Treatment of insomnia

Insomnia has a major impact on health, performance, economic productivity and quality of life. It is important to assess patients with sleep disturbance comprehensively and distinguish insomnia from other conditions, such as excessive daytime sleepiness and parasomnias. Once a diagnosis of insomnia is established, behavioural treatments should be tried initially. Prescription of short-term medication can often restore sleeping patterns to normal before maladaptive behaviours become established, and also reduce anxiety about sleeping, which makes sleep problems worse. Choice of hypnotic drug is discussed; most drugs used to help people sleep increase the function of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) in the brain. Shorter-acting, safe and selective drugs with this action, such as zolpidem and zopiclone, are available, zolpidem having the shorter half-life and therefore less liability to morning ‘hangover’ effects. Chronic insomnia has a strong conditioned element with negative expectations and anxiety at bedtimes and is a difficult problem to treat. Effective treatments include those involving psychological intervention such as cognitive–behavioural therapy (CBT), combined with education, sleep hygiene and specific behavioural strategies such as sleep restriction. Regarding stopping medication, brain receptors change in character in response to chronic treatment with benzodiazepines. There can therefore be a rebound of symptoms after stopping hypnotics, including the ‘z’ drugs (zopiclone and zolpidem), involving a worsening of sleep disturbance for one or two nights. Antidepressants with 5-HT2-blocking properties, such as mirtazapine, are indicated in the depressed patient with severe insomnia and may occasionally be effective in insomniac patients who are not depressed.