30-50% of adults report transient concerns with insomnia and about 5-10% of adults have chronic problems with insomnia. Insomnia is defined as a subjective difficulty with initiating or maintaining sleep that results in daytime impairment. It can occur as a primary disorder or as a secondary disorder related to another medical condition, medication side effect, or environmental or lifestyle concern.
Insomnia is a common symptom in various psychiatric disorders, including mood and anxiety disorders. In fact it is a criteria for several DSM 5 Anxiety Disorders and one of the criteria for Major Depressive Disorder. It is important to inquire about sleep disturbance as part of a psychiatric assessment, especially because there is clear evidence that the presence of insomnia in mental health disorders leads to more impairment in functioning. It is important to carefully assess for medical problems that could be causing or contributing to the insomnia, as well as side effects (from prescribed medications, alcohol and illegal drug use, and caffeine) that could be contributing factors. It is also important to ask about sleep hygiene and a patient’s bedtime routine if the patient is reporting a sleep disturbance.
Once the above assessment has been completed, treatment of insomnia includes pharmacological and non-pharmacological approaches. For most patients with co-morbid anxiety or mood disorder and insomnia, one should consider treating the insomnia separately, as treatment for the anxiety or mood symptoms traditionally with an SSRI or other antidepressant medication can take a few weeks to be effective. This is especially important to consider if the insomnia is causing a lot of impairment, to help achieve more immediate relief. Several studies have shown that treating the insomnia concurrently helps improve the response of the co-morbid mental health disorder to treatment.
Currently, the FDA has several approved drugs for the short-term treatment of insomnia: non-benzodiazepines (eszopiclone, zolpidem, zolpidem ER, and zaleplon); benzodiazepines (estazolam, flurazepam, quazepam, temazepam, and triazolam; a tricylic antidepressant (low-dose sinequan); an orexin inhibitor (Belsomra or suvorexant) and a melatonin agonist: ramelteon. These FDA approved agents have been shown to have efficacy for short-term management of insomnia for 4-6 weeks but have not been studied for long-term use. Both non-benzodiazepines and benzodiazepines are associated with adverse effects that include fatigue, dizziness, ataxia, and the development of dependence and tolerance with long-term use. Belsomra also shares some of these concerns. If there is concern about alcohol or other substance abuse, avoid a sleep agent that could have a risk of addiction. Long-term use of non-benzodiazepines or benzodiazepines needs to be reassessed monthly. Short-acting benzodiazepines like Xanax and Ativan are not effective medications for insomnia, particularly if sleep maintenance is an issue. Non-FDA approved options for insomnia include: Melatonin, Benadryl and Trazodone. Even though they are not FDA approved, they are also good options because they can be used on a more long-term basis if needed because they do not carry a risk for addiction. They do have possible side effects related to grogginess and dizziness.
Generally a sleep medication should not be taken if the patient is not planning on getting 7-8 hours of sleep and should not be taken in the middle of the night. These medications should be used cautiously in older patients because of fall risks and risk of daytime sedation.
Non-pharmacological approaches to treat insomnia related to anxiety are also well-studied. Cognitive behavioral therapy for insomnia (CBT-I) is a well-studied therapy approach to treating insomnia but it is underutilized. Components of CBT-I include stimulus control, sleep hygiene, sleep restriction, relaxation techniques, and cognitive therapy. If one cannot find a therapist to help a patient with CBT-I, there are self-help books offering CBT-I that are also available, including “The Insomnia Answer” by Paul Glovinsky and Art Spielman and “Quiet Your Mind and Get to Sleep” by Colleen E. Carney and Rachel Manber.
Consider referral to a sleep specialist if treatment is not working and/or if a specific sleep disorder, like obstructive sleep apnea, periodic limb movements, narcolepsy or rapid eye movement behavior disorder, is suspected.
The goal of this article is to reiterate the importance of assessing for and potentially treating sleep disturbance that is related to other psychiatric conditions. The treatment for insomnia specifically can help to see better outcomes for the treatment of the other mental health disorder as a whole. Please feel free to utilize SmartCare provider line 858-880-6405 for help on specific cases.