Psychiatric Annals

CME Article 

Disorders of Sleep in Women: Insomnia

Safia S. Khan, MD; Imran S. Khawaja, MBBS, FAASM

Abstract

Insomnia is defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment. A comprehensive history and physical examination differentiate the subtypes of insomnia: acute, chronic, and associated with comorbid disorders. Evaluation of insomnia entails understanding the predisposing, precipitating, and perpetuating factors of insomnia unique to each person. Effective treatment is incomplete without implementing cognitive-behavioral therapy for behaviors nonconducive to sleep as monotherapy or in combination with pharmacotherapy. Setting realistic goals and expectations of quality and quantity of sleep required to feel rested determine treatment success and outcomes. This article reviews the prevalence, symptoms, subtypes, and diagnosis and management of insomnia, particularly in women with emotional and hormonal changes of symptomatic premenstrual syndrome, pregnancy, and menopause. [Psychiatr Ann. 2019;49(12):518–523.]

Abstract

Insomnia is defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment. A comprehensive history and physical examination differentiate the subtypes of insomnia: acute, chronic, and associated with comorbid disorders. Evaluation of insomnia entails understanding the predisposing, precipitating, and perpetuating factors of insomnia unique to each person. Effective treatment is incomplete without implementing cognitive-behavioral therapy for behaviors nonconducive to sleep as monotherapy or in combination with pharmacotherapy. Setting realistic goals and expectations of quality and quantity of sleep required to feel rested determine treatment success and outcomes. This article reviews the prevalence, symptoms, subtypes, and diagnosis and management of insomnia, particularly in women with emotional and hormonal changes of symptomatic premenstrual syndrome, pregnancy, and menopause. [Psychiatr Ann. 2019;49(12):518–523.]

Insomnia is a public health disorder affecting millions of people worldwide. The onset of insomnia is often preceded by chronic illnesses, mental disorders, and other sleep disorders including obstructive sleep apnea, delayed-phase circadian rhythm disorders, or sleep-related movement disorders generally in the presence of an often undiagnosed mood disorder. Insomnia can present as a symptom of other chronic diseases, or it may present as a disorder of its own. Common symptoms of insomnia are listed in Table 1. These features of insomnia are interrelated with a state of hyperarousal, leading to difficulty with sleep onset, or sleep maintenance, or early awakening, or combined symptoms. Differentiating and identifying the types of symptoms will assist in diagnosis and treatment of insomnia, differentiating it from other sleep disorders particularly circadian disorders.1

Sleep Disorders Associated with Insomnia

Table 1:

Sleep Disorders Associated with Insomnia

Women have a 1.3- to 1.8-fold greater risk for developing insomnia.2 Insomnia and other sleep disturbances are reported during specific situations associated with the female reproductive cycle, such as symptomatic premenstrual periods, pregnancy, and menopause.2 Changes in sleep patterns and sleep disorders are more frequent in older women. These changes possibly are influenced by the emergence of coexisting medical conditions and the presence of other hormonal, physiologic, and even psychosocial factors.2

A small number of models have been presented to understand the development of insomnia and the stress experienced by patients with acute, chronic, or intermittent symptoms. The comprehensive 3P model of Spielman describes the predisposing, precipitating, and perpetuating factors of insomnia. This model is instrumental in understanding the conditions that lead to insomnia. Developing hypothesis around the predisposing, precipitating, and perpetuating factors will help the clinician weave the connections between the premorbid picture of sleep, initial insomnia, changes over time, and the current sleep disturbance.3 The predisposing factors can be biological (eg, regularly elevated cortisol), psychological (eg, tendency to worry), or social (eg, work schedule incompatible with sleep schedule).3 Precipitating factors, such as stressful life events, then trigger the acute onset of insomnia.3 Perpetuating factors, such as maladaptive coping skills or an extension of time in bed, can then contribute to the acute insomnias developing into a chronic or longer-term disorder.3 To clinically diagnose and understand some of the subtypes of insomnia, Table 2 lists the associated key features.

