|Posted: Wed 11 Feb, 2009
Sandra suggested I post this somewhere so that a mod can move it to the knowledge base. Hope it's of some value!
Insomnia: Treatment Methods
Treatment Methods for Insomnia
Description and Critical Evaluation
Insomnia is an illness said to be prevalent in approximately 10-15% of the population (Oyahon, Caulet, & Guilleminault, 1997; cited in Espie, Jones, Macphee, Broomfield, & Jones, 2005), a significant percentage of the community not getting a restful night’s sleep. There are a variety of diagnosis and treatments depending on what symptoms are displayed and the specific physiological and historical details of the subject. With this mind, it is of paramount importance that an accurate diagnosis is made so that relevant treatments may be pursued and implemented.
The importance of accurate diagnosis and treatment of insomnia cannot be overstated. Due to the high prevalence, it is apparent that this is one disorder which has become epidemic, and that without comprehensive research and successful application of treatment methods, likely not to improve. It is with this importance in mind that we now turn to the key terminology used in the diagnosis and treatment of insomnia.
There are several different forms of insomnia, ranging in severity from acute to chronic (Pallesen, Nordhus, & Kvale, 1998). Acute insomnia refers to a short period of insomnia, while chronic insomnia lasts for a more extensive period of time. There appears a fine distinction between acute and chronic insomnia, the difference relying on the diagnosis of the clinician. In fact, acute insomnia may become ‘chronic’ if the condition is perpetuated by other factors, thus worsening the condition.
In addition, primary and secondary insomnia diagnosis depend on whether the insomnia has arisen independently of any other condition, as in primary insomnia (PI), or when the condition has arisen as the result of a medical disorder, as with secondary insomnia (SI), (Lichstein, Wilson, & Johnson, 2000; American Psychiatric Association, 1994).
Finally, insomnia may further be defined into three classifications of disorder depending on characteristics; extended sleep onset latency (SOL), the inability to fall asleep, wake time after sleep onset (WASO), the inability to fall back to sleep after awakening, and number of awakenings or total sleep time (TST), (Pallesen et al., 1998).
This essay will address treatments for these forms of insomnia, paying particular attention to behavioural and pharmacological treatments, in addition to examining sleep hygiene (SH), cognitive behavioural therapy (CBT), psychotherapy and hypnosis/meditation, and finally alternative herbal remedies.
Pharmacological interventions for insomnia involve the use of hypnotics (benzodiazepines, barbiturates), antidepressants, antihistamines, or less frequently tranquillisers. While each possess different side effects and produce differing degrees of relaxation or drowsiness, some introduce a greater risk of tolerance and dependence than others (Rivas-Vazquez, 2003; Pallesen, Nordhus, Havik & Nielsen, 2001; Espie, 1991; cited in Murtagh & Greenwood, 1995). The two most common hypnotics that fall under this category include benzodiazepines and more typically barbiturates, the choice of treatment in the 20th century (Hauri & Linde, 1990).
Benzodiazepines are used in the treatment of various forms of insomnia, and although considered to be quite safe in the short term a number of adverse side effects may accompany use with both short and long-term consumption. These include daytime sedation, drowsiness, amnesia and rebound insomnia (Moskowitz, Linnoila, & Roehrs, 1990; cited in Belanger, Morin & Bastien, 2005).
Barbiturates tend to carry the same side effects as benzodiazepines, but to a greater extent, and are considered to be far more dangerous and are less preferred by practitioners over benzodiazepines (Hauri & Linde, 1990). Due to the greater risk that barbiturates pose, it seems logical to turn to this mode of pharmacological treatment only if benzodiazepines or nonhypnotic medications prove unhelpful.
Nonbenzodiazepine hypnotics have become more favoured in recent times, due to their high efficacy and low toxicity (Pallesen et al, 2001), though in general the use of hypnotic drugs should not be recommended over an extended period of time. Benefits need to be weighed against the disadvantages when considering the use of hypnotics as a form of long-term treatment, as it is preferable to avoid the risks of possible drug tolerance, psychological dependence and addiction. In fact, if behavioural or cognitive treatments are introduced in the first instance and found to be effective, pharmaceutical intervention may not even be necessary.
The two behavioural techniques addressed here include cognitive behavioural therapy (CBT) and sleep hygiene. These two techniques are often used effectively to treat insomnia and resolve bad sleeping habits (Currie, Wilson, Pontefract, & deLaplante, 2000), though they appear to be dependent on the subject’s ability to follow direction and apply techniques appropriately and consistently.
CBT involves identifying and altering beliefs and attitudes about sleep, such as excessive worry over sleep habits and unrealistic expectations regarding sleep requirements (Pallesen et al., 1998). This technique has been effective in producing significant changes in sleep efficiency, total wake time and sleep quality, as well as showing improvement around beliefs and attitudes about sleep (Bastien et al., 2004). Meaningful improvements in sleep results can occur even if patients do not alter their medication intake (Currie et al., 2000), demonstrating that many participants suffering from insomnia may benefit from implementation of CBT, regardless of pharmaceutical treatment methods currently in operation.
