How is insomnia treated in conventional medicine?

Insomnia is often caused by another disease or psychological problem. In any such case, it is important that the underlying condition be treated to eradicate the insomnia. A psychologist or psychiatrist may be able to determine if psychological issues are causing the insomnia. A physical examination may help determine if the insomnia is caused by other health issues. Recent research has reported that cognitive behavior therapy can be more effective than medication in controlling insomnia. In this therapy, patients are taught improved sleep habits and are counseled on counter-productive thoughts about sleep. For success with this type of therapy, the individual may need to see a therapist weekly over two to three months.

The U.S. Food and Drug Administration (FDA) has issued warnings for all sedative-hypnotic drugs used for sleep regarding the potential for adverse events. Anaphylaxis and severe facial angioedema (swelling) can occur the first time a sleep product is taken. Complex sleep-related behaviors may include sleep-driving (driving while not fully awake, and with no memory of driving), making phone calls, and preparing and eating food while asleep.

Benzodiazepines: Benzodiazepines are a class of sedative/hypnotic drugs that were once the standard therapy for insomnia. The benzodiazepines used for insomnia include temazepam (Restoril®), flurazepam (Dalmane®), estazolam (ProSom®), and triazolam (Halcion®). Benzodiazepines have the potential of causing psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat. Benzodiazepines may cause depletion of the natural hormone melatonin from the body. Melatonin helps the body regulate sleep/wake cycles and circadian rhythm.

Non-benzodiazepines: In recent years, a newer class of sedative hypnotic medications has been developed, often termed the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and less adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien®), zaleplon (Sonata®), and eszopiclone (Lunesta®).

Zolpidem (Ambien®, Ambien CR®) may help the individual have a more restful sleep and stay asleep longer. It is typically prescribed for administration at bedtime and may be used when the individual has trouble falling asleep and/or staying asleep. Zaleplon (Sonata®) is generally used in individuals who have trouble falling asleep. It is often taken at bedtime or later, such as when awakening during the night, as long as there are at least four or more hours left to sleep. Eszopiclone (Lunesta®) helps people get to sleep faster and also appears to help the individual stay asleep through the night. The FDA has approved Eszopiclone for patients who have difficulty falling asleep, as well as those who are unable to sleep through the night. Eszopiclone must be taken immediately before bedtime and the individual should make sure that he or she has a full eight hours devoted to sleeping before taking it. As with the other medications, side effects can occur, including daytime drowsiness, dry mouth, and dizziness. Unlike the other medications in this class which are recommended only for use on a temporary basis, Eszopiclone is approved for longer term use (longer than seven days).

Melatonin agonists: Ramelteon (Rozerem®) belongs to a new class of drugs called melatonin agonists. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle, also known as the circadian rhythm. Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Ramelteon is approved by the U.S. Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep. These drugs have a relatively mild side effect profile, a lower likelihood of causing morning sedation, and may lack the potential for abuse and dependence. The body regulates back to normal daytime levels of melatonin when it is daylight. Side-effects may include daytime sleepiness, dizziness, and fatigue.

Antidepressants: The sedating antidepressant medications most commonly used to help with sleep include trazodone (Desyrel®), amitriptyline (Elavil®), and doxepin (Sinequan®). When used for sleep, these medicines are used in lower doses than when used in the treatment of depression. Benefits of these antidepressants include a lack of addictive properties or tolerance and the added benefit of providing some analgesic (pain relieving) benefit. Side effects include dry mouth, blurred vision, a "hangover" in the morning, constipation, urinary retention, and nausea.    

Over The Counter (OTC) sleep aids: Antihistamines may be used short-term for insomnia. Diphenhydramine (Benadryl®) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl®, Nytol®, Sominex®) or in combination with other OTC items such as acetaminophen (Tylenol PM®). Combining diphenhydramine with acetaminophen has the added benefits of not only helping the individual sleep better, but providing pain relief also. OTC sleep aids are not intended for long term use, because dependency can develop. Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation. Also, many OTC products contain the same ingredients, such as acetaminophen which can be purchased in many combinations. Tylenol® and Tylenol PM® both contain acetaminophen and should not be taken together. Acetaminphen has been reported to cause severe liver damage in overdose. It is recommended by healthcare professionals to not take more than four grams of acetaminophen daily.    

Atypical antipsychotic drugs: Other medications used off-label for insomnia are low doses of the atypical antipsychotics, including quetiapine (Seroquel®), mirtazapine (Remeron®), and olanzapine (Zyprexa®). Antipsychotics appear to work by blocking the action of the neurotransmitters serotonin and dopamine, thus producing a tranquilizing, sedating, and antipsychotic effect. Atypical antipsychotics may increase the incidence of extrapyramidal side effects (abnormal movements, muscle stiffness/shaking, or an uncomfortable restless feeling) and weight gain in higher doses. More serious side effects may include diabetes and high cholesterol and triglycerides.

Others: Requip® (ropinirol) may be used if restless leg syndrome (RLS) is present. Restless legs syndrome (RLS) causes a powerful urge to move the legs. The legs become uncomfortable when lying down or sitting. Some people describe it as a creeping, crawling, tingling or burning sensation. Moving makes the legs feel better, but not for long. RLS occurring at night can disrupt sleeping patterns and cause insomnia. Common side effects associated with Requip® include nausea, drowsiness, vomiting, and dizziness.

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