Characteristics of Insomnia Subtypes

Table 2:

Characteristics of Insomnia Subtypes

Prevalence of Insomnia in Women

Estimates of the prevalence of insomnia depend on the criteria used to define insomnia and more importantly the population studied.4 Insomnia prevalence depends vastly on the criteria used for diagnosis within the population studied. Population-based studies show presence of one or more symptoms of insomnia among approximately 30% of adults from different countries.4 Several studies have shown complaints of insomnia to be predominant among women compared to men of similar age when corrected for other comorbid conditions and covariates, and some studies identify female gender as a risk factor for insomnia.5 Female gender also is related significantly to an increased number of awakenings per night after controlling for age, anxiety, depression, and smoking.2 These findings are consistent with other reports of difficulty initiating or maintaining sleep in a significant percentage of women, particularly among the elderly, people who have depression, or those who are medically ill, especially those who have pain or dyspnea.2

Insomnia and Premenstrual Sleep

Gender differences also seem to exist in younger and adolescent populations, with a female predominance.6 The increasing trends for unhealthy sleep-related behaviors (eg, electronic media use at bedtime and high-caffeine consumption) and other factors such as school pressure affect sleep in adolescents and may precipitate or perpetuate insomnia.6 There are reports of sleep fragmentation, daytime hypersomnia, and insomnia particularly in the days preceding the menstrual cycle; however, consistent evidence of changes in sleep architecture associated with symptomatic premenstrual periods is lacking.6

At puberty, there is a noticeable sleep-phase delay anywhere from 2 to 4 hours. Two factors play a role in this circadian delay. First, the nocturnal melatonin secretion shifts to a later time, which parallels a shift in circadian-phase preference from morning to evening; this results in difficulty falling asleep earlier.7 Second, sleep pressure accumulates more slowly after puberty; after 14.5 to 18.5 hours spent awake, postpubertal children take longer to fall asleep than do prepubertal children.8

Insomnia in Pregnancy

Sleep disruption and deprivation in pregnancy is linked to prolonged length of labor and may affect type of delivery.9 Lee and Gay,9 in a prospective, longitudinal follow-up of 131 pregnant women, demonstrate that women who slept less than 6 hours at night had longer labors and were 4.5 times more likely to have a cesarean delivery.9 Therefore, it is important to monitor and inquire about the quality of sleep and the number of hours of sleep during prenatal visits, as these may potentially help predict labor and delivery course.9

Over the course of pregnancy, sleep-disordered breathing increases due to many factors, including weight changes, mucosal congestion and edema, and changes in respiratory mechanics due to reduced lung volumes. Although not common, significant obstructive sleep apnea can occur in this population. Timely treatment of obstructive sleep apnea is imperative given the implications for adverse maternal and fetal health outcomes.2 More commonly, frequent arousals may be contributed to increased upper airway resistance throughout pregnancy, leading to insomnia of sleep-maintenance type resulting in daytime sleepiness.2

Insomnia in Menopause

Menopause is a natural aging event as a result of ovarian failure that occurs typically when a woman is in her late 40s to early 50s. Sleep problems are one of the most prevalent and bothersome symptoms during perimenopause, being reported by approximately 40% of women, with frequent night-time awakenings being the most common and severe symptom.6 The approach to menopause is associated with significant changes in the hormonal milieu with an increase in follicle-stimulating hormone due principally to the decline in negative feedback from inhibin as follicular reserves in the ovaries decline.10,11 Estradiol levels are erratic during the early menopausal transition before declining to low levels after menopause.10,11 Insomnia is a common complaint during the menopausal transition, affecting up to 60% of women.2 Significant sleep disruption in these women depends on the severity of nocturnal hot flashes, hyperarousal due to hormonal fluctuations, underlying mood disorders, sleep-disordered breathing, and the presence of other chronic medical illnesses.

Insomnia in Chronic Medical Disorders

According to Roth,4 “the close association of insomnia with depression is likely related to common underlying pathophysiological mechanisms for sleep and mood regulation that make the person vulnerable to both conditions.” Overactivation of the hypothalamic-pituitary-adrenal axis and hypersecretion of cortisol have been related to the severity of sleep disturbance.4 Both disorders—depression and insomnia—may, therefore, respond to similar therapeutic interventions (eg, corticotropin-releasing hormone antagonists).4 Importantly, insomnia is a risk factor for suicidal ideation, plans, and attempts even after controlling for mood disorders.6

