Treating Insomnia

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Chianti

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Just curious as to the logorithim that some of you guys use to treat insomnia.
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I don't really have an algorithm but this is my general plan.

1) Sleep Hygeine education after obtaining a proper h/p to rule out other causes. This is usually ongoing and can include sleep diaries/actigraphy.
2) Psychotherapy
3) SHORT TERM use of medication. This should be a rare option and if you find yourself doing it a lot, something is wrong.
 
Thanks. Specifically I was wondering about a logorithim (sp?) for medication use to treat insomnia. I always start out with OTC melatonin and increase that upwards of 15-20 mg qhs. If that doesn't work I will start a strong anti-histamenergic or other aid. And then if that doesn't work I move on to stronger stuff. Just wondering what others do.
 
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In addition to above, try to identify anything during the H&P stage that may give some leads on why the person could not sleep.

E.g. I had a patient that drank over 24 cups of coffee a day and she didn't know coffee was a stimulant. Over the course of 4 months I got her to wean herself off of coffee down to about 2-3 cups a day and she was then able to sleep.

From my own experience, I am the only doctor I know that recommends sleep hygiene. I don't know WTF is going on with this. I'm not trying to toot my horn, I'm trying to figure out why so many doctors treating patients in the community don't follow the standards set out by professional societies and the academic curriculm. Virtually every doctor whose patients I took over immediately started the person on a sleep medication without educating the patient on sleep hygiene and trying it out for a month. Worse, several of those doctors prescribed a benzo immediately and kept the patient on it for years.

After informing the patient about sleep hygiene and asking if any of their other doctors ever talked about it, it's always news to them. (That, and the information that benzos can cause dependence and often work less the longer one is on them.)
 
melatonin...upwards of 15-20 mg qhs. If that doesn't work I will start a strong anti-histamenergic or other aid. And then if that doesn't work I move on to stronger stuff.
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I know you always try sleep hygeine followed by some nice CBT before this...

Sooo...I am going to pretend I didn't read that.
 
Chianti said:
I always start out with OTC melatonin and increase that upwards of 15-20 mg qhs.
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That is a lot of melatonin. My humble understanding is that it is typically effective in the microgram up to perhaps 3 mg range. I also seem to recall that it may have depressogenic (implicated in seasonal depression, 5-HT is melatonin precursor) and antioxidant properties, in addition to possibly lowering testosterone levels (?).

I'd be very interested to hear more about melatonin, and how it compares with Rozerem. Another melatonin receptor agonist in the pipeline, agomelatine (available in Europe), also looks interesting.
 
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Chianti said:
Just curious as to the logorithim that some of you guys use to treat insomnia.
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Depends on the cause of the insomnia, right? Pain? Anxiety? Depression?

First line is always a proper history and physical (maybe they have obstructive sleep apnea, right?). Likely, the patient has inadequate sleep hygiene/improper sleep habits and needs education and encouragement.

For primary insomnia, you can consider Melatonin 3-6 mg, or Ramelteon 8-16mg (per a couple of articles in the Journal of Clinical Sleep Medicine). I'm not aware of any proven therapeutic benefit to melatonin beyond 6 mg for insomnia, (and beyond 12 mg for REM behavior disorder) - but would welcome opinions founded on the literature.

I tend to shy away from Ambien.
 
surftheiop said:
When approaching any problem, I think its always best to first consider natural logarithms
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👍

Nicely done.

I'm embarrassed it took us so long to make that joke.
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I was totally snoozing on that one. Didn't even notice the word until you brought it up. I actually wrote algorithm in my reply.
 
Of course I try basic sleep hygiene and CBT first. I figured it was understood so I didn't bother typing it.
 
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I always submit my insomniacs to a 24 hour sleep lab workup with 8-hour continuous polysomnography. I also expect 100% reimbursement.
 
