Pharmacological and Behavioral Based Treatments for Insomnia

The Prevalence and Treatment of Insomnia Today

Everyone experiences trouble sleeping from time to time. Indeed, the events from a busy day can easily intrude on sleep to the point where people fail to get enough rest each night and the ongoing global Covid-19 pandemic has added more fuel to these sleep-disrupting fires. When people consistently fail to get enough sleep for sustained periods of time, however, they can suffer from a wide range of physical and mental health disorders that can have life-changing implications. Although greater attention has been focused on sleep disorders such as insomnia in recent years, far too many people continue to suffer from this common but potentially harmful condition today. The purpose of this evidence synthesis paper is to provide a review of the relevant literature concerning the prevalence of insomnia among American adults today, a summary of the adverse mental health and physical problems the disorder can cause and what pharmacological and behavioral-based regimens have been identified as most efficacious for its treatment. Finally, a summary of the research and important findings concerning insomnia and its treatment are provided in the conclusion.

Review and Discussion

Background and overview

Like fire and dark energy, sleep is still a mysterious phenomenon in many ways to scientists today. Despite having been the focus of a growing body of research over the past several centuries, much still remains unknown or unclear about sleep and its role in human physiology. Moreover, there are still numerous misconceptions and myths about sleep that may prevent people from seeking professional assistance when they need it for disordered sleep. For example, according to the American Sleep Association (2020), “Prior to the mid-20th century, researchers conceptualized sleep as a “passive, dormant part of our daily lives [but] fast forward 70 years and we now know that our brains are very active during sleep” (What is sleep and why is it important?, para. 2).

Although there is no universally accepted definition, two representative definitions of sleep include the following:

1. A condition of body and mind such as that which typically recurs for several hours every night, in which the nervous system is relatively inactive, the eyes closed, the postural muscles relaxed, and consciousness practically suspended (Google dictionary).

2. The natural, easily reversible periodic state of many living things that is marked by the absence of wakefulness and by the loss of consciousness of one's surroundings, is accompanied by a typical body posture (such as lying down with the eyes closed), the occurrence of dreaming, and changes in brain activity and physiological functioning, is made up of cycles of non-rapid eye movement (REM) sleep and REM sleep, and is usually considered essential to the restoration and recovery of vital bodily and mental functions (Merriam-Webster).

As can be readily discerned from the above definitions, the first is more closely aligned with the conceptualizations of passive sleep that prevailed prior to the 1970s while the second definition takes into account the elevated brain activity that occurs during REM sleep. This evolution in the precision of the definition of sleep may have also affected the prevalence of sleep-related disorders such as insomnia by raising consumer awareness and these issues are discussed further below.

Prevalence of insomnia

At the global level, insomnia is widely prevalent and the disorder has been reported to affect up to 33% of the adult population (Sharma & Andrade, 2017). Indeed, some researchers estimate the global prevalence of insomnia as being even higher, perhaps as high as 50% to 60% in some cases. In this regard, Bhaskar, Hemavathy and Prasad (2016) report that, “Various studies worldwide have shown the prevalence of insomnia in 10%–30% of the population, some even as high as 50%–60%” (p. 780). Although anyone can suffer from insomnia, the elderly and those with preexisting mental health and medical disorders are at especially high risk (Sharma & Andrade, 2017).

Domestically, the prevalence of insomnia is slightly less than the global level. For example, using a definition of insomnia that is aligned with the DSM V diagnostic criteria, researchers at the Perelman School of Medicine at the University of Pennsylvania found that approximately one in four American adults, or about 75 million people, develop acute insomnia annually; however, of these new cases, a majority (about 75% or 56.25 million) successfully recover from these transient episodes without going on to experience chronic sleep disorders including acute insomnia (Perlis, 2018). Based on their analysis of a sample of 1,435 adults, Perlis (2018) and his associates found that, “Whether caused by stress, illness, medications, or other factors, poor sleep is very common” (Perlis, 2018, para. 4).

Beyond the human toll that is exacted by insomnia in the United States, there is also a high economic burden that is associated with treating this sleep disorder. For instance, according to Alexandru and Róbert (2009), the cost of treatments for patients in the United States that suffered from insomnia in 2004 increased to more than $2.1 billion, a total that grew to more than $3.2 billion by 2009. While it is possible to quantify the economic burden that is associated with treating insomnia, quantifying the lost productivity, diminished performance and increased absenteeism of people that suffer from chronic insomnia is far more difficult but these costs are also believed to be staggering in their adverse effects on individual sufferers and the national economy (Alexandru & Róbert, 2009). Indeed, the results of an insomnia study by Reddy and Chakrabarty (2011) found that, “While 30-48% individuals report some problem in sleeping in a year, when diagnostic criteria were used for insomnia syndrome, 6% of the respondents indicated a disorder of insomnia that impaired daytime function” (p. 3).

