09.02 - Treatment Options for Insomnia

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From the course by University of Michigan

Sleep: Neurobiology, Medicine, and Society

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University of Michigan

Sleep: Neurobiology, Medicine, and Society

42 ratings

The objective of this course is to give students the most up-to-date information on the biological, personal, and societal relevance of sleep. Personal relevance is emphasized by the fact that the single best predictor of daytime performance is the quality of the previous night's sleep. The brain actively generates sleep, and the first section of the course is an overview of the neurobiological basis of sleep control. The course provides cellular-level understanding of how sleep deprivation, jet lag, and substances such as alcohol, ,caffeine, and nicotine alter sleep and wakefulness. The second section of the course covers sleep-dependent changes in physiology and sleep disorders medicine. Particular emphasis will be placed on disorders of excessive sleepiness, insomnia, and sleep-dependent changes in autonomic control. Chronic sleep deprivation impairs immune function and may promote obesity. Deaths due to all causes are most frequent between 4:00 and 6:00 a.m., and this second section of the class highlights the relevance of sleep for preventive medicine. The societal relevance of sleep will be considered in the final section of the class. In an increasingly complex and technologically oriented society, operator-error by one individual can have a disastrous negative impact on public health and safety. Fatigue-related performance decrements are known to have contributed as causal factors to nuclear power plant failures, transportation disasters, and medical errors.

From the lesson

Unit 09 - Medicine: Treatments for Insomnia - (Standard Track)

Unit 9 further continues the Medicine section of the course with a lecture from J. Todd Arendt, Ph.D. on the range of available treatments for Insomnia.

09.01 - Behavioral and Pharmacological Treatments for Insomnia7:10

09.02 - Treatment Options for Insomnia4:36

09.03 - BzRA Hypnotics5:43

09.04 - Abuse Liability of Hypnotic Agents5:18

09.05 - Pharmacological Treatments for Insomnia3:57

09.06 - Nonpharmacological Treatments for Insomnia5:31

09.07 - How CBT-I Works6:27

09.08 - Pharmacological Treatments for Insomnia Part III6:26

09.09 - Summary 2:49

Meet the Instructors

Ralph Lydic, Ph.D.
Professor Emeritus, Molecular and Integrative Physiology, Professor Emeritus, Anesthesiology
University of Michigan Medical School
Helen Baghdoyan, Ph.D.
Professor Emeritus, Anesthesiology, Professor Emeritus, Pharmacology, Professor of Psychiatry
University of Michigan Medical School

So let's now talk about the various treatment options for insomnia.

First, there are FDA approved

medications that are specifically indicated for insomnia problems.

They fall across several classes.

The first common class are Benzodiazepine receptor agonists.

Within this class, there are true Benzodiazepines,

five true Benzodiazepines that are approved for insomnia.

And there are the more commonly used non Benzodiazepine receptor agonist medication.

These include Zolpidem or Ambien, Zolpidem M.R.

or Ambien C.R., Zaleplon or Sonata and Eszopiclone or Lunesta.

More recently, there have been medications that followed

different classes that are used to treat insomnia and approved by the FDA.

These include a melatonin receptor agonist,

Ramelteon, also known as Rozerem.

And an older antidepressant Doxepin, also known as Silenor.

In addition to FDA approved prescription medications,

there are other prescription medications that don't have FDA approval for insomnia,

but are frequently used in clinical settings because they have

sedating impact on individual sleep.

The most common of these is the antidepressant Trazodone

which is widely used in psychiatric settings as well as primary care settings.

Other medicines such as Amitriptyline or Elavil,

Mirtazapine or Remeron are also frequently used for insomnia.

Then there are medications in other classes such as

anti-psychotics like Seroquel or anti-convulsants like Gabapentin,

that can be used to treat insomnia.

But again, don't have FDA approval to do so.

Many people use non-prescription

over-the-counter agents that they might get at health food stores or drugstores.

Most of these agents use anti-histamines as the active ingredient.

But there are others such as Camomile, Valerian, Melatonin,

L-tryptophan and even alcohol is widely used to help insomnia problems.

Finally, there are non-pharmacological or non-medication agents.

These include cognitive behavioral therapy for insomnia as well as others.

So what treatments work?

In 2005, the NIH,

the National Institutes of Health,

held a state of the science conference to discuss treatments for insomnia.

I've taken here a couple of the conclusions from their final report in 2005.

The first statement indicates that CBT,

or cognitive behavioral therapy,

and Benzodiazepine receptor agonists,

have been shown to be beneficial in the acute management of chronic insomnia.

They also said that the research indicated that other therapies have shown

some promise but little is known about the comparative benefits of these treatments,

their combination and their effects on understudied features of chronic insomnia.

So let's look a little bit more at the research that's supported these statements.

And let's start first with pharmacological or medication treatments for insomnia.

These are the most widely used first line treatments of

insomnia typically given to individuals in primary care settings.

Before talking about the research that indicates how

pharmacological agents work for insomnia,

I think a useful starting point is to consider what might be

the characteristics of the ideal hypnotic agent.

Such an agent would have

beneficial characteristics across a number of different categories.

So for instance, it would be absorbed rapidly.

It would ideally address underlying pathophysiology.

It would induce sleep rapidly helping people to fall asleep quickly.

It would have minimal effects on

sleep physiology or what we call sleep architecture of the different stages of sleep.

It would work just for long enough, in other words,

it would have the optimal duration of action.

In addition to these positive attributes,

it would also not do a number of things.

So for example, it wouldn't form active metabolites.

There would be no residual effects associated with the medications.

There would be no worsening of insomnia or what we call rebound

insomnia when people discontinue the medications in particular.

There would be no physical dependence, no tolerance,

no interaction with alcohol,

no respiratory depression and no memory deficits associated with the hypnotics.

Now that we've looked at the ideal hypnotic and its characteristics,

let's discuss what the research tells us about

how the efficacy of these hypnotics and their safety.

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