Cruzinman said:
I always submit my insomniacs to a 24 hour sleep lab workup with 8-hour continuous polysomnography. I also expect 100% reimbursement.
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I prefer to do 72 hour.
Im ok with 80% reimbursement.
 
danielmd06 said:
Depends on the cause of the insomnia, right? Pain? Anxiety? Depression?

First line is always a proper history and physical (maybe they have obstructive sleep apnea, right?). Likely, the patient has inadequate sleep hygiene/improper sleep habits and needs education and encouragement.

For primary insomnia, you can consider Melatonin 3-6 mg, or Ramelteon 8-16mg (per a couple of articles in the Journal of Clinical Sleep Medicine). I'm not aware of any proven therapeutic benefit to melatonin beyond 6 mg for insomnia, (and beyond 12 mg for REM behavior disorder) - but would welcome opinions founded on the literature.

I tend to shy away from Ambien.
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How many psych patients do you know with primary insomnia?
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I'm a sleep fellow...not a psychiatry resident. So point taken. If there is a cause of the insomnia (like pain) I find it easier to target that first.
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From a sleep perspective I think your approach is exactly the way it should be however I would agree that with psychiatric illness clouding the picture it is very hard to tell if the insomnia is primary (even on the rare occasion it is).
 
If the insomnia is truly intermittent (1-2x/month), I think Melatonin sometimes works. If the problem is daily, Melatonin seems to stop working after several days in a row. Ramelteon is beautiful when it works, but that seems to be 10-20% in my pop'n. Still, it's worth a try.
Then antihistamines, trazodone, or switch to a primary med (antipsychotic, mood stabilizer, or antidepressant) that's sedating.
Then Ambien with a clear warning about complex sleep behaviors and the need to warn family/roommates, and likelihood of becoming habit forming. I actually prefer to use Sonata b/c it can be given as late as only 3 hrs remaining in the sleep period. In other words, pt's can try all the non-med remedies and sleep hygiene and then take the Sonata if they still can't get to sleep. That way, they never have to anticipate insomnia - and develop the expectation that they will not sleep without a medication.

Then ...
NO, I won't go to BZD's for sleep in the psych outpatient pop'n.
(Agitated psychotics and manics may get it for a few days - inpt ONLY).
I'll continue those that are chronically prescribed with a clear statement that the pt WILL be tapered.


Even in the psych ER, everyone with a sleep complaint (who doesn't get admitted) gets a sleep hygiene handout.
 
OldPsychDoc said:
How many psych patients do you know with primary insomnia?
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Exactly my sentiment.

kugel said:
If the insomnia is truly intermittent (1-2x/month), I think Melatonin sometimes works. If the problem is daily, Melatonin seems to stop working after several days in a row. Ramelteon is beautiful when it works, but that seems to be 10-20% in my pop'n. Still, it's worth a try.
Then antihistamines, trazodone, or switch to a primary med (antipsychotic, mood stabilizer, or antidepressant) that's sedating.
Then Ambien with a clear warning about complex sleep behaviors and the need to warn family/roommates, and likelihood of becoming habit forming. I actually prefer to use Sonata b/c it can be given as late as only 3 hrs remaining in the sleep period. In other words, pt's can try all the non-med remedies and sleep hygiene and then take the Sonata if they still can't get to sleep. That way, they never have to anticipate insomnia - and develop the expectation that they will not sleep without a medication.

Then ...
NO, I won't go to BZD's for sleep in the psych outpatient pop'n.
(Agitated psychotics and manics may get it for a few days - inpt ONLY).
I'll continue those that are chronically prescribed with a clear statement that the pt WILL be tapered.


Even in the psych ER, everyone with a sleep complaint (who doesn't get admitted) gets a sleep hygiene handout.
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The most practical post in this thread.
 
Thats really interesting.

I am curious to know how many psychiatrists prescribe antipsychotics or mood stabilizers solely to treat insomnia. Don't include something like changing from abilify to seroquel if the patient was already being treated for something.

Specifically if you use it prior to using something like ambien/lunesta etc.
 