These adverse effects are consistent with many of the problems that are associated with insomnia which further underscore the importance of securing sufficient restful sleep each night, including the symptoms identified by the Mayo Clinic that are listed below:

· Difficulty falling asleep at night;

· Waking up during the night;

· Waking up too early;

· Not feeling well-rested after a night's sleep;

· Daytime tiredness or sleepiness;

· Irritability, depression or anxiety;

· Difficulty paying attention, focusing on tasks or remembering;

· Increased errors or accidents; and,

· Ongoing worries about sleep (Insomnia overview, 2020).

Despite its increased prevalence in recent years and potential to cause serious mental and physical health problems, insomnia has received scant clinical attention (Sateia et al., 2000). As also reported previously, some of the research concerning insomnia has been characterized by disparities that are attributable to a lack of definitional clarity. For instance, insomnia has been alternatively described as dissatisfaction with sleep, with or without daytime consequences or insomnia disorder. The current DSM-V diagnostic criteria for insomnia are provided at Appendix A. The DSM-V diagnostic criteria are similar to those set forth in the International Classification of Sleep Disorders which specify that “symptoms must cause clinically significant functional distress or impairment, be present for at least 3 nights/week for at least 3 months, and not be linked to other sleep, medical, or mental disorders” (Bhaskar et al., 2016). Clearly, without this type of uniform assessment of insomnia diagnoses, the results of sleep disorder studies may vary in documented cases and overall prevalence.

What is known with some degree of certainty, however, is that the increased prevalence of insomnia over the past 20 years has been linked to increases of prescription medication (Bertisch, Herzig & Winkelman, 2014). At present, between 50% and 80% of patients seeking clinical assistance report having experienced significance problems in falling asleep and staying asleep at some point during the preceding year (Bertisch et al., 2014) Furthermore, a growing body of research confirms that sleep has a profound impact on mental and physical healthy, but additional research in these areas is also needed (What is sleep and why is it important?, 2020). What is also known at present concerning the adverse physical and mental health problems that are associated with insomnia is discussed further below.

Adverse physical and mental health problems associated with insomnia

As noted previously, insomnia is one of the most common types of sleep disorders. A growing body of evidence confirms that people that suffer from insomnia are at greater risk of experiencing a mood disorder or recurrence of an existing disorder as well as exacerbating psychiatric symptoms including mania and depression (Khawaja & Hurwitz, 2017). Some of the other types of problems that are frequently associated with poor sleep habits include anxiety and chronic illness as well as inadequate physical exercise and some types of medications (Sateia, Buysse, Krystal et al., 2000).

One of the more challenging aspects of determining the adverse physical and mental health problems that are associated with insomnia is the fact that sleep needs differ between adults, and some people appear to require far more or far less sleep than others to maintain their normal day-to-day functioning levels. Indeed, even when a sleep disorder does not satisfy all of the DSM-V diagnostic criteria, it is clear that diminished sleep levels or interrupted sleep patterns can still have severe mental and physical health effects.

In an effort to develop some findings that are applicable to most American adults that can help guide clinical practice, researchers at the U.S. Centers for Disease Control and Prevention (CDC) used 7 hours of sleep per night as the benchmark for the minimal daily requirement for adults to evaluate the effects of sleep deprivation similar to those experienced in insomniac cases. Some of the more alarming findings that emerged from the CDC study included the fact that people that fail to get at least 7 hours of sleep a night are at greater risk of heart attack, stroke, coronary heart disease, asthma, chronic obstructive pulmonary disease, cancer, arthritis, chronic kidney disease and diabetes, in this descending order (Short sleep duration among American adults, 2020).

Taken together, it is clear that obtaining sufficient restful sleep is a critically important part of the human condition and there are some evidence-based interventions that can help in this regard and these are discussed below.

Pharmacological and behavioral-based interventions for insomnia

In response to the growing prevalence of diagnosed cases of insomnia over the past 20 years or so, there has been an increase in pharmacological interventions (Sateia et al., 2000). It remains unclear at present, however, whether the use of behavioral-based sleep hygiene principles is more effective when combined with medications (Khawaja & Hurwitz, 2017). This type of debate of common with many other disorders, of course, but developing efficacious interventions for insomnia has been a challenging enterprise due to a number of constraints. For example, the current lack of knowledge concerning best practices for treating insomnia is due in large part to the multiple antecedents that can exacerbate existing medical or mental health conditions or cause new ones that prevent people from getting enough sleep (Khawaja & Hurwitz, 2017).

