Insomnia

Insomnia is a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and being unable to return to sleep. It can lead to daytime fatigue, poor concentration, irritability, and reduced quality of life. Insomnia may be acute (short-term, lasting days to weeks) or chronic (lasting 3 months or longer and occurring at least 3 times a week).

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Causes of Insomnia

• Lifestyle factors: Caffeine, nicotine, alcohol, irregular sleep schedule, excessive screen use before bedtime.

• Psychological conditions: Anxiety, depression, stress, post-traumatic stress disorder (PTSD).

• Medical conditions: Chronic pain, asthma, gastroesophageal reflux disease (GERD), overactive thyroid, restless legs syndrome, sleep apnea, cardiovascular disease.

• Medications: Corticosteroids, stimulants, some antidepressants, beta-blockers, decongestants.

• Environmental factors: Noise, uncomfortable bed, extreme temperatures, shift work, jet lag.

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Symptoms of Insomnia

• Difficulty falling asleep (sleep latency > 30 minutes).

• Waking frequently during the night.

• Early morning awakening with inability to fall back asleep.

• Daytime sleepiness and fatigue.

• Mood changes: irritability, anxiety, low mood.

• Reduced concentration, memory problems, decreased productivity.

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Diagnosis

• Clinical history: Sleep patterns, daily habits, stressors, medications, and medical history.

• Sleep diary: Tracking bedtime, wake time, awakenings, naps.

• Actigraphy: Wrist-worn device to monitor sleep/wake patterns.

• Polysomnography (sleep study): For suspected sleep apnea or other complex sleep disorders.

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Management of Insomnia

1. Non-Pharmacological Treatments (First-Line)

   • Cognitive Behavioral Therapy for Insomnia (CBT-I): Evidence-based, highly effective. Techniques include sleep restriction, stimulus control, relaxation, and cognitive restructuring.

   • Sleep hygiene:

     • Maintain regular sleep/wake times.

     • Avoid stimulants (caffeine, nicotine) close to bedtime.

     • Reduce alcohol and heavy meals late at night.

     • Limit screen exposure before sleep.

     • Ensure comfortable sleep environment (dark, quiet, cool).

   • Relaxation techniques: Meditation, deep breathing, progressive muscle relaxation.

   • Exercise: Regular daytime physical activity improves sleep quality.

2. Pharmacological Treatments (When non-drug approaches fail or for short-term use)

   • Benzodiazepines (e.g., temazepam, lorazepam): Effective for sleep initiation but risk of dependence and tolerance.

   • Non-benzodiazepine hypnotics (Z-drugs): Zolpidem, zaleplon, eszopiclone; used short-term for sleep onset and maintenance.

   • Melatonin and melatonin receptor agonists: Melatonin supplements or ramelteon can help regulate circadian rhythm.

   • Antidepressants with sedative effects: Trazodone, mirtazapine, or doxepin (low dose) may be useful in comorbid depression/anxiety.

   • Antihistamines (diphenhydramine, hydroxyzine): Sometimes used but may cause next-day drowsiness and anticholinergic effects.

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Doses (Typical Examples – may vary by country and patient factors)

• Zolpidem: 5–10 mg orally at bedtime (short-term).

• Temazepam: 7.5–30 mg orally at bedtime (short-term).

• Melatonin: 2–5 mg taken 30–60 minutes before bedtime.

• Doxepin (low-dose for sleep): 3–6 mg orally at bedtime.

Note: Doses must be individualized, especially in elderly patients due to risk of falls and cognitive impairment.

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Contraindications

• Severe liver or respiratory disease (with sedatives).

• Sleep apnea (caution with hypnotics).

• Pregnancy and breastfeeding (avoid most hypnotics).

• History of substance abuse (avoid benzodiazepines and Z-drugs).

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Side Effects

• Daytime drowsiness, dizziness, headache.

• Dependence and tolerance (benzodiazepines, Z-drugs).

• Rebound insomnia after withdrawal.

• Impaired memory or concentration.

• Falls and accidents (especially in older adults).

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Precautions

• Use lowest effective dose for shortest duration possible.

• Avoid combining sedative medications with alcohol.

• Monitor for depression, anxiety, or underlying medical conditions.

• In elderly patients, avoid strong sedatives when possible; prefer CBT-I or melatonin.

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Drug Interactions

• CNS depressants (opioids, alcohol, antihistamines, antipsychotics): Additive sedation and respiratory depression.

• CYP3A4 inhibitors (ketoconazole, erythromycin, fluvoxamine): Increase levels of zolpidem and benzodiazepines.

• CYP inducers (rifampin, carbamazepine): Reduce effectiveness of hypnotics.

• SSRIs: May alter metabolism of sedative antidepressants