Treatment for insomnia

Medication should never be considered as the first and only solution to insomnia. There are various behavioural interventions which should first be initiated.

Some sleeping tablets may be bought over the counter (OTC) at a pharmacy. These are usually antihistamines – often the older types, which cause drowsiness. Unfortunately, they sometimes cause daytime drowsiness, which may be defeating the purpose of attempting to get a good night sleep, in order to feel less drowsy during the day….

The prescription sleeping tablets (hypnotics) are usually Schedule 5 drugs, because of the potential to be addictive. They should only be used over the short term.

Different medications used for insomnia:

• Antidepressants: These include trazodone, mirtazepine and amitriptyline. Amitriptyline should be used with care, as it is dangerous in overdose and has other side effects as well.
• Benzodiazepines: There are a number of sleeping tablets (hypnotics) in this group – they are the so-called ‘classic sleeping tablets’. Unfortunately, they have some problematic side-effects (especially after prolonged use):
  • Addiction and dependence
  • Loss of efficacy over time
  • Fall-episodes (especially in the elderly)
  • Rebound insomnia after stopping the medication
• Zopiclone and zolpidem: These are similar to the benzodiazepines
• Melatonin: this is a so-called sleep-hormone, but has limited efficacy for chronic insomnia. It is mostly used for shift-workers and people with jet-lag
• Over the counter medications: As mentioned before, these are mostly antihistamines. They are relatively safe, but could cause daytime drowsiness.
• Some sleeping tablets not available in SA:
  • Eszopiclone (Lunesta)
  • Lemborexant (Dayvigo)
  • Ramelteon 
  • Suvorexant
  • Zaleplon 

Behavioural interventions for insomnia:

When sleeplessness is a problem, “the right medication” seems like a quick and easy fix. The problem is, that none of the available sleeping tablets are without side effects, and they seldom provide a long-term cure. In order to address chronic insomnia, there are certain changes in thinking and behaviours related to sleep, that would need to be addressed.

1. SLEEP HYGIENE
   • This does not refer to personal cleanliness before going to sleep, but rather to “cleaning up” one’s sleep habits
   • It includes the following:
     • Sticking to a set sleep routine
     • Avoiding caffeine late afternoon or earlier the evening
     • Ensuring the sleep environment is safe and comfortable
     • Avoiding daytime naps!!
2. STIMULUS CONTROL
   • Some people struggle to fall asleep, and this may be a cause of distress – e.g. “I can’t sleep… I have to get up at 6am….. now I won’t be able to function at work tomorrow” etc.
   • This anxiety/distress about not sleeping actually worsens the insomnia, as the worry causes further agitation which makes it even more difficult to fall asleep.
   • Usually, sleep onset should be less than 15 minutes after going to bed to sleep. If this does not happen, then, rather than staying in bed and worrying about not sleeping, get up and do something else (e.g. reading). As soon as sleepiness sets in, go back to bed and try again. This patterns should be repeated anytime sleep onset is more than 15 minutes.
   • The purpose of this intervention is to start associating the bed with sleep, and not with excessive worrying and stress (about not sleeping).
3. TEMPORAL RESTRICTION
   • Some people spend enough time in bed, but their sleep is fragmented – e.g. sleeping for 90 minutes, then awake for 30 minutes, then sleeping again for 40 minutes and awake for 25 minutes etc.
   • This implies that the normal phases of sleep are not completed, and this affects the quality of sleep.
   • With fragmentation of sleep, a sleep diary for 1-2 weeks should be used to give an indication as to the exact pattern of sleeping and waking up.
   • The total hours of sleep are then combined and an average nightly total determined.
   • This average period is then the only time that should be spent in bed – even if this means from 01h00 to 04h30.
   • As soon as 90%+ of this allowed sleep time is actually spent sleeping, then 30 minutes may be added.
   • This is not a comfortable intervention, but as soon as the sleep consolidates, then the quality of sleep also improves.
4. COGNITIVE THERAPY FOR INSOMNIA
   • Virtually all insomnia sufferers have some dysfunctional thoughts or assumptions about their sleep. Cognitive therapy would then address these issues.
   • Sleep state misperception is one of these incorrect assumptions. This is where the amount of sleep is underestimated, e.g. “I have not slept at all for the past week”. This is highly unlikely. Most people sleep more than they realize – often dozing off and not realizing it.