Managing insomnia

Sleep hygiene should be considered the foundation of a good night’s sleep for everyone. Good sleep hygiene habits include controlling the bedroom environment (dark, quiet and cool is best), exercising earlier in the day, avoiding caffeine and nicotine, restricting alcohol before bedtime, winding down an hour before bed, keeping a consistent bed and wake time, and avoiding liquids before bed. These simple lifestyle changes can help prevent a few nights of poor sleep from turning into a longstanding problem.

Over-the-counter medications, most of which contain sedating antihistamines, may be helpful for many patients who require only intermittent or short-term treatment, but they are usually not helpful for those with more persistent insomnia and may even be detrimental.

For those with chronic insomnia, following proper sleep hygiene guidelines is not going to cure the problem. Although good habits still need to be followed, the addition of other treatments can prove beneficial.

There are different treatment approaches that can be effective for insomnia, and discussing the options with your primary care doctor or sleep specialist may help you decide the most appropriate course. If you have tried various treatments with your primary care physician and are still not making much improvement, then you should ask for a referral or seek out a sleep specialist.

One option, not widely known, is cognitive-behavior therapy for insomnia, or CBT-I. This approach may be particularly useful for those who prefer not to take medications to help them sleep. It is an evidence-based, nondrug, short-term (usually four to eight sessions) therapy based on the concept that chronic insomnia is maintained by a number of physical and behavioral factors. These factors then become the focus of treatment.

Therapy includes, for example, education about what can interfere with sleep, sleep hygiene measures, individualized sleep-wake scheduling programs, elimination of sleep-incompatible behaviors (like watching TV), relaxation training and identification of challenging thoughts that can meddle with good sleep. It is considered by many sleep specialists to be a first-line treatment for insomnia.

Drugs for insomnia are considered when an underlying medical disorder, like depression, is contributing to the sleep disturbance, when a rapid elimination of the disturbance is required, or if behavioral approaches have been unsuccessful. Prescription medications require that the insomnia be evaluated by a medical professional. Different classes of medications can be helpful, including regular sleeping pills (hypnotics), sedating antidepressants, sedating antipsychotics and atypical medications like melatonin or melatonin-stimulating drugs.

The most well-known sleeping pills are the non-benzodiazepine hypnotics like Ambien, Lunesta or Sonata. These drugs affect structures in the brain called GABA receptors. When used appropriately, these medications can be very helpful and have few side effects. There are certain individuals, though, who should not take hypnotics, including most patients with suspected obstructive sleep apnea and women who are pregnant or nursing.

Patients who have anxiety, depression or psychotic disorders may need treatment with psychiatric medications. Sedating antianxiety medications, antidepressants or antipsychotic medications may be helpful in such cases.

When medication is used, good sleep hygiene and some behavioral treatments are still important, as utilizing either behavioral or medication treatments alone are not enough. Some patients benefit from a combination of both cognitive-behavior therapy and medication, and even choose to begin both treatments simultaneously. As sleep improves, they are slowly weaned off the medication while shifting focus solely to behavioral methods to maintain good sleep.