Furthermore, the highly subjective nature of the sleep experience itself makes it difficult to formulate across-the-board comparisons. In this regard, Reddy and Chakrabarty (2011) report that, “Insomnia is a symptom that arises from multiple environmental, medical, and psychological and mental disorders [and] can be transient, short-term, or chronic in its presentation” (p. 2). In addition, further research in also needed to determine with greater precision whether medications with insomnia side effects tend to cause insomnia or whether insomnia results in the onset of other health conditions that then require pharmaceutical interventions (Do, 2020).

At present, some of the most commonly prescribed medications for insomnia (MCUFI) at present include, in descending order, the following: benzodiazepine receptor agonists (eszopiclone, zaleplon, zolpidem, estazolam, flurazepam, quazepam, temazepam, triazolam), barbiturates (amobarbital, amobarbitalsecobarbital, chloral hydrate), doxepin, quetiapine, ramelteon, and trazodone (Bertisch et al., 2014). Each of these medications has its own set of side effects and reactions with other drugs, so pinpointing the precise causes of drug-related problems represents a daunting enterprise when treating insomnia pharmacologically (Bertisch et al., 2014).

Many of the patients in the Bertish et al (2014) study were prescribed two or more MCUFIs to treat their primary insomnia. For example, based on their analysis of the National Health and Nutrition Examination Survey, 1999-2010, Bertisch and his associates (2014) conclude that, “In this nationally representative sample, reported use of prescription medications commonly used for insomnia (MCUFIs) within the preceding month was common, particularly among older adults and those seeing a mental health provider, with high use of sedative polypharmacy among MCUFI users” (p. 349).

These are important issues because humans need sufficient restful sleep to remain healthy and diminished or disrupted sleep patterns can have a severe effect on mental and physical health. Insomnia causes severe distress, social, interpersonal and professional dysfunction. It affects well-being and the quality of life and is often associated with affective disorders, such as irritability and dysphoria. The impredictibility and uncontrollability of the sleeping pattern can lead to feelings of helplessness and to the onset of depressive and anxiety disorders (Alexandru & Róbert, 2009).

Even with optimal results and clinical outcomes, however, such polypharmacological interventions are not only expensive, they can cause unintended side effects that can exacerbate the insomniac condition. Because many insomniac patients suffer from a wide array of comorbid conditions for which they have prescribed medications, these sides effects can become severe but in any case a pharmacological treatment strategy used in isolation may not be appropriate or lack the behavioral component that is needed to maximize the effectiveness of sleep disorder interventions. For example, according to Alexandru and Róbert (2009), “Some of the deficiencies of the current treatments of insomnia are side effects in the case of sleeping pills and high costs in the case of psychotherapeutic treatment” (p. 68).

These deficiencies have compelled a growing number of health care practitioners consider various types of behavioral-based interventions for insomnia, including self-help treatments. Indeed, self-help treatments have a number of benefits over conventional pharmacological interventions, including their far greater accessibility and low cost (Alexandru & Róbert, 2009). Given the enormous human and economic costs that are associated with treating insomnia in the United States each year, behavioral-based interventions represent a pragmatic solution to a complex problem.

Beyond the foregoing, there are also some other straightforward methods that can be used to improve sleep architecture and hygiene. In this context, architecture refers to sleep that is “easily susceptible to external and internal disruption” while hygiene is used to refer to the management strategies that are used to minimize such disruptions (Reddy & Chakrabarty, 2011). Although many if not most people experience transient episodes of insomnia from time to time, the conditions becomes far more severe when it satisfies the diagnostic criteria set forth in the DSM-V. In this regard, Reddy and Chakrabarty (2011) emphasize that:

The insomnia syndrome becomes chronic when it is present for a month or longer and is defined by whether it is primary or associated with comorbid disorders. It is estimated that 10-15% of patients who have chronic insomnia are of primary origin. Insomnia that is comorbid with psychiatric disorders, medical disorders, circadian rhythm disorders, or substances or medications accounts for nearly 85-90% of chronic insomnia. (p. 4)

Therefore, clinicians should ensure they rule out the possibility that other factors, including most especially polypharmacological regimens, are causing or exacerbating disordered sleep. Further, the effective management of underlying pain conditions in elderly adults has been shown to help alleviate insomnia and improve the quality of sleep (Dunietz, Swanson, Jansen et al., 2018). In addition, developed and maintaining good sleep hygiene can also help adults get the recommended amount of sleep each night, and some of the habits that have been shown to improve sleep health include the following:

· Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends

· Make sure bedrooms are quiet, dark, relaxing, and at a comfortable temperature

· Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom

· Avoid large meals, caffeine, and alcohol before bedtime

· Get some exercise. Being physically active during the day can help people fall asleep more easily at night (Tips for better sleep, 2020).

