User:Caimolgn/Insomnia

Insomnia

Insomnia, also known as sleeplessness, is a sleep disorder in which people have trouble sleeping. They may have frequent morning awakenings, difficulty falling asleep or difficulty staying asleep. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. It may result in an increased risk of motor vehicle collisions, as well as problems focusing and learning. Additional impacts of insomnia may include impaired job performance, more visits for health care services and increased stagnant days spent in bed. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month.

Insomnia can occur independently or as a result of another problem. Conditions that can result in insomnia include psychological stress, chronic pain, heart failure, hyperthyroidism, heartburn, restless leg syndrome, menopause, allergies, diabetes, certain medications, and drugs such as caffeine, nicotine, and alcohol. A few medications that have been associated with insomnia include salbutamol, serotonin antidepressants and psychostimulants like methylphenidate. Other risk factors for insomnia include working night shifts, sleep apnea and travelling across different time zones. Diagnosis is based on sleep habits and an examination to look for underlying causes. A sleep study may be done to look for underlying sleep disorders. Screening may be done with two questions: "do you experience difficulty sleeping?" and "do you have difficulty falling or staying asleep?"

Sleep hygiene and lifestyle changes are typically the first treatment for insomnia. Sleep hygiene includes practicing a consistent bedtime, limiting exposure to sunlight, ensuring a quiet and dark room, establishing a pre-bed ritual such as reading and regular exercise. In addition, using the bedroom for only sleeping and intimacy and avoiding excessive other activities such as studying or working in the bedroom. Cognitive behavioral therapy may be added to this. While sleeping pills may help, they are associated with injuries, dementia, and addiction. These medications are not recommended for more than four weeks. The effectiveness and safety of alternative medicine is unclear.

Between 10% and 30% of adults have insomnia at any given point in time and up to half of people have insomnia in a given year. In 2007, the financial burden for each individual with insomnia was estimated to be $5000 USD. Roughly 40% of people with insomnia have a diagnosable psychiatric disorder. About 6% of people have insomnia that is not due to another problem and lasts for more than a month. People over the age of 65 are affected more often than younger people. Females are more often affected than males. Descriptions of insomnia occur at least as far back as ancient Greece.

Risk Factors

Insomnia affects people of all age groups but the following groups have a higher chance of acquiring insomnia:

• Individuals older than 60
• History of mental health disorder including depression, etc.
• Emotional stress
• Working late night shifts
• Traveling through different time zones
• Having chronic diseases such as diabetes, kidney disease, lung disease, Alzheimer's, or heart disease
• Alcohol or drug use disorders
• Gastrointestinal reflux disease
• Heavy smoking
• Work stress
• Women

Substance-induced

Drug Induced

Medications that have been associated with insomnia include diuretics, oral contraceptives, anticonvulsants, antihypertensives and antibiotics.

Insomnia In Children

The child should undergo thorough assessments to rule out medical conditions such as ADHD or autism that may contribute to insomnia. It is estimated that 25% of children struggle with some aspect of sleep, with behavioural insomnia being the most commonly occurring sleep disorder in children. Insomnia in children may result in poor academic performance, poor decision making, poor impulse control and mood irritability. Behavioural interventions are the appropriate first line recommendation as there are currently no FDA approved medications for insomnia in children. Guardians should aid with establishing bedtime routines for the child, and implementing relaxation techniques.

Prevention

Prevention and treatment of insomnia should always start with implementation of lifestyle changes. In addition to lifestyle changes, insomnia may require a combination of cognitive behavioral therapy and/or medications.

Among lifestyle practices, going to sleep and waking up at the same time each day can create a steady pattern which may help to prevent insomnia. Avoidance of vigorous exercise and caffeinated drinks 6 hours before going to sleep is recommended, while exercise earlier in the day may be beneficial. Other practices to improve sleep hygiene may include:

• Avoiding or limiting naps to increase the drive to sleep at night
• Treating pain at bedtime
• Avoiding large meals, beverages, alcohol, and nicotine before bedtime
• Finding soothing ways to relax into sleep, including use of white noise
• Making the bedroom suitable for sleep by keeping it dark, cool, and free of lights
• Turn off devices such as clocks, cell phones, or televisions
• Maintain regular exercise
• Try relaxing activities before sleeping

Management

Insomnia may be secondary to another medical condition such as depression, sleep apnea, or chronic pain. The management of insomnia should always start with optimizing treatment of any comorbid medical conditions that may contribute to insomnia. It is necessary to rule out medical and psychological potential causes for sleeplessness before deciding on the treatment for insomnia. Cognitive behavioral therapy (CBT) is generally the first line treatment once this has been done. It has been found to be effective for chronic insomnia. The beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the stopping of therapy.

