A report issued earlier this year from the Institute of Medicine said that 50-70 million Americans struggle with chronic sleep disorders such as insomnia, sleep apnea, and restless legs syndrome. The report said not enough health care professionals are trained to diagnose and treat these problems. As we know, sleep problems are often comorbid with anxiety, depression, or other psychiatric disorders. What kinds of treatments have you used to help patients with either sleep disorders or sleep problems get better?
Proper Treatment Essential
The number of Americans with insomnia is growing; however, the percentage has been over 33% for 30 years.
We know that most people still treat insomnia primarily with alcohol, over-the-counter antihistamines, and now herbal products such as valerian root and melatonin. This occurs even though prescription medications are clearly more efficacious and safer than are any of the self-treatments.
Resistance to taking hypnotics still resides in fears of addiction, data to the contrary notwithstanding. This is one of the reasons trazodone is so widely used despite its lack of efficacy in approximately 50% of patients and its risk of cardiac arrhythmias, serotonin syndrome, and cognitive impairment the next day.
In my research and practice, I mostly treat insomnia that is comorbid with psychiatric disorders. I have become more convinced over the years that most in-somnias secondary to depression will remit once the depression has been adequately treated, although compliance with treatment is usually enhanced by using a hypnotic such as zolpidem (Ambien) for the first week or two.
Behavioral treatments for insomnia work well for mild to moderate insomnia and enhance the effects of pharmacotherapy for moderate to severe insomnia. More research is needed to determine how to make behavioral treatments more accessible to patients.
Research on hypnotics has finally begun to focus on receptors other than the [gamma]-aminobutyric acid (GABA) complex at the synapse. Serotonin agonists and antagonists; adenosine and melatonin receptor agonists; and drugs that affect extrasynaptic GABA receptors, to name just a few, are now in clinical trials, and those investigations are a sign that the systems controlling sleep and wakefulness need to be fully explored.
Our task is to continue to reach out to the public emphasizing the effects of insomnia on mental and physical health and cognition--especially memory and attention rather than on worries that we need to get 8 hours of sleep because we may die if we don't.
Henry W. Lahmeyer, M.D.
Dr. Fink replies:
In general, sleep disorders are seen as a symptom of other major Axis I illnesses, and they are handled as important indicators and problems that must be addressed in the course of the treatment. Sleep problems in depression and anxiety are often the first to come and the last to disappear, and they are pathognomonic for the disorders.
In anxiety disorders, the patient cannot fall asleep and may twist and turn for hours until he/she falls asleep. In depression, the patient can fall asleep, but wakes up very early, perhaps 3 a.m. or 4 a.m., and cannot fall back to sleep. This often goes along with another symptom of depression--feeling worse in the morning and getting better as the day progresses. Patients with depression say they are not thinking of anything when they are staring at the ceiling, other than ruminating about their inability to fall back to sleep again. In mania, the patient will often tell the emergency department doctor that he has not slept in 3-5 days. They do not feel exhausted, however, because of excitement and elation tied to the primary illness.
In each of these conditions, the patient should be given a medication for sleep to get the symptoms out of the way. In anxiety conditions, the patient is often very grateful. …