Diagnosis

Insomnia is primarily diagnosed by clinical evaluation, thorough sleep history, and detailed medical, substance, and psychiatric history.12 A thorough assessment of pre-bedtime activities is recommended, including screen time, blue light exposure, and detailed bedtimes with weekday versus weekend variation. The meticulous history helps to establish the type and evolution of insomnia, perpetuating factors, and identification of comorbid medical, substance, and/or psychiatric conditions.12 A 2-week sleep log to identify general patterns of sleep-wake times, Pittsburgh Sleep Quality Index, Insomnia Severity Index, Epworth Sleepiness Scale, or other sleepiness assessment to identify sleepy patients and comorbid disorders of sleepiness should be used at the initial and subsequent encounters to track progress.12

For the purpose of diagnosis of comorbid sleep disorders it is recommended to perform a polysomnogram, particularly when the initial diagnosis is uncertain, or treatment for insomnia fails. Polysomnogram is also recommended in case of dream enactment behaviors or occurrence of violent or injurious behaviors during sleep.12 Circadian rhythm disorders may be characterized by performing actigraphy studies in which the patient is requested to wear a watch-like instrument that detects movements and translates it to periods of activity or wakefulness and periods of rest or sleep. Routine laboratory and radiologic testing is not recommended for the evaluation of chronic insomnia; however, these may be required to evaluate for comorbid conditions.12

Differential Diagnoses

Circadian rhythm disorders of delayed or advanced sleep-phase type may be distinguished from insomnias with a detailed history of sleep/wake times and absence of daytime impairment. Insomnia may present as a symptom of other medical disorders including obstructive sleep apnea, restless legs syndrome, parasomnias, acute or chronic pain, chronic obstructive pulmonary disease, congestive heart failure, liver diseases, gastroesophageal reflux, neurologic disorders, urologic disorders, bipolar disorder, anxiety, and depression. Hypersomnia with fragmentation of sleep may present as nighttime insomnia, because the patient takes multiple naps during the day, thus reducing the homeostatic drive for sleep. A person with bipolar disorder in the manic phase may exhibit periods of severely impaired sleep, associated mania, racing thoughts, and alternating history of depression, which may give a clue to this diagnosis. Effects of certain medications may lead to insomnia; a thorough medication evaluation is essential.

Treatment of Insomnia

Treatment of insomnia is multifactorial with a heavy emphasis on behavior interventions to obtain sustaining results or a cure for insomnia. This is facilitated in cases where the patient is either highly motivated to make changes in behavior or is very reluctant to initiate pharmacologic therapy due to risk for habituation, dependence, tolerance, and/or interactions with other medications already being taken for comorbid conditions. Obtaining and documenting detailed history of previously used medications with doses and length of trial will determine future selection of medications if needed.

Other important strategies to aid treatment of insomnia include identifying behaviors and ideas that may be perpetuating insomnia.12 It is important to identify medications that may cause worsening of insomnia by way of increasing alertness or by way of side effects; these should be adjusted to be taken during the day.

The ideal long-term goal for treatment of insomnia is being able to fall asleep and stay asleep without medications, and to wake up feeling well-rested. This goal, although not impossible, is not achievable without significant effort and commitment on the part of the patient. Setting a realistic expectation of number of hours of sleep required at a given age, and from a patient's prior history will reduce anxiety associated with perceived notion of insufficient sleep and insomnia. Stimulus control, sleep restriction, relaxation training, cognitive-behavioral therapy (CBT), sleep hygiene education, CBT for insomnia (CBT-I), brief behavior therapy for insomnia, and pharmacotherapy may be used for treatment of insomnia. Selection of treatment modalities should be based on three critical factors: (1) most distressing symptoms, (2) presenting symptoms, and (3) underlying medical or mood disorder. Although a comprehensive review of treatments for insomnia is beyond the scope of this article, a few key points to discuss when making treatment recommendations are listed in Table 3.

Steps for Improving Sleep Hygiene and Cognitive-Behavioral Therapy for Insomnia

Table 3:

Steps for Improving Sleep Hygiene and Cognitive-Behavioral Therapy for Insomnia

Cognitive-Behavioral Therapy for Insomnia

An in-depth evaluation of factors that lead to precipitating and perpetuating the symptoms of insomnia identify modifiable behaviors to target for CBT-I. The CBT-I sessions are conducted over weeks to months, preferably in collaboration with a behavior therapist or psychiatrist. Numerous investigations have demonstrated that hypnotic medications are comparably efficacious to CBT-I during acute treatment.13–15 However, these studies also make clear that the gains associated with CBT-I are durable after completion of treatment, whereas those associated with medication tend to dissipate after discontinuation of the drug.13

