Up to 50% of patients complain of insomnia. Treating insomnia improves patient satisfaction, compliance, and medical care. Insomnia is often under-reported and under-treated since patients are often focusing on other medical issues when they visit their doctor or they haven’t found relief from their insomnia from previous treatment.
Insomnia and chronic sleep deprivation can have a significant impact on many areas of a person’s life including:
– Decreased job performance
– Impaired focus and concentration
– More frequent car accidents
– Increased risk of suicide
– Worsening health condition
– Poor medication compliance
By addressing and treating a person’s insomnia, you can make a great impact on the quality of life. There are many causes of insomnia and many of them are overlapping. Some of the most frequent causes include:
– Working late
– Computer, Internet, IPAD before bed
– Exercising in the late evening
– Depression and anxiety
– Reflux 2
– Restless leg syndrome
– Sleep Apnea
– Substance abuse
– Medications ex. antidepressants, stimulants, steroids
Here are 10 essential questions to ask: When did it start? Any changes at work or home? Any new medications or supplements? When do you work out? Do you snore or kick your partner? Has this happened before? What have you tried? What medical problems do you have? Do you have a history of depression, anxiety or ADHD? How many times a week do you drink? What do you like to drink? There are numerous treatments available for insomnia.
Here are some tips on medications that I have found helpful for my patients:
1. Ambien is an intermediate acting medication. It’s effect lasts for 6-8 hours. It should be taken on an empty stomach. It is recommended to use for only 2 weeks, but often I have found that patients require longer periods of use. 3
2. Sonata has a very short half-life. Thus, it is useful for the patients that are able to fall asleep but wake up at 4 or 5 am and need an additional 2-3 hours of sleep without a hangover. This also should be taken on an empty stomach.
3. I rarely use Lunesta because it has a high rate of the side effect of a metallic taste. This occurs in 40% of patients.
4. Another medication that I often like for patients is trazodone. This is an off-label use. I prescribe 25- 100 mg at night. There is a risk of hypotension and thus a risk of falls. Also, in men, there is a risk of a priapism which must be discussed with the patient prior to prescribing.
5. Seroquel is another medication that I prescribe off-label. Even though there is a lot of press about the risk of metabolic syndrome, I have found this medication to be very help, especially in patients with PTSD, bipolar disorder or chronic insomnia.
6. I try to avoid benzodiazepines such as Klonopin (clonazepam) and Xanax (alprazolam) because they often help with anxiety and insomnia initially; however, the sedative effect often wears off over time.
7. Tricyclic antidepressants such as desipramine or Tofranil may also be helpful in small doses, especially if the patient has chronic pain or IBS.
8. Clonidine 0.1-0.2 mg can be an effective off-label treatment for insomnia, especially in patients with Adult ADD/ADHD and PTSD. Insomnia is very common and a careful history and assessment along with effective treatments can greatly help your patient have a better quality of life.
Scott Shapiro, MD
March 2, 2012