Insomnia: Diagnosis and Treatment

Diagnosis

History and physical examination, including a sleep history and psychiatric history, should include evaluation of sleep habits, sleep environment, drug and alcohol use, medical and medication history, and family medical history. It is often helpful to interview the patient's bed partner and to ask the patient to keep a sleep log.

Laboratory testing may identify medical disorders (such as endocrinopathies) that can contribute to sleep difficulties.

Sleep testing is used in some patients. Polysomnography can identify sleep-related breathing disorders. Multiple sleep latency testing evaluates for inappropriate daytime sleepiness. Actigraphy measures motion during sleep.

Treatment

Underlying medical, surgical, or psychiatric disorders should be treated as appropriate.

It is helpful to ask the patient to maintain good sleep hygiene, the essentials of which are to exercise regularly but not before bedtime, avoid caffeine, and limit alcohol, particularly near bedtime.³ Exercise has been shown to improve total sleep duration, sleep onset latency, and global sleep quality.⁵ However, timing is important. Physical activity early in the day is generally not associated with improved sleep, and exercise taken shortly before bedtime can delay sleep onset.³

Other beneficial practices include sleeping only as much as necessary to feel rested, keeping a regular sleep schedule, avoiding smoking, and adjusting the bedroom environment as needed. Many individuals with insomnia report poorer sleep hygiene practices, including increased use of alcohol, smoking near bedtime, and taking frequent daytime naps.⁶ Proper sleep hygiene is an often overlooked high-yield, low-risk means of helping patients with insomnia.

Nonpharmacologic Therapy

Maladaptive behaviors or thought patterns can sustain insomnia symptoms, independent of the initial underlying cause. Cognitive-behavioral sleep therapy addresses these problems and has proven more effective over the long term than pharmacologic therapy.⁷ Although additional evidence from controlled trials is needed, cognitive-behavior therapy was also found effective for insomnia related to a spectrum of medical and psychiatric conditions (eg, cancer, chronic pain, human immunodeficiency virus (HIV), depression, posttraumatic stress disorder, alcoholism, bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder).⁸

Although placebo-controlled trials are not possible, a review of available evidence indicated that warm-bath immersion to the mid-thorax, with water temperature at 40 to 41 degrees C, for 30 minutes in the evening can increase slow-wave sleep (deep sleep) in healthy elderly women with insomnia.⁹

Pharmacologic Therapy

Zolpidem, zaleplon, and eszopiclone are often the first drugs prescribed for sleep. Other frequently prescribed drugs are benzodiazepines (eg, temazepam, lorazepam, flurazepam), antihistamines (eg, diphenhydramine), and antidepressants (eg, amitriptyline, trazodone). In most cases, however, these drugs do not improve the quality of sleep.

Benzodiazepines are contraindicated in women who are pregnant and in patients with renal, hepatic, or pulmonary disease. They should be used with caution in patients who consume alcohol.

Ramelteon, a melatonin-receptor agonist, has recently been approved by the Federal Drug Administration (FDA) for insomnia treatment. Supplemental use of melatonin and valerian may also be effective for sleep disorders (see Nutritional Considerations).