Medications have been used mainly to reduce symptoms in insomnia of short duration; their role in the management of chronic insomnia remains unclear. Several different types of medications may be used. Many doctors do not recommend relying on prescription sleeping pills for long-term use. Many people with insomnia remain insufficiently treated as of 2003.

Non-Medication Based

Non-medication based strategies have comparable efficacy to hypnotic medication for insomnia and they may have longer lasting effects. Hypnotic medication is only recommended for short-term use because dependence with rebound withdrawal effects upon discontinuation or tolerance can develop.

Non medication based strategies provide long lasting improvements to insomnia and are recommended as a first line and long-term strategy of management. Behavioral sleep medicine (BSM) tries to address insomnia with non-pharmacological treatments. The BSM strategies used to address chronic insomnia include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, paradoxical intention, patient education, and relaxation therapy. Some examples are keeping a journal, restricting the time spent awake in bed, practicing relaxation techniques, and maintaining a regular sleep schedule and a wake-up time. Behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. Behavioral therapy may include, learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies and regulating the circadian clock.

Music may improve insomnia in adults (see music and sleep). EEG biofeedback has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as quality of sleep. Self-help therapy (defined as a psychological therapy that can be worked through on one's own) may improve sleep quality for adults with insomnia to a small or moderate degree.

Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of sleep hygiene. Examples of such environmental modifications include using the bed for sleep or intimacy only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not result in a reasonably brief period of time after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during nighttime hours, and eliminating daytime naps.

A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation. Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when sleep efficiency improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock. Bright light therapy may be effective for insomnia.

Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).

Cognitive Behavioural Therapy

Main article: Cognitive behavioral therapy for insomnia

There is some evidence that cognitive behavioral therapy for insomnia (CBT-I) is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include:

1. unrealistic sleep expectations (e.g., I need to have 8 hours of sleep each night)
2. misconceptions about insomnia causes (e.g., I have a chemical imbalance causing my insomnia)
3. amplifying the consequences of insomnia (e.g., I cannot do anything after a bad night's sleep) and
4. performance anxiety after trying for so long to have a good night's sleep by controlling the sleep process.

Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and the relaxation therapies. Hypnotic medications have a quick onset whereas CBT-I takes several weeks to notice any effect. Both options are equally effective in the short-term treatment of insomnia, but their effects wear off over time due to tolerance. The effects of CBT-I have sustained and lasting effects on treating insomnia long after therapy has been discontinued. The addition of hypnotic medications with CBT-I adds no benefit in insomnia. The long lasting benefits of a course of CBT-I shows superiority over pharmacological hypnotic drugs. Even in the short term when compared to short-term hypnotic medication such as zolpidem, CBT-I still shows significant superiority. Thus CBT-I is recommended as a first line treatment for insomnia.

CBT is the first line, well-accepted form of therapy for insomnia since it has no known adverse effects, whereas taking medications to alleviate insomnia symptoms have been associated with withdrawal, dependence and tolerance. CBT-I typically consists of once weekly sessions, 6-8 weeks in duration. And so, the downside of CBT is that it may be a tedious process that some cannot commit to or afford.

Metacognition is a recent trend in approach to behaviour therapy of insomnia.

Medications

Many people with insomnia use sleeping tablets and other sedatives. In some places medications are prescribed in over 95% of cases. They, however, are a second line treatment. In 2019, the US Food and Drug Administration stated it is going to require warnings for eszopiclone, zaleplon, and zolpidem, due to concerns about serious injuries resulting from abnormal sleep behaviors, including sleepwalking or driving a vehicle while asleep.

