Management of Insomnia

The National Institute of Mental Health Consensus Development Conference divided insomnia into three categories as follows  

Transient insomnia lasts less than 3 d and usually is caused by a brief environmental or situational stressor. It may respond to attention to sleep hygiene rules. If hypnotics are prescribed, they should be used at the lowest dose and for only 2 to 3 nights. 

Long-term insomnia is insomnia that lasts for more than 3 weeks no specific stressor may be identifiable. A more complete medical evaluation is necessary in these patients, but most do not need an all-night sleep study. 

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Walsh JK. Pharmacologic management of insomnia. J Clin Psychiatry 2004 65(Supplement 16) 41-45. 

Circadin is the proprietary preparation of melatonin, which is used for the short-term management of insomnia. 

Estazolam (Prosom) [C-IV] [Hypnotic/Benzodiazepine] Uses Short-term management of insomnia Action Benzodiazepine Dose 1-2 mg PO qhs PRN -1- in hqjatic impair/elderly/debilitated Caution [X, -] t Effects w/ CNS d ressants Contra PRG Disp Tabs SE Somnolence, weakness, palpitations, anaphylaxis, angioedema, amnesia Interactions t Effects W7 amoxicillin, clarithromycin T effects OF diaz am, phen5rtoin, warfarin X effects W7 food X effects OF azole antifungals, digoxin EMS Use caution w/ other benzodiazepines, may need a reduced dose concurrent EtOH and caffeine use can t CNS effects OD May cause alt ed reflexes, drowsiness, CNS depression, slurred speech, and Szs flumazenU can be used as an antidote... 

McCall WV. Diagnosis and management of insomnia in older people. 1 Am Geriatr Soc 2005 53 S272-S277... 

American Psychiatric Association Benzodiazepine Dependence, Toxicity, and Abuse A Task Force Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1990 Cohn JB, Wilcox CS Low-sedation potential of buspirone compared with alprazolam and lorazepam in the treatment of anxious patients a double-blind study. J Clin Psychiatry 47 409 12, 1986 Dolovich LR, Addis A, Vaillancourt JM, et al Benzodiazepine use in pregnancy and major malformations or oral cleft meta-analysis of cohort and case-control studies. BMJ 317 839-843, 1998 Goldberg HL, Finnerty RJ The comparative efficacy of buspirone and diazepam in the treatment of anxiety. Am J Psychiatry 136 1184—1187, 1979 Kupfer DJ, Reynolds CF 111 Management of insomnia. N Engl J Med 336 341-346, 1997... 

This non-BZD hypnotic, cyciopyrroione, is indicated for short-term management of insomnia. Zopiclone has a BZD-like profile, a short half-life of 3.5 to 6.5 hours, no active metabolites, minimal rebound effects, and less abuse potential than BZDs. The usual therapeutic dose is oral 7.5 mg administered 30 to 60 minutes before bedtime. Zopiclone has a well-documented capacity to reduce sleep latency, improve quality and duration of sleep, and reduce the frequency of nighttime awakenings. In clinical trials, 7.5 mg doses of zopiclone have been found to be as effective as triazolam 0.5 mg, temazepam 20 mg, flurazepam 15-30 mg, and nitrazepam 5 to 10 mg for the short-term treatment of insomnia (136). 

Berlin RM. Management of insomnia in hospitalized patients. Ann intern Mea 1984 100 398-404. 

Verster JC et al Residual effects of sleep medication on driving ability. Sleep Med Rev 2004 8 309. [PMID 15233958] Walsh JK Pharmacologic management of insomnia. J Clin Psychiatry 2004 65(Suppl 16) 41. 

Dundar Y, Dodd S, StroblJ, et al. Comparative efficacy of newer hypnotic drugs for the short-term management of insomnia a systematic review and meta-analysis. Hum Psychopharmacol. 2004 19 305—... 

SRT has become a standard therapeutic approach, either alone or in combination with other methods, for the management of insomnia. Although it was formally described only 15 years ago, sleep restriction has probably been used as a naturalistic countermeasure to insomnia for much longer. The evidence available, although not very extensive, indicates that SRT is an effective intervention for... 

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],... 

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],... 

Soldatos CR., Dikeos D (2003) An integrative approach to the management of insomnia. Curr Opin Psychiatry 16 (Suppl 2) 93-99... 

Zhdanova IV (2004) Advances in the management of insomnia. Expert Opin Pharma-cother 5 1573-1579... 

Freeman H, Puech AJ, Roth T (eds) (1996) Zolpidem an update of its pharmacological properties and therapeutic place in the management of insomnia. Elsevier, Paris... 

DundarY, Boland A, Strobl J, Dodd S, Haycox A,BagustA, Bogg J, Dickson R, Walley T (2004) Newer hypnotic drugs for the short-management of insomnia a systematic review and economic evaluation. Health Technolol Assess 8 1-125... 

Stiefel F, Stagno D. Management of insomnia in patients with chronic pain conditions. CNS Drugs 2004 18(5) 285-96. 

Kirkwood CK. Management of insomnia. J Am Pharm Assoc (Wash) 1999 39 688-96. 

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