198.

42. Aslan S, Isik E, Cosar B. The effects of mirtazapine on sleep: a placebo controlled, double-blind study in young healthy volunteers. Sleep. 2002; 25:677–679.

43. Coe HV, Hong IS. Safety of low doses of quetiapine when used for insomnia. Ann Pharmacother. 2012; 46:718–722.

44. Monti JM. Serotoinin control of sleep-wake behavior. Sleep Med Rev. 2011; 15:269–281.

45. Hoever P, Hay J, Rad M, Cavallaro M, van Gerven JM, Dingemanse J. Tolerability, pharmacokinetics, and pharmacodynamics of single-dose almorexant, an orexin receptor antagonist, in healthy elderly subjects. J Clin Psychopharmacol. 2013; 33:363–370.

46. Winrow CJ, Renger JJ. Discovery and development of orexin receptor antagonists as therapeutics for insomnia. Br J Pharmacol. 2013; 06. 03. [Epub]. http://dx.doi.org/10.1111/bph.12261.