The percentage of adults using a prescription sleep aid increases with age. During 2005–2010, about 4% of U.S. adults aged 20 and over reported that they took prescription sleep aids in the past 30 days. Rates of use were lowest among the youngest age group (those aged 20–39) at about 2%, increased to 6% among those aged 50–59, and reached 7% among those aged 80 and over. More adult women (5%) reported using prescription sleep aids than adult men (3%). Non-Hispanic white adults reported higher use of sleep aids (5%) than non-Hispanic black (3%) and Mexican-American (2%) adults. No difference was shown between non-Hispanic black adults and Mexican-American adults in use of prescription sleep aids.

Antihistamines

As an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief by taking over-the-counterantihistamines such as diphenhydramine or doxylamine. Diphenhydramine and doxylamine are widely used in nonprescription sleep aids. They are the most effective over-the-counter sedatives currently available, at least in much of Europe, Canada, Australia, and the United States, and are more sedating than some prescription hypnotics. Antihistamine effectiveness for sleep has been shown to rapidly decrease over very little time. In one study, those taking diphenhydramine subjectively reported to being more successful for inducing sleepiness versus those taking placebo on day 1. But by day 4 of the study, levels of sleepiness achieved by diphenhydramine and placebo were indistinct. Moreover, antihistamines produce anticholinergic side-effects such as dry mouth and urinary retention, which may also be a drawback with these particular drugs. Antihistamine use is recommended to avoid in the elderly aged 65 years old and up. While addiction does not seem to be an issue with this class of drugs, they can induce dependence and rebound effects upon abrupt cessation of use.^{[citation needed]} However, people whose insomnia is caused by restless legs syndrome may have worsened symptoms with antihistamines.

Melatonin

The evidence for melatonin in treating insomnia is generally poor. There is low quality evidence that it may speed the onset of sleep by 6 minutes. However, melatonin may be helpful in regulating the circadian rhythm and may be useful in insomnia related to jet lag specifically. Melatonin has shown potential benefit for those that sleep early, advanced sleep phase disorder, or sleep late, delayed sleep phase disorder in that melatonin may help to restore the sleep schedule to a societal normal time. Ramelteon, a melatonin receptor agonist, does not appear to speed the onset of sleep or the amount of sleep a person gets.

Most melatonin drugs have not been tested for longitudinal side effects. Prolonged-release melatonin may improve quality of sleep in older people with minimal side effects.

Studies have also shown that children who are on the Autism spectrum or have learning disabilities, Attention-Deficit Hyperactivity Disorder (ADHD) or related neurological diseases can benefit from the use of melatonin. This is because they often have trouble sleeping due to their disorders. For example, children with ADHD tend to have trouble falling asleep because of their hyperactivity and, as a result, tend to be tired during most of the day. Another cause of insomnia in children with ADHD is the use of stimulants used to treat their disorder. Children who have ADHD then, as well as the other disorders mentioned, may be given melatonin before bedtime in order to help them sleep.

Antidepressants

While insomnia is a common symptom of depression, antidepressants are effective for treating sleep problems whether or not they are associated with depression. While all antidepressants help regulate sleep, some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can have an immediate sedative effect, and are prescribed to treat insomnia. Amitriptyline and doxepin both have antihistaminergic, anticholinergic, and antiadrenergic properties, which contribute to both their therapeutic effects and side effect profiles, while mirtazapine's side effects are primarily antihistaminergic, and trazodone's side-effects are primarily antiadrenergic. Mirtazapine is known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep efficiency and increasing the total amount of sleeping time in people with both depression and insomnia. Mirtazapine may be beneficial in underweight populations as it is associated with weight gain.

Agomelatine, a melatonergic antidepressant with sleep-improving qualities that does not cause daytime drowsiness, is licensed for marketing in the European Union and TGA Australia. After trials in the United States its development for use there was discontinued in October 2011 by Novartis, who had bought the rights to market it there from the European pharmaceutical company Servier.

A 2018 Cochrane review found the safety of taking antidepressants for insomnia to be uncertain with no evidence supporting long term use.

Benzodiazepines

Normison (temazepam) and Serax (oxazepam) are benzodiazepines commonly prescribed for insomnia and other sleep disorders.