Pharmacotherapy for Insomnia

Hypnotic therapy should be considered for insomnia when the patient is significantly distressed by the presence or possibility of disturbed sleep, or when the physician judges the sleep disturbance to be deleterious to the patient's health.16

For most patients with chronic insomnia, pharmacotherapy should be initiated with a benzodiazepine receptor agonist (BzRA) at the lowest effective dose.17 A number of agents other than BzRAs are preferred in the treatment of insomnia when there is intolerance or nonresponse to BzRAs, the treatment of insomnia occurring with substance use disorders, allergy-associated sleep disturbance, and insomnia occurring with psychosis, mania, hypomania, depression, or chronic pain where a single agent is desired.17

In 2017, the American Academy of Sleep Medicine published clinical practice guidelines with recommendations for or against medications commonly used for chronic insomnia.13Table 4 lists these medications with a recommendation for use in the specific type of insomnia symptoms. This guideline did not include multiple US Food and Drug Administration-approved medications commonly used in clinical practice due to a lack of sufficient data evidence. Given the known sedative effects of these agents, particularly those with longer half-lives, clinicians must be diligent in cautioning patients regarding potential complications related to sedation.13

Summary of Recommendations for Pharmacotherapy of Sleep Onset, Sleep Maintenance, or Combined Type of Insomnia Symptoms

Table 4:

Summary of Recommendations for Pharmacotherapy of Sleep Onset, Sleep Maintenance, or Combined Type of Insomnia Symptoms

Treatment of Insomnia in Women During Pregnancy, Premenstrual Syndrome, and Menopause

During pregnancy, early interventions to treat sleep disturbance are recommended to avoid adverse outcomes.18 Management strategies include improving sleep hygiene, behavioral therapies, and pharmacotherapy. The risks of pharmacotherapy must be weighed against their benefits due to the possible risk of teratogenicity associated with some medications.18

Sleep disturbances in premenstrual syndrome and premenstrual dysphoric disorders have not been independently studied, and symptomatic treatment may be pursued.

Among women with menopausal symptoms, higher levels of habitual physical activity, particularly non-leisure time physical activity, were associated with more favorable sleep characteristics.10 Considering the potential impact of physical activity on sleep, even at the relatively modest levels characteristic of household physical activity, may be important for women with vasomotor symptoms, a subgroup at high risk for sleep problems.10 Certainly use of hypnotic medications, hormone therapy, and serotonin reuptake inhibitors have shown improvement in sleep maintenance insomnia.

Conclusion

Insomnia is a recurrent disorder of sleep, warranting evaluation of symptom severity during and after treatment. Self-administered questionnaires of insomnia severity and daytime sleepiness may be employed to guide treatment interventions that include retraining, cognitive-behavioral therapy, stimulus control, and pharmacotherapy. The clinician must make the ultimate judgment regarding propriety of any specific care considering the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.13

