When patients can’t sleep: Practical guide to using and choosing hypnotic therapy

Table 1

Antidepressants’ effects on sleep and wakefulness

Sleep clinic referrals. Consider an evaluation by a sleep disorders center when:

• the diagnosis remains unclear
• or treatment of the presumed conditions fails after a reasonable time

BEHAVIORAL TREATMENTS

Behavioral treatments—with or without hypnotics—are appropriate for a wide variety of insomnia complaints, including adjustment sleep disorder, psychophysiologic insomnia, and depression. Behavioral measures may take longer to implement than drug therapy, but their effects have been shown to last longer in patients with primary insomnia. In many cases, it may be useful to start with both hypnotic and behavioral treatments and withdraw the hypnotic after behavioral measures take effect.

Sleep hygiene. Many individuals unknowingly engage in habitual behaviors that impair sleep. Those with insomnia, for example, often try to compensate for lost sleep by staying in bed later in the morning or by napping, which further fragment nocturnal sleep. Advise these patients to adhere to a regular awakening time—regardless of how long they slept the night before—and to avoid naps. Other tips for getting a good night’s sleep are outlined in Table 2.¹²

Caffeine has a plasma half-life of 3 to 7 hours, although individual sensitivity varies widely and caffeine’s erratic absorption can prolong its effects. Advise patients with insomnia to avoid caffeine-containing beverages—including coffee, tea, and soft drinks—after noon.

Relaxation training. Muscle tension can be reduced through electromyography (EMG) biofeedback, abdominal breathing exercises, or progressive muscle relaxation techniques, among others. Relaxation training is usually effective within a few weeks.

Psychotherapy. Cognitive-behavioral therapy can help identify and dispel tension-producing thoughts that are disrupting sleep, such as preoccupation with unpleasant work experiences or school examinations. Reassurance may help patients overcome fears about sleeplessness; suggest that patients deal with anxiety-producing thoughts during therapy sessions and at times other than bedtime.

Insight-oriented psychotherapy may enhance patients’ awareness of psychological conflicts from their past that may be producing anxiety and contributing to sleeplessness.

PRESCRIBING HYPNOTICS

Sedative-hypnotics are indicated primarily for short-term management of insomnia. Most are used prophylactically at bedtime until insomnia dissipates or the physician advises the patient to take a break.

Treatment principles. Because many insomnias are recurrent, prolonged hypnotic treatment given in short bouts is often optimal. Longer treatment—months to years—is not recommended by standard textbooks but is clearly needed by a small number of patients with chronic insomnia. In these cases, carefully monitor for tolerance, as manifested by dosage escalation. Long-term hypnotic treatment is not suitable for patients with drug abuse or dependence histories.

Table 2

How to get a good night’s sleep

Although chloral hydrate and barbiturates are effective hypnotics, adverse effects limit their safety and usefulness. Benzodiazepines and more recently introduced agents have milder side effect profiles (Table 3). Choose agents based on the patient’s situation, preferences, and effects of prior trials with similar agents. Guidelines for hypnotics discourage chronic use to minimize abuse, misuse, and habituation (Table 4).

Elimination half-life is the primary pharmacokinetic property that differentiates the hypnotics from each other:¹³

• longer half-life: flurazepam, quazepam
• intermediate half-life: estazolam, temazepam
• short half-life: triazolam, zolpidem, zaleplon (Table 3).

Table 3

Actions and available doses of common hypnotics

Whereas benzodiazepines bind to benzodiazepine receptor types 1 and 2, zolpidem and zaleplon (and possibly quazepam) bind selectively to type 1. This selectivity may explain why zolpidem and zaleplon are more easily tolerated.

Hypnotic agents with relatively longer half-lives tend to be associated with greater potential for residual daytime effects such as sedation, motor incoordination, amnesia, and slowed reflexes. These effects may impair performance and increase the risk of auto accidents and injuries, especially hip fractures in the elderly.

Nonbenzodiazepines. Because of its ultra-short half-life, zaleplon is least likely to cause residual daytime effects when administered at bedtime. At 10-mg doses, its side effects seem to last no more than 4 hours following administration. Zaleplon can be safely taken after nocturnal awakenings if the patient remains in bed 4 hours or longer after taking it.¹⁴