The most commonly used class of hypnotics for insomnia are the benzodiazepines. Benzodiazepines are not significantly better for insomnia than antidepressants. Chronic users of hypnotic medications for insomnia do not have better sleep than chronic insomniacs not taking medications. In fact, chronic users of hypnotic medications have more regular nighttime awakenings than insomniacs not taking hypnotic medications. Many have concluded that these drugs cause an unjustifiable risk to the individual and to public health and lack evidence of long-term effectiveness. It is preferred that hypnotics be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly. Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of nonbenzodiazepines.

The benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of side-effects such as day time fatigue, motor vehicle crashes and other accidents, cognitive impairments, and falls and fractures. Elderly people are more sensitive to these side-effects. Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer term benzodiazepines can lead to tolerance, physical dependence, benzodiazepine withdrawal syndrome upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods of time. Benzodiazepines, while inducing unconsciousness, actually worsen sleep as – like alcohol – they promote light sleep while decreasing time spent in deep sleep. A further problem is, with regular use of short-acting sleep aids for insomnia, daytime rebound anxiety can emerge. Although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase. This is likely due to their addictive nature, both due to misuse and because – through their rapid action, tolerance and withdrawal they can "trick" insomniacs into thinking they are helping with sleep. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the long-term use of benzodiazepines and is recommended whenever possible.

Benzodiazepines all bind unselectively to the GABA_A receptor. Some theorize that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α₁ subunit of the GABA_A receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α₁subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics – alprazolam and diazepam, in turn, have higher activity at the α₂ subunit compared to triazolam and temazepam, making them superior anxiolytic agents). Modulation of the α₁ subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). Modulation of the α₂ subunit is associated with anxiolytic activity and disinhibition. For this reason, certain benzodiazepines may be better suited to treat insomnia than others.

Orexin Blockers

Orexin blockers regulate the neurotransmitters responsible for wakefulness. Suvorexant is an FDA approved medication for insomnia when there are difficulties with sleep onset and/or sleep maintenance in those 18 years old and up. In one randomized control trial, lemborexant significantly improved both sleep onset and maintenance compared to both placebo and zolpidem, a nonbenzodiazepine sedative. It is well established that orexin blockers are more effective than placebo. The comparison of orexin blockers to other insomnia medications is not well defined; however, orexin blockers relative lack of rebound insomnia and withdrawal when compared to benzodiazepines perhaps make it a favourable choice. Orexin blockers are more expensive that benzodiazepine drugs.

Other Sedatives

Drugs that may prove more effective and safer than benzodiazepines for insomnia is an area of active research. Nonbenzodiazepine sedative-hypnotic drugs, such as zolpidem, zaleplon, zopiclone, and eszopiclone, are a class of hypnotic medications that are similar to benzodiazepines in their mechanism of action, and indicated for mild to moderate insomnia. However, unlike benzodiazepines, nonbenzodiazepine sedative drugs are not indicated for anxiety. Their effectiveness at improving time to sleeping is slight, and they have similar – though potentially less severe – side effect profiles compared to benzodiazepines.

Prescribing of nonbenzodiazepines has seen a general increase since their initial release on the US market in 1992, from 2.3% in 1993 among individuals with sleep disorders to 13.7% in 2010.

Barbiturates, while once used, are no longer recommended for insomnia due to the risk of addiction and other side affects.

Alternative Medicine

Alternative medicine includes L-Trptophan and herbs such as valerian, chamomile, lavender, or cannabis. L-Tryptophan is a precursor to metabolites including serotonin and melatonin. These alternatives may be used and explored, but there is no clinical evidence that they are effective. Consumers should consider the placebo effect. It is unclear if accupuncture is useful.

Cannabis

The evidence for cannabis efficacy in insomnia remains unclear as there are few trials available. There have been anecdotal reports that cannabis helps with initiation of sleep initially but may be associated with disrupted sleep or poorer sleep quality with chronic use. Upon discontinuation of cannabis, sleep difficulties and unpleasant dreams may last for weeks. A few hurdles with Cannabis include which route of administration is the most optimal, which dose is the most effective for sedative properties and perhaps the disagreement of state and federal legislation surrounding marijuana in the United States.