Treatment of Sleep Problems

TREATMENT OF SLEEP PROBLEMS

Sleep disorders are common and often result from inadequate treat-ment of underlying medical conditions or psychiatric illness. True primary insomnia is rare. Nonpharmacologic therapies that are useful for sleep problems include proper diet and exercise, avoiding stimu-lants before retiring, ensuring a comfortable sleeping environment, and retiring at a regular time each night. In some cases, however, the patient will need and should be given a sedative-hypnotic for a limited period. It should be noted that the abrupt discontinuance of many drugs in this class can lead to rebound insomnia.

Benzodiazepines can cause a dose-dependent decrease in both REM and slow-wave sleep, though to a lesser extent than the barbiturates. The newer hypnotics zolpidem, zaleplon, and eszopiclone are less likely than the benzodiazepines to change sleep patterns. However, so little is known about the clinical impact of these effects that statements about the desirability of a particular drug based on its effects on sleep architecture have more theoretical than practical significance. Clinical criteria of efficacy in alleviating a particular sleeping problem are more useful. The drug selected should be one that provides sleep of fairly rapid onset (decreased sleep latency) and sufficient duration, with minimal “hangover” effects such as drowsiness, dysphoria, and mental or motor depression the following day. Older drugs such as chloral hydrate, secobarbital, and pentobar-bital continue to be used occasionally, but zolpidem, zaleplon, eszopiclone, or benzodiazepines are generally preferred. Daytime sedation is more common with benzodiazepines that have slow elimination rates (eg, lorazepam) and those that are biotrans-formed to active metabolites (eg, flurazepam, quazepam). If benzodiazepines are used nightly, tolerance can occur, which may lead to dose increases by the patient to produce the desired effect. Anterograde amnesia occurs to some degree with all ben-zodiazepines used for hypnosis.

Eszopiclone, zaleplon, and zolpidem have efficacies similar to those of the hypnotic benzodiazepines in the management of sleep disorders. Favorable clinical features of zolpidem and the other newer hypnotics include rapid onset of activity and mod-est day-after psychomotor depression with few amnestic effects. Zolpidem, one of the most frequently prescribed hypnotic drugs in the United States, is available in a biphasic release formulation that provides sustained drug levels for sleep main-tenance. Zaleplon acts rapidly, and because of its short half-life, the drug has value in the management of patients who awaken early in the sleep cycle. At recommended doses, zaleplon andeszopiclone (despite its relatively long half-life) appear to cause less amnesia or day-after somnolence than zolpidem or benzo-diazepines. The drugs in this class commonly used for sedation and hypnosis are listed in Table 22–3 together with recom-mended doses.

Note: The failure of insomnia to remit after 7–10 days of treat-ment may indicate the presence of a primary psychiatric or medi-cal illness that should be evaluated. Long-term use of hypnotics is an irrational and dangerous medical practice.