Although many patients with insomnia respond to standard treatments, some continue to experience insufficient sleep. When your patient appears “treatment-resistant,” you may be tempted to add another therapy or try an unorthodox medication. But choosing an appropriate next treatment is impossible without first looking back for a rationale:
- Have you overlooked one of insomnia’s many causes?
- Have you customized treatment for this patient?
- Is he or she unaware of behaviors that may be undermining attempts to sleep?
Refreshing sleep may elude some thoroughly evaluated and optimally treated patients, but they comprise a small minority. You can help most chronic insomnia sufferers by re-evaluating their behaviors, comorbidities, sleep-wake cycles, and medications (Table 1).
Table 1
Recommended approach to treatment-resistant insomnia
| Evaluation |
| Review your patient’s 24-hour sleep cycle, sleepiness, and sleeplessness, and note persistent patterns (a sleep log or diary may help) |
| Re-evaluate stimulating or sedating effects of prescribed and over-the-counter medications, caffeine, and alcohol |
Consider:
|
| Monitor insomnia-related daytime symptoms as key outcome measure |
| Treatment |
| Re-address sleep hygiene (Table 2) |
| Consider cognitive behavioral therapy for insomnia |
| Consider an FDA-approved medication for insomnia (Table 3), customized to your patient’s symptoms |
‘3 Ps’ and 8 questions
Thirty percent of adults experience insomnia at least occasionally, and 10% have persistent insomnia. Women, older persons, and patients with chronic medical conditions such as diabetes mellitus and lung disease have higher insomnia rates than the general population.1
An enormous variety of psychological and physiologic processes may influence sleep (Box 1). Multiple factors may contribute to an individual’s inability to achieve sufficient sleep, and the relative significance of these influences can shift over time. Factors that might trigger an insomnia episode are not necessarily those that maintain sleeplessness.
1 Does the patient have realistic goals for falling asleep and remaining asleep?
Patients view insomnia as being unable to sleep when they believe they should be sleeping. To be diagnosed as a disorder, insomnia must have daytime consequences associated with:
- difficulty falling asleep
- difficulty maintaining sleep
- awakening excessively early
- or experiencing nonrestorative sleep.
Recommendation. Determine how the patient defines “having insomnia” (there are no absolute thresholds). Ask how he or she is functioning during the day. Those who complain of imperfect nighttime sleep may admit that treatment has helped with the daytime symptoms that prompted them to seek treatment.
If daytime symptoms have diminished, reassure the patient that treatment apparently is helping. Patients are less likely to focus on perceived nighttime impairment when their distress about daytime functioning has eased.
Also determine if the patient has followed recommended treatment. Cognitive-behavioral therapy (CBT) may increase adherence to behavioral changes, sleep hygiene, and medication schedules.
2 Have I identified and optimally managed comorbidities?
Identifying comorbidities that may contribute to chronic insomnia is particularly important because managing these conditions may alleviate the sleep disturbance. Pain or discomfort caused by a medical condition may undermine sleep quality. Certain cardiovascular, pulmonary, endocrine, neurologic, rheumatologic, and orthopedic disorders are associated with insomnia.
Most patients experiencing exacerbations of mood and anxiety disorders suffer insomnia, and many other psychiatric disorders are associated with sleep disruption.
Insomnia’s clinical features: Subtypes to consider
Insomnia may be the chief complaint of a patient with obstructive sleep apnea or restless legs syndrome.Diagnostic subtypes recognized by the American Academy of Sleep Medicine may suggest why recommended treatments have not relieved a patient’s symptoms. Insomnia may be:
- due to a mental disorder, medical condition, drug or substance
- adjustment-related (acute insomnia), psychophysiologic, paradoxical, or idiopathic
- related to inadequate sleep hygiene
- a behavioral characteristic of childhood
- organic (due to an unspecified physiologic condition)
- nonorganic, NOS (not due to a substance or known physiologic condition).
NOS: not otherwise specified
Insomnia often accompanies substance abuse and may continue after the patient stops abusing drugs or alcohol. Abused stimulants and sedatives can worsen sleep quality, and discontinuation can cause acute and chronic sleep disruption.
Recommendation. Treat mood and anxiety disorders independently of insomnia. Minimize pain and discomfort from medical conditions. Address substance abuse, and dispel patients’ notion that alcohol is a sleep aid.