Chianti said:
Thanks. Specifically I was wondering about a logorithim (sp?) for medication use to treat insomnia. I always start out with OTC melatonin and increase that upwards of 15-20 mg qhs. If that doesn't work I will start a strong anti-histamenergic or other aid. And then if that doesn't work I move on to stronger stuff. Just wondering what others do.
Click to expand...

I agree that is a lot of melatonin. I think it's important to remember that OTC meds aren't benign and most recommendations max out at doses<10mg, usually <5mg. High doses can lead to side effects including increased risk of bleeding problems.

I always deal with sleep hygiene first, including caffeine intake, alcohol use, exercise, environment, timing of medications. If it's an alcoholic I try ot educate them on how alcohol disrupts the sleep cycle and how it can take some time for this to normalize. I'll also emphasize bright light exposure x20-30 minutes in the morning and dark bedroom to help as well.

I very rarely use antipsychotics for sleep, unless it's to target other symptoms, or they've failed multiple other meds. You can often rationalize using it as an adjunt in depression as well.
 
Can Insomnia be cured completely? What are actual causes of insomnia? Any home remedy, please suggest...
 
Yes true insomnia can be cured completely.

The best cure, really the only cure, is sleep hygiene. Implementation may involve therapy.
 
Although sleep hygiene should be an element of the tx of insomnia, sleep hygiene alone is rarely effective. CBT for insomnia is effective but few people are trained in this (and many of those physicians trained, like myself, don't have time to do the full version). I will often use elements of CBT-I with my insomnia patients. If there is a psychologist in your area trained in CBT-I, this is a good option for many insomnia patients.

When I use medications, I like to use meds that are FDA-indicated for insomnia. I usually start off with Ambien and will then switch to Lunesta. It's fine to start off with Rozerem, but this med usually doesn't work.

When treating insomnia associated with a psych illness, I think it is fine to use a med for insomnia (trazodone for depression-associated insomnia; seroquel for bipolar associated insomnia) that has an FDA indication for the underlying psych d/o
 
Just FYI: I took a doxylamine (Unisom) the other evening and my brother woke me up at noon the next day 😴 Glad it was a Saturday.
 
michaelrack said:
Although sleep hygiene should be an element of the tx of insomnia, sleep hygiene alone is rarely effective. CBT for insomnia is effective but few people are trained in this (and many of those physicians trained, like myself, don't have time to do the full version). I will often use elements of CBT-I with my insomnia patients. If there is a psychologist in your area trained in CBT-I, this is a good option for many insomnia patients.
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What do you consider the appropriate implementation of sleep hygiene?
I was having this discussion with a pulmonary friend and he had very different ideas than myself and a neurologist who is trained in behavioral sleep.

I/we think that CBT-I ultimately is aimed precisely at sleep hygiene. Sounds like you have a different view on what sleep hygiene is. What did you learn to treat with CBT-I?
 
Manicsleep said:
What do you consider the appropriate implementation of sleep hygiene?
I was having this discussion with a pulmonary friend and he had very different ideas than myself and a neurologist who is trained in behavioral sleep.

I/we think that CBT-I ultimately is aimed precisely at sleep hygiene. Sounds like you have a different view on what sleep hygiene is. What did you learn to treat with CBT-I?
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We do a five week (individual or group) program that includes stimulus control and sleep restriction as the primary modalities used, with a smattering of cognitive-behavioral approaches to dealing with the "racing thoughts" that are common in psychophysiologic insomnia. That usually comes in at session three.

I would recommend the book "Cognitive Behavioral Treatment of Insomnia" by Michael Perlis (I think he's a Pittsburgh) - there are some good algorithms in there for behavioral tx of insomnia as well as some scenarios that help to instruct on how to deal with the common roadblocks patients present in tx.

http://www.amazon.com/Cognitive-Behavioral-Treatment-Insomnia-Session/dp/0387222529
 
Manicsleep said:
What do you consider the appropriate implementation of sleep hygiene?
I was having this discussion with a pulmonary friend and he had very different ideas than myself and a neurologist who is trained in behavioral sleep.