Further to this, research by Morin, Kowatch, Barry and Walton (1993) highlights the short-term effectiveness of CBT as a means of treatment on elderly patients. While this may be the case, long-term treatment was not demonstrated, in young or older participants, and thus the usefulness of this technique as a long-term cure for insomnia is brought into question.
Research conducted by Rybarczyk, Lopez, Alsten, Benson and Stepanski (2002), provides evidence that CBT is effective for those who suffer from insomnia secondary to chronic pain. This may not seem a major finding, but considering the quality of life experienced by those who suffer SI to a primary medical condition, the importance of these findings becomes apparent.
Although efficacy of CBT appears multifaceted, the study conducted by Currie et al. (2000) indicates that CBT helps, but does not entirely eliminate insomnia experienced secondary to chronic pain. This highlights the necessity to adjust treatment options depending on the nature of the insomnia, whether it is primary or secondary to a medical or psychiatric disorder. In some instances, simply altering sleep hygiene habits may contribute to significant improvements in sleep quality and duration.
Sleep hygiene (SH) is a collection of behavioural modifications aimed at altering bad sleep habits, such as restricting activities in bed, promoting exercise, sleep schedules, and limiting alcohol, nicotine and caffeine intake (Stepanski, 2002).
Poor SH-related behaviours may contribute to or perpetuate insomnia, thus aggravating the condition. Fears and expectations as to the amount of sleep that a person may obtain may also contribute to poor SH (Stepanski, 2002). Changes made to SH may decrease incidence of insomnia to different degrees in any chosen subject, as efficacy is likely to be dependent on a number of variables including age, weight, medical history and any pre-existing substance dependencies or medical disorders.
This being said, SH should not be underrated as a very useful supplement to major cognitive or pharmaceutical treatment options, offering the possibility of relief to a large number of people who suffer from acute insomnia.
Therapy, Hypnosis and Meditation
Although not considered to be behavioural interventions in the same sense that SH and CBT are, hypnosis and meditation provide many benefits to acute insomniacs. Research conducted by Alexander, Chandler, Langer, Newman, and Davies (1989) suggests that certain forms of meditation may promote a healthier lifestyle and extended longevity, hypothetically influencing depth and quality of sleep obtained by those who practice. While this mode of treatment is somewhat alternative to behavioural and pharmaceutical approaches, the benefits should be considered. It should be kept in mind that individuals differ in their degree of suggestibility (Perlini, R., Johns, R., & Hoof, P., 2004), when considering relaxation or hypnotic techniques to supplement a mainstream approach, or as part of a therapeutic session.
Psychotherapeutic techniques include stress reduction and relaxation, hypnosis and meditation, and therapy; group, self-help and individual (Bastien, Morin, Ouellet, Blais, & Bouchard, 2004). Each therapy carries with it its own advantages and disadvantages, depending on the individual qualities of the patient and type of insomnia that has been diagnosed.
Many sufferers of insomnia turn to herbal remedies prior to seeking clinical attention. Various herbal remedies are available, from melatonin and vitamins through to ginseng and valerian (Roberto, Dominguez, Bravo-Valverde, Kaplowitz, & Cott, 2000), though the efficacy of some of these various herbal remedies has not been shown to have a consistent effect in clinical trials (Stevinson & Ernst, 2000; cited in McCall, 2002). In essence, these popular herbal remedies may be taken in conjunction with clinically proven treatments, but their efficacy is not proven and require more research.
Throughout this essay the different methods for treatment of insomnia have been brought forward, with particular attention to pharmacological and behavioural interventions.
Pharmacological interventions were the favoured form of treatment for insomnia, though it appears that clinicians have relied perhaps too heavily on this approach. Quite often, side affects of medication appear to outweigh the reported benefit, and a more combined or alternative approach may be more effective and less detrimental to participant’s health. This is not to say that medication should be completely out ruled, but that long term advantages and disadvantages need to be weighed against each other to ensure that the side effects do not outweigh the benefits. If this is the case, CBT, SH, or a relaxation/hypnotic approach should be considered.
In the event that a treatment provides benefits and minimal disadvantages, it appears nothing is to be lost from introducing other behavioural and SH interventions in the mean time, ensuring the subject introduces permanent and lasting changes into their lifestyle.
In any event, more research is required for the best means of treatment for chronic and acute, primary and secondary insomnia, of all age groups, of all socio-economic and ethnic backgrounds.
In summary, the critical evaluation of the above treatment techniques suggests that a combined approach is the most effective and responsible means of treatment currently available.
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