Insomnia: Therapeutic Approach

, MD, , MD, , Department of Psychiatry and Behavioral Medicine, University of Louisville School of Medicine, Louisville, Ky

South Med J. 2001;94(9) 

In This Article

Abstract and Introduction

Insomnia is a common complaint. Transient and short-term insomnias usually result from stress or the use of certain pharmaceuticals or drugs and may be managed by reduced caffeine use, behavioral means, and/or pharmacologic treatment. Long-term insomnia is often a symptom of a medical or psychiatric condition or a primary sleep disorder. A diagnostic workup is expected; treatment should focus on the causative condition, as well as addressing the sleep problem itself. Established medications for the symptomatic treatment of insomnia include benzodiazepines, zolpidem, zaleplon, and certain antidepressant or occasionally antihistaminic drugs.

Introduction

Insomnia is characterized by difficulty in initiating or maintaining sleep and by finding sleep nonrestorative.[1] Insomnia periodically affects 50% of adults,[2] and more than 90% of the population have trouble with sleep at some point during their lives.[3] Insomnia becomes a problem when excessive daytime sleepiness impairs feeling well and performing functions that require alertness. Inadequate sleep can result in adverse personal, medical, or psychiatric sequela and increased risk for accidents. Many people with a sleep problem seek help from their doctor.[4] Difficulties with sleep are divided into transient, short-term insomnias and more chronic versions ( Table 1 ).

Transient and short-term insomnias lasting from days to weeks, are common during emotional distress.[5] Bereavement or other personal crises often disturb sleep. Such difficulty is observed also initially with the initiation, use, or discontinuance of certain pharmaceuticals or drugs and ethanol.[6] This includes stimulants, such as theophylline, cocaine, and caffeine. The emergence of some physical illnesses, such as peptic ulcer disease, with awakenings due to dyspepsia, also can present in such a way. The same can occur with environmental disturbances and job shift changes or travel-initiated jet lag.[6]

Chronic insomnias last over several weeks[7] and are usually related to specific medical or psychiatric conditions[8,9]; the nocturia of prostatic hypertrophy is an example. Depression and anxiety-related disorders are common causes of poor sleep and characterize the bulk of psychiatric causes.[1] Psychophysiologic insomnia can emerge once one becomes worried about insomnia, thus actually perpetuating conditioned inability to sleep. There are also a number of primary sleep disorders.

Medical evaluation of insomnia should define a causative diagnosis with an etiology-specific treatment plan. Insomnias may call also for the use of "sleeping pills." Combining time-linked drug treatments with nonpharmacologic therapies gives the best results.

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