I/we think that CBT-I ultimately is aimed precisely at sleep hygiene. Sounds like you have a different view on what sleep hygiene is. What did you learn to treat with CBT-I?
Click to expand...

Sleep hygiene includes things like avoiding etoh near bedtime, avoiding caffeine late in the day. According to the AASM practice parameters, there is insufficient evidence to support sleep hygiene as a single modality for the treatment of insomnia. Sleep hygiene is usually included when treating a patient with CBT-I, along with stimulus control and/or sleep restriction therapy.

When I treat pts with CBT-I, it is predominately sleep restriction with elements of stimulus control and sleep hygiene added.

Here are the AASM practice parameters:

http://www.aasmnet.org/Resources/PracticeParameters/PP_BTInsomnia_Update.pdf
 
Sleep hygiene includes things like avoiding etoh near bedtime, avoiding caffeine late in the day. According to the AASM practice parameters, there is insufficient evidence to support sleep hygiene as a single modality for the treatment of insomnia. Sleep hygiene is usually included when treating a patient with CBT-I, along with stimulus control and/or sleep restriction therapy.

When I treat pts with CBT-I, it is predominately sleep restriction with elements of stimulus control and sleep hygiene added.
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I think you are confusing sleep hygiene education with therapy directed at sleep hygiene. What do you think sleep restriction does? Nowhere does it say that therapy directed at sleep hygiene lacks evidence.

Sleep Hygiene Definition: From Wikipedia 😀
"all behavioural and environmental factors that precede sleep and may interfere with sleep"

Then again, you could think like our pulmonary sleep friend who thinks that CBT-I is CBT-I and sleep hygiene is sleep hygiene.
What I think is that sleep hygiene is just the set of behaviors, driven sometimes by certain thoughts, that impact our sleep. These can be therapized by a therapist who is good at therapy.
 
watto said:
We do a five week (individual or group) program that includes stimulus control and sleep restriction as the primary modalities used, with a smattering of cognitive-behavioral approaches to dealing with the "racing thoughts" that are common in psychophysiologic insomnia. That usually comes in at session three.

I would recommend the book "Cognitive Behavioral Treatment of Insomnia" by Michael Perlis (I think he's a Pittsburgh) - there are some good algorithms in there for behavioral tx of insomnia as well as some scenarios that help to instruct on how to deal with the common roadblocks patients present in tx.

http://www.amazon.com/Cognitive-Behavioral-Treatment-Insomnia-Session/dp/0387222529
Click to expand...

Thanks.
However, CBT doesn't need to be cookbooked to insomnia. I still do CBT quite a bit, even for insomnia, I just don't drink the CBT-I kool aid. Its just CBT, you can do behavioral, cognitive, dialectical, combinations etc etc.

It's a very versatile and powerful therapy modality and it should be taught from theory upward as a tool that can be used as such. Not as some kind of therapy by numbers. At least not for psychiatrists.
 
Manicsleep said:
I think you are confusing sleep hygiene education with therapy directed at sleep hygiene. What do you think sleep restriction does? Nowhere does it say that therapy directed at sleep hygiene lacks evidence.

Sleep Hygiene Definition: From Wikipedia 😀
"all behavioural and environmental factors that precede sleep and may interfere with sleep"

Then again, you could think like our pulmonary sleep friend who thinks that CBT-I is CBT-I and sleep hygiene is sleep hygiene.
What I think is that sleep hygiene is just the set of behaviors, driven sometimes by certain thoughts, that impact our sleep. These can be therapized by a therapist who is good at therapy.
Click to expand...

Maybe I am a little confused, I don't do that much CBT-I anymore. However, I am certified by the AASM in Behavioral Sleep Medicine (this certification was recently taken over by the old American Board of Sleep Medicine). I also served on the AASM Behavioral Sleep Medicine Comm for a little over a year. The Wikipedia definition is overly broad, IMHO.

I think like your pulmonary sleep friend.
 