References

  1. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darrien, IL: American Academy of Sleep Medicine; 2014.
  2. Soares CN, Murray BJ. Sleep disorders in women: clinical evidence and treatment strategies. Psychiatr Clin North Am. 2006;29(4):1095–1113. https://doi.org/10.1016/j.psc.2006.09.002 PMID: doi:10.1016/j.psc.2006.09.002 [CrossRef]17118284
  3. Harvey AG, Spielman AJ. Insomnia: diagnosis, assessment, and outcomes. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 5th ed. St. Louis, MO: Elsevier Saunders; 2011:838–849. doi:10.1016/B978-1-4160-6645-3.00077-3 [CrossRef]
  4. Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007;3(suppl):S7–S10. PMID:17824495
  5. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep. 1995;18(6):425–432. https://doi.org/10.1093/sleep/18.6.425 PMID: doi:10.1093/sleep/18.6.425 [CrossRef]7481413
  6. de Zambotti M, Goldstone A, Colrain IM, Baker FC. Insomnia disorder in adolescence: diagnosis, impact, and treatment. Sleep Med Rev. 2018;39:12–24. https://doi.org/10.1016/j.smrv.2017.06.009 PMID: doi:10.1016/j.smrv.2017.06.009 [CrossRef]
  7. Frey S, Balu S, Greusing S, Rothen N, Cajochen C. Consequences of the timing of menarche on female adolescent sleep phase preference. PLoS One. 2009;4(4):e5217–e5217. https://doi.org/10.1371/journal.pone.0005217 PMID: doi:10.1371/journal.pone.0005217 [CrossRef]19384418
  8. Taylor DJ, Jenni OG, Acebo C, Carskadon MA. Sleep tendency during extended wakefulness: insights into adolescent sleep regulation and behavior. J Sleep Res. 2005;14(3):239–244. https://doi.org/10.1111/j.1365-2869.2005.00467.x PMID: doi:10.1111/j.1365-2869.2005.00467.x [CrossRef]16120098
  9. Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstetr Gynecol. 2004:191(6)2041–2046. doi:10.1016/j.ajog.2004.05.086 [CrossRef] PMID: doi:10.1016/j.ajog.2004.05.086 [CrossRef]
  10. Lambiase MJ, Thurston RC. Physical activity and sleep among midlife women with vasomotor symptoms. Menopause. 2013;20(9):946–952. https://doi.org/10.1097/GME.0b013e3182844110 PMID: doi:10.1097/GME.0b013e3182844110 [CrossRef]23531686
  11. de Zambotti M, Colrain IM, Baker FC. Interaction between reproductive hormones and physiological sleep in women. J Clin Endocrinol Metab. 2015;100(4):1426–1433. https://doi.org/10.1210/jc.2014-3892 PMID: doi:10.1210/jc.2014-3892 [CrossRef]25642589
  12. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504. PMID:18853708
  13. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349. https://doi.org/10.5664/jcsm.6470 PMID: doi:10.5664/jcsm.6470 [CrossRef]
  14. Wu JQ, Appleman ER, Salazar RD, Ong JC. Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis. JAMA Intern Med. 2015;175(9):1461–1472. https://doi.org/10.1001/jamainternmed.2015.3006 PMID: doi:10.1001/jamainternmed.2015.3006 [CrossRef]26147487
  15. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002;159(1):5–11. https://doi.org/10.1176/appi.ajp.159.1.5 PMID: doi:10.1176/appi.ajp.159.1.5 [CrossRef]11772681
  16. Walsh JK, Roth T. Pharmacologic treatment of insomnia: benzodiazepine receptor agonist. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 5th ed. St. Louis, MO: Elsevier Saunders; 2011:905–915. doi:10.1016/B978-1-4160-6645-3.00081-5 [CrossRef]
  17. Krystal AD. Pharmacologic treatment: other medications. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 5th ed. St. Louis, MO: Elsevier Saunders; 2011:916–928. doi:10.1016/B978-1-4160-6645-3.00082-7 [CrossRef]
  18. Hashmi AM, Bhatia SK, Bhatia SK, Khawaja IS. Insomnia during pregnancy: diagnosis and rational interventions. Pak J Med Sci. 2016;32(4):1030–1037. https://doi.org/10.12669/pjms.324.10421 PMID:27648062

Sleep Disorders Associated with Insomnia

<list-item>

■ Insomnia symptoms <list-item>

Delayed sleep onset (more than 30 minutes after bedtime)

</list-item><list-item>

Frequent arousals from sleep

</list-item><list-item>

Early morning awakening

</list-item><list-item>

Total sleep time less than 6 hours in 24 hours

</list-item><list-item>

Daytime fatigue associated with disturbed nighttime sleep

</list-item>

</list-item><list-item>

■ Noninsomnia sleep disorders <list-item>

Restless legs syndrome

</list-item><list-item>

Parasomnias

</list-item><list-item>

Obstructive sleep apnea

</list-item><list-item>

Nocturia

</list-item>

</list-item><list-item>

■ Other medical disorders <list-item>

Chronic pain disorder

</list-item><list-item>

Headaches

</list-item><list-item>

Hot flashes

</list-item><list-item>

Night sweats

</list-item><list-item>

Neuropathic pain

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Acute exacerbation of chronic medical conditions

</list-item><list-item>

Congestive heart failure

</list-item><list-item>

Asthma/chronic obstructive pulmonary disease

</list-item>

</list-item><list-item>

■ Psychiatric disorders <list-item>

Anxiety (acute or chronic)

