Insomnia: A Concise Review of Conventional Treatments

Widespread Use and Unresolved Safety Problems

Posted Apr 28, 2019

This post is offered as a concise review of widely used conventional treatments of insomnia, including cognitive-behavioral therapy, relaxation, sleep hygiene and pharmacologic treatments. I include comments on important safety issues associated with benzodiazepines and other drugs widely used to treat insomnia. 

Physicians often recommend behavioral and pharmacologic treatments of insomnia (Riemann & Perlis 2009). Sleep hygiene is an important part of conventional management. Effective sleep hygiene includes restricting time spent in bed, going to bed only when sleepy, getting out of bed when unable to sleep, reducing noise or light in the sleep environment, getting up at the same time every morning, and avoiding daytime naps. Moderately severe insomnia often responds well to improved sleep hygiene. Relaxation before bedtime, including progressive muscle relaxation, meditation, and listening to music, is often effective for sleep problems.

The conventional management of situational or chronic insomnia generally relies on prescription medications such as benzodiazepines (e.g., diazepam (Valium™), clonazepam (Klonopin™) and lorazepam (Ativan ™)) or other sedative-hypnotic drugs. Two drugs, zolpidem (Ambien™) and zaleplon (Sonata™), act on benzodiazepine receptors but are not true benzodiazepines. Both are short-acting agents and do not have the same potential for abuse and dependence that has made long-term use of benzodiazepines problematic in chronic insomniacs.

Prescription benzodiazepines are used to manage 80 to 90% of all complaints of insomnia in Western countries. This practice has led to the overprescribing or inappropriate prescribing of potentially addictive sedative-hypnotics (Dollman et al., 2003). A significant percentage of patients hospitalized for any reason are prescribed benzodiazepines for management of sleep or anxiety, and many continue to use these drugs long after being discharged. Morning drowsiness, dizziness, and headache are common adverse effects of benzodiazepines. Inappropriate long-term use or high doses of benzodiazepines frequently result in confusion, daytime somnolence, and short-term memory impairment (Mant et al., 1995). Benzodiazepine use in the elderly is especially problematic because of the significantly increased risk of serious fall injuries associated with their use in this population (Herings et al., 1995).

In addition to benzodiazepines and benzodiazepine-like agents, some antidepressants are widely used to treat insomnia. Many antidepressants, including doxepin (Siniquan™), trazodone (Desyrel™), and mirtazapine (Remeron™), are moderately sedating, and their use in the management of insomnia has steadily increased since the mid-1980s (Walsh & Schweitzer, 1999). Research findings suggest that antidepressants used to treat insomnia may cause serious adverse effects more often than benzodiazepines, including elevated liver enzymes, dry mouth, nausea, weight gain, orthostatic hypotension, daytime sleepiness, and dizziness (Riemann et al., 2002).

Diphenhydramine, an antihistamine, is frequently prescribed for insomnia because of its sedating side effects. In recent years certain antipsychotics that have sedating side effect profiles have come into increasing use for the management of insomnia in the absence of approval from the U.S. Food and Drug Administration (FDA) for this clinical application, and in spite of the absence of findings from controlled trials supporting the efficacy and safety of these drugs for the treatment of insomnia. Atypical agents frequently prescribed for insomnia include quetiapine (Seroquel™) and olanzapine (Zyprexa™).

Meta-analyses of conventional treatment approaches suggest that conventional drugs are probably more effective in the acute management of insomnia, whereas cognitive-behavioral approaches are more effective over the long term (Holbrook, Crowther, Lotter, Cheng, & King, 2000).

In some cases the conventional pharmacologic management of insomnia may be potentially unsafe because of a non-disclosed history of alcohol abuse or prescription drug dependence, concurrent use of medications that interact with sedative-hypnotics, or the existence of medical conditions that make the use of benzodiazepines unsafe.

Finally, the effectiveness of insomnia treatments is often difficult to evaluate because of the absence of rating scales that are able to show correlations between subjective complaints of insomnia and objective measures of sleep.