AANP: Sleep Is Best Treatment for Insomnia

INDIANAPOLIS, June 25 -- Both behavioral and medication interventions have their place in treatment of insomnia.

"If you can get a patient to sleep, they worry less about being awake, they feel better during the day, and that confidence decreases the factors that take a person from transient to chronic insomnia," Phyllis Zee, M.D., Ph.D., a sleep specialist at Northwestern University told attendees at the American Academy of Nurse Practitioners meeting here.

Before it is possible to help patients return to healthy sleep patterns, those who are experiencing trouble must be identified, said co-presenter Mary Adams, R.N., ANP, of Newark, Del. This is not always easy.

Studies have shown that 70% of patients do not seek treatment for insomnia. A similar percentage of patients say their health care provider has never asked them about their sleep or sleep habits.

"Clinicians need to ask their patients about their sleep habits and be able to recognize the signs and symptoms when they are present," Adams said.

A step-wise approach is suggested starting with discussing sleep patterns with the patient, diagnosing the reason, educating the person on good sleep practices, using non pharmacologic therapies, and finally going on to using medications if indicated.

Some interventions to attempt early in treatment include sleep hygiene measures, stimulation control therapy, restricting time spent in bed, and relaxation therapy.

Cognitive behavioral therapy (CBT) can help those who are kept awake by the fear of not falling asleep or other cognitive distortions such as unrealistic expectations, exaggerations of the consequences of insomnia and causal links that are not real.

"Non-pharmaceutical strategies like behavioral interventions are key to every patient with insomnia," said Dr. Zee. "There are individuals where that is not sufficient or they need to have sleep more quickly than the six to eight weeks that behavioral interventions sometimes require. There is a role for combining behavioral and pharmaceutical therapies."

When deciding which medication to prescribe, she said, consider whether the problem is delayed sleep onset or sleep maintenance. Some medications are indicated only for short-term use while others have no restrictions. Also, keep in mind that some are Schedule IV controlled substances and others are non-scheduled.

Zolpidem, for example, has shown improvements in latency, number of awakenings, and wakefulness after sleep onset versus placebo. Ramelteon significantly reduced patient-reported time to sleep versus placebo. Neither tolerance nor rebound is a problem with either one, Dr. Zee said.

A National Institutes of Health State-of-the-Science statement said that both benzodiazepine and non-benzodiazepine medications have demonstrated efficacy in managing insomnia, Dr. Zee noted. The non-BZD medications have a lower frequency and severity of adverse events. The same group raised significant concerns about using over-the-counter and herbal preparations, antidepressant, and antipsychotic use in this group.

"Another important aspect of treating insomnia is to know when referral to a sleep specialist is indicated," said Adams.

Among the indications are:

• Insomnia persisting despite a reasonable trial of treatment.
• Excessive daytime sleepiness that might endanger the patient or someone else.
• Unpleasant sensations occur during the night.
• The occurrence of restless legs, witnessed incidents of apnea.
• Unintentional sleep episodes, loss of muscle tone or hallucinations occur during the day, accompanied by disturbed sleep at night.