This review by American authors provides recommendations for the practical treatment of insomnia and the scientific basis of modern treatment methods. Insomnia tends to increase with age and prevails among women, although laboratory studies show that older men are more affected by sleep disturbance. People who are divorced, widowed or separated are more likely to report suffering from insomnia than those living in a marriage; low socioeconomic status also correlates with insomnia. Persistent insomnia is a risk factor and a harbinger of depression. Thus, an effective treatment for insomnia can prevent serious depression. Chronic insomnia is also associated with an increased risk of car accidents, increased alcohol consumption and drowsiness throughout the day. Therefore, patients suffering from insomnia deserve serious attention.
The duration of insomnia in a patient is of important diagnostic value. Short-term insomnia, lasting only a few days, is often the result of severe stress, acute illness, or self-medication. Insomnia lasting more than three weeks is considered chronic and usually has different causes. Diagnostic and pharmacotherapeutic findings depend on whether the symptoms are short-term or chronic.
The diagnosis of chronic primary insomnia is made when it is difficult to stimulate or maintain sleep, or when at least for a whole month the sleep does not restore strength, which causes significant distress or a decrease in social, professional or other important functions. Sleep disturbance in primary or psychophysiological insomnia is not caused by some other cause of sleep disturbance, mental illness, or drug exposure.
Doctors should try to determine the cause of insomnia.
The first step is to identify the main symptom of sleep – for example, insomnia, excessive drowsiness, or restless behavior during sleep. Doctors should then consider possible causes, which include: concomitant disease states or their treatment; the use of substances such as caffeine, nicotine or alcohol; mental disorders (anxiety, fear); acute or chronic stress, such as occurs as a result of bereavement (loss of loved ones); violation of circadian rhythms (caused by night shifts); apnea (accompanied by snoring or obesity); night myoclonia (muscle twitching), etc.
The most common obstacle to diagnosis is the difficulty in understanding that chronic insomnia has many causes.
Patients should be taught to go to bed only when they want to sleep, and use the bedroom only for sleep and sex, and not for reading, watching TV, eating or working. If patients cannot fall asleep after 15-20 minutes in bed, they should get out of bed and move to another room. They should read in low light and avoid watching programs on television, which emits bright light and therefore has an exciting effect; patients should return to bed only when they want to sleep. The goal is to restore the psychological connection between the bedroom and sleep, and not between the bedroom and insomnia. Patients should get out of bed at the same time every morning, regardless of how much they slept during the previous night. This stabilizes the sleep-wake schedule and improves sleep efficiency. Finally, a short daytime nap should be minimized or avoided altogether in order to increase sleep desire at night. If the patient needs a daytime nap, a 30-minute brief nap at noon will probably not disturb sleep at night.
Another useful behavioral intervention that has been shown to be effective is to limit your stay in bed only to your actual sleep time. The effectiveness of this approach, known as sleep restriction treatment, has been demonstrated in a randomized clinical trial with older people. This method allows you to slightly “accumulate sleep in debt,” which increases the patient’s ability to fall asleep and stay asleep. The time allowed to stay in bed is gradually increasing, as much as is required for a full sleep. For example, if a patient with chronic insomnia sleeps 5.5 hours at night, his time in bed is limited to 5.5-6 hours. The patient then adds approximately 15 minutes a week to the beginning of each night’s bedtime, rising at the same time each morning, until at least 85% of the time in bed he is in a state of sleep.
Rational pharmacotherapy of insomnia, especially chronic in adults and senile people, is characterized by five basic principles: apply the lowest effective dose; use a spasmodic dosage (from two to three times a week); prescribe medications for short-term use (i.e., regular use for no more than three to four weeks); stop using the medicine gradually; and ensure that insomnia does not resume after its cessation. In addition, drugs with a short elimination half-life are usually preferred in order to minimize the sedation in the daytime. Alcohol and freely tradable drugs (such as antihistamines) have only a minimal effect on causing sleep, further affect sleep quality and adversely affect performance the next day. In the table. Table 1 lists sedative hypnotic drugs that are usually prescribed, with information regarding the dose (for adults and senile age), the onset of their exposure, the half-life, and the presence or absence of active metabolites in them.