</list-item><list-item>

Bipolar disorder

</list-item><list-item>

Depressive symptoms

</list-item><list-item>

Dysthymia

</list-item>

</list-item>

Characteristics of Insomnia Subtypes

Insomnia Type Symptoms and Characteristics
Psychophysiologic insomnia Heightened arousal, excessive focus on sleep, sleep-onset symptoms greater than sleep-maintenance symptoms
Paradoxical insomnia Sleep state misperception, complaints of severe sleep disturbance in the absence of evidence of the degree of sleep disturbance claimed, normal sleep efficiency on polysomnography with preservation of normal sleep architecture
Idiopathic insomnia Longstanding difficulty with sleep onset and sleep maintenance
Inadequate sleep hygiene Highly variable sleep/wake schedules, routine use of tobacco, nicotine, and alcohol, use of electronic screens in bed at or close to bedtime, use of bed and bedroom for activities other than sleep
Behavioral insomnia of childhood (limit-setting type, sleep-onset association disorder, mixed type) Inappropriate sleep training, inadequate limit setting by parents or caregivers
Insomnia due to mental disorder Secondary to co-occurring psychiatric conditions, mood disorders and/or anxiety disorders, psychiatric spectrum disorders or personality disorders
Insomnia due to medical condition Pain disorders, mobility limitations, pregnancy, restless legs syndrome, menopause, cancers, sleep-related breathing disorders, acute exacerbation of chronic medical conditions
Insomnia due to drugs or substance use Use of drugs or withdrawal from drugs

Steps for Improving Sleep Hygiene and Cognitive-Behavioral Therapy for Insomnia

<list-item>

Instructions for patients <list-item>

Set realistic expectations for number of sleep hours required

</list-item><list-item>

Restrict time in bed to match hours of sleep required

</list-item><list-item>

Keep scheduled wake-up and bedtimes

</list-item><list-item>

Follow an unwinding routine prior to bedtime (deep breathing, relaxation techniques)

</list-item><list-item>

Turn off bright lights and electronics at least 1 hour before bedtime

</list-item><list-item>

Reserve the bed and bedroom for sleep and intimacy

</list-item><list-item>

Avoid nicotine and caffeine 4–6 hours before bedtime

</list-item><list-item>

Increase daytime physical activity to improve quality of nighttime sleep

</list-item><list-item>

Reduce daytime naps to 30 minutes

</list-item><list-item>

Schedule “worry-time” during the early part of the day

</list-item><list-item>

Anticipate night-to-night variation in sleep quality

</list-item>

</list-item><list-item>

■ Instructions for physicians <list-item>

Set achievable and customized goals with each patient

</list-item><list-item>

Educate patients on number of hours of sleep needed according to age and physical activity

</list-item><list-item>

Sleep hygiene optimization

</list-item><list-item>

Identify 3Ps (predisposing, precipitating, and perpetuating factors) and ameliorate modifiable factors

</list-item><list-item>

CBT-I

</list-item><list-item>

Prescribe sedatives/hypnotics if benefits outweigh risks

</list-item><list-item>

Optimize doses of medications as appropriate

</list-item><list-item>

Evaluate polypharmacy

</list-item><list-item>

Frequently reassess symptoms of insomnia and customize treatment

</list-item><list-item>

Reassure regarding night-to-night variation in sleep quality and quantity

</list-item>

</list-item>

Summary of Recommendations for Pharmacotherapy of Sleep Onset, Sleep Maintenance, or Combined Type of Insomnia Symptoms

Medication Insomnia Symptoms
Zaleplon, triazolam, ramelteon Sleep-onset insomnia
Suvorexant, doxepin Sleep-maintenance insomnia
Eszopiclone, zolpoidem, temazepam Sleep-onset and sleep-maintenance insomnia
Trazodone, tiagabine, diphenhydramine, melatonin, tryptophan, valerian root Not recommended for sleep-onset insomnia, not recommended for sleep-maintenance insomnia
Authors

Safia S. Khan, MD, is an Assistant Professor, Sleep Medicine and Family Medicine, and the Director, Didactics Sleep Medicine Fellowship, University of Texas (UT) Southwestern Medical Center. Imran S. Khawaja, MBBS, FAASM, is a Clinical Professor, Department of Psychiatry and Neurology, UT Southwestern Medical Center; and the Chief Executive Officer, MD TruCare PA.

Address correspondence Safia S. Khan, MD, Sleep Medicine and Family Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390; email: safia.khan@UTSouthwestern.edu.

Grant: Safia S. Khan received a grant (FP00012281) for obesity and obstructive sleep apnea in pregnancy research from the National Institutes of Health National Heart, Lung and Blood Institute.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20191106-04

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