I am looking into getting that certification as well but the fact we even have to do it irritates me (not happy about the cost either). Which was actually what myself and my friends, all ex sleep fellows, were discussing.

First of all, it is like having to get more certifications for titrating a cpap, reading a PSG, actigraphy etc etc. after you have done a sleep fellowship. It would be really dumb. Same with BSM. Especially when I am already a psychiatrist who was doing CBT before sleep. Plus we learned CBT-I in fellowship. If you are board certified in sleep medicine, thats it, end of story. If its not enough, then clearly the board certification is not enough and CBT needs to be a part of the requirements for board certification. Why do we need futher certification. Same with this idea put forth by certain psychologists that every lab needs a BSM person. Its politics and its patently absurd.

The discussion regarding CBT and sleep hygeine is purely theoretical and was just a small portion of the entire conversation. How you conceptualize it doesn't really matter to me (ok it does I wont lie) as long as you do it correctly.
 
michaelrack said:
http://www.aasmnet.org/Resources/PracticeParameters/Review_Insomnia.pdf

Page 2 (1399) has a table with basic definitions.

ManicSleep, since this is a psychiatry forum, you can use a broader definition of sleep hygiene if you like. If we discuss this on the sleep forum, I will insist on a strict definition:laugh:
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This is what you are talking about right?
...health practices and environmental factors that promote or interfere with sleep...basic information about normal sleep and changes in sleep patterns with aging"

How is therapy aimed at that not what I am talking about.
Remember I am not talking about education but therapy. The table you have specifically lists educations. This is the whole problem with the sleep field, they think the sleep hygiene handout is education while therapy about the same thing is CBT-I.

Its all the same thing.
 
Manicsleep said:
I am looking into getting that certification as well but the fact we even have to do it irritates me (not happy about the cost either). Which was actually what myself and my friends, all ex sleep fellows, were discussing.

The discussion regarding CBT and sleep hygeine is purely theoretical and was just a small portion of the entire conversation. How you conceptualize it doesn't really matter to me (ok it does I wont lie) as long as you do it correctly.
Click to expand...

FYI I tried to apply for the BSM certification exam last year and was negged due to being an M.D. -- it is only open to doctoral (read: PhD) degrees "or the equivalent." After emailing the committee, this was judged NOT to include MDs. I figure that having the sleep med fellowship will trump the BSM cert anyway (esp. since I have a lot of training in BSM) and I'm going to practice the subject even without certification.
 
Watto,

I havent looked into beyond discussion with colleagues and i know someone got certified in 2008 who was an MD.

You could be right, you should be right...perhaps Dr. Rack could shed some light on this?
 
Manicsleep said:
Watto,

I havent looked into beyond discussion with colleagues and i know someone got certified in 2008 who was an MD.

You could be right, you should be right...perhaps Dr. Rack could shed some light on this?
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I posted on this in the sleep forum. Starting in 2010, the requirements/board for the BSM certification changed. It is NOT for sleep specialists. Those who are board certified in sleep medicine (by the ABSM or an ABMS board) are assumed to be competent in behav sleep medicine.

Watto, based on the web page for the new exam, it is not clear whether an MD like a non-sleep psychiatrist would be eligible. I guess it is up to the comm who runs the exam ( I am not one of the MD's who was asked to be on the committee).
 
turnershaun43 said:
Some people drink pills to treat insomia and some people just relax because they believe that is only stress.
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Ok this is prob dumb but I have heard the term "drink pills" used a lot in some areas. Pills are solid, so how do you drink[\I] them!? Unless its referring to the take with water thing. I thought the accepted term was "take pills." just wondering if anyone else is familiar with this?
 
toothless rufus said:
Ok this is prob dumb but I have heard the term "drink pills" used a lot in some areas. Pills are solid, so how do you drink[\I] them!? Unless its referring to the take with water thing. I thought the accepted term was "take pills." just wondering if anyone else is familiar with this?
Click to expand...


Just refers to taking them with water...or whatever other fluid.
 
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