Treatment of insomnia

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The effective management of insomnia begins with recognition and adequate assessment. Family doctors and other health care providers should routinely enquire about sleep habits as a component of overall health assessment. Identification and treatment of primary psychiatric disorders, medical conditions, circadian disorders, or specific physiological sleep disorders, such as sleep apnea and periodic limb movement disorder, are essential steps in the management of insomnia [8].

Insomnia may be distinguished in two different states. The first is a state of transient insomnia due to an acute event, while the second is the state of chronic insomnia. What is required in the first case is a treatment lasting for a few days only, i.e., for the period of the underlying event that caused insomnia. Such a case requires a medicine able to induce sleep immediately, while its effect quickly diminishes, so that the individual does not experience after effects when awakened. In the case of chronic insomnia, i.e. , when a person cannot relax in order to fall asleep, the therapeutic effort should be aimed at the reduction of chronic stress. The objective is to reduce the level of arousal when going to bed. Thus, the treatment may be more on a psychological basis, employing psychotherapeutic techniques, so that the patient can control the levels of his or her stress. In fact, all psychotherapeutic techniques, ranging from those of a psychoanalytical nature to those of behavioral or cognitive orientation, aim at a long-term reduction of the patient's inner conflicts and levels of stress. Consequently, all successful psychotherapeutic endeavors lead to a more effective stress management, creating relaxation and smooth sleep induction. Another important factor, however, in the management of insomnia is that patients should be informed about the underlying mechanisms causing their disorder. Therefore, a clarification of the physiological function of sleep, as well as the decline in the need for sleep as the individual grows older, helps at reducing stress linked to sleep disturbances. It is common that old people want to sleep more hours than are needed.

However, it is known that even older adults who do not complain of insomnia, manifest significantly disturbed sleep relative the younger subjects, indicating that many healthy older individuals apparently adapt their perception of what is "acceptable" sleep for their age [50].

It is worth mentioning that patients with primary insomnia overestimate their sleep onset latency and underestimate their total sleep time. In a recent study, when individuals with primary insomnia realized how distorted their perception of sleep was, they reported less anxiety and preoccupation about sleep [51]. In this context cognitive behavior therapy may be useful in young and middle-age patients with sleep-onset insomnia [52]. On the other hand, an effective sleep-inducing medication generates a feeling of reassurance to an insomniac patient. Knowing that, in case they cannot sleep, there is an effective drug at their disposal helps insomniacs reduce their stress and facilitates both the sleep induction and the overall quality of their sleep.

It is, therefore, inferred that apart from the psychologically oriented means of treating chronic insomnia, drugs can also be helpful. It should be mentioned, however, that drugs could help in two different ways. On the one hand, they may generate reassurance, as mentioned above. On the other hand, they may be used for generally reducing the level of stress. However, while in the first case the appropriate drug is a hypnotic of rapid effect and short half-life, in the second case the doctor should rather resort to a minor tranquilizer of longer half-life. In any event, approved hypnotic drugs have clearly been shown to improve subjective and objective sleep measures in various short-term situations [53].

Despite widespread use of standard hypnotics and sedating antidepressants for chronic insomnia, their role for this indication still needs to be defined by further research [8]. In particular, clinicians must be cautious with antidepressants, which disturb sleep architecture and have various side effects [54, 55].

On the other hand, hypnotics, although they improve total sleep time as well as sleep onset latency during short-term use, induce rebound insomnia after cessation of treatment [56, 57]. This is pertinent not only for the short half-life benzodiazepines, but also for newer hypnotic drugs such as zolpidem [58], whereas when they were first launched, there were reports of a more favorable profile for rebound insomnia and daytime anxiety [59]. Moreover, a recent review of controlled trials that compared benzodiazepines to the Z-drugs (zaleplon, zolpidem and zopiclone), for short-term management of insomnia, concludes that short-term-acting drugs are equally effective [60].

In clinical practice, it is not rare to find chronic insomniacs taking a hypnotic for years. In this population, a progressive 15-day withdrawal, may not help avoiding an immediate worsening of sleep parameters [61]. Furthermore, discontinuation of the hypnotic has been demonstrated to be a very difficult task for prolonged users of benzodiazepines, even when their medication taper was combined with cognitive-behavior therapy [62].

However, to avoid rebound insomnia as well as the progressive diminishing of effectiveness of the hypnotics during the chronic use, it has been suggested that they are not taken every night. This intermittent dosing strategy, which has recently been gaining popularity among clinicians, has been documented to be effective [63].

The hormone melatonin is involved in the control of the circadian system, and has been implicated in the control of sleep [64]. Several studies have examined the effectiveness of melatonin as a treatment of insomnia. While some researchers have reported a positive effect [65, 66], others have reported little or no effect [67, 68]. At present, the magnitude of beneficial effects following melatonin administration to insomniacs is unclear. Furthermore, the mechanism of action of this hormone with relation to sleep initiation, has not yet been fully described [69]. Finally, exposure to bright light therapy during the early morning hours has been reported to relieve sleep onset insomnia, even in elderly patients [70]. This may be due to the restoration of circadian rhythms in these insomniacs.

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