Besides these tips, sleep specialists also recommend the following to improve sleep hygiene:

· Avoid using beds for anything besides sleep and sex;

· Budget 30 minutes of time to “wind down” engaged in favored relaxing activities in preparation for bed; and,

· Do not “toss and turn.” If sleep is not attained in 20 minutes or so (estimated mentally without watching a clock), patients should get out of bed and read, stretch, or engage in other relaxing activities in low light before reattempting sleep (Vyas & Suni, 2020).

The above lists, of course, are not exhaustive nor are they universally applicable to all insomnia sufferers. Indeed, some people may find the white noise generated by computer-based applications extremely soothing in ways that help them get and stay asleep while others experience sleep benefits from television, an electronic “look-at device,” a nightlight or even a low-wattage bedside table lamp. In other words, entering a deep, restless state that is characterized by high levels of REM activity is different for everyone, and some people may be awakened by a creak in a floorboard or a distant whisper while others may be able to sleep through an earthquake without waking. This also means that treating insomnia requires a highly individualized approach that takes both environmental factors as well as individuals’ genetic and medical history into account (Chaput, Dutil & Sampasa-Kanyinga, 2018).

Encouraging insomnia sufferers to change their lifestyle and adopt behaviors that are conducive to helping them fall and stay asleep may be difficult, but there are some major “selling points” that clinicians can use to reinforce the importance of sleep architecture and hygiene for insomniacs. For example, people that experience problems falling asleep and just toss and turn are only wasting precious time. Likewise, individuals that attempt to squeeze as much quality out of life as possible by packing their days full of exciting activities and adventures at the expense of the amount of sleep they get each night (read: young people but increasingly older Americans as well) will likely suffer from any number of severe mental and physical health disorders, including premature death, that are proven to be associated with insufficient sleep. In other words, 7 hours may seem like a major sacrifice in time (and it is, 7 hours of sleep each day equals nearly 106 days each year) but like healthy eating and simply breathing, people sacrifice sleep at their peril. In addition, it is also important to note that making the substantive lifestyle changes that are needed to achieve healthy sleep patterns may require time since many of the contributing factors to insomnia such as smoking or alcohol use may be lifelong habits that are exceedingly difficult to break (Mulcahy, 2009).

Conclusion

The research showed that obtaining a sufficient amount of restful, REM sleep each night is essential for maintaining good mental and physical health. The research also showed, however, that the frail human condition is replete with events that intrude on individuals’ ability to get to sleep and stay asleep for the full 7 hours that are recommended for adults by the CDC. In sum, and to paraphrase Hamlet, “To sleep, perchance to dream – ay, there’s the rub.” Even under the best of circumstances, the human brain is a relentlessly busy machine, constantly churning out random neurotransmissions during sleep that manifest in infinite ways which accounts, in part, for the increased prevalence rate for insomnia in the United States in recent years. Improvements in definitional clarity with respect to insomnia disorder have also contributed to this increase by helping clinicians better diagnose the condition. The research was also consistent in showing that there are several evidence-based behavioral and pharmacological interventions that have been used to treat insomnia disorder with varying degrees of effectiveness, suggesting there is no “one-size-fits-all” treatment strategy that is appropriate for all adult insomniacs. In the final analysis, it is reasonable to conclude that the prevalence of insomnia in the United States will continue to escalate unless and until and an effective vaccine for the ongoing Covid-19 pandemic is developed and made widely available and the social, political and economic turmoil that is wracking the nation has been successfully resolved. Finally, as noted throughout, even under optimal circumstances, though, most people will experience trouble sleeping at some point in their lives but the vast majority manage to overcome these transient episodes and return to their normal sleeping patterns. Therefore, clinicians should remain vigilant concerning new evidence-based behavioral and pharmacological interventions that can be used to treat the symptoms and insomnia and help patients regain a healthy lifestyle that includes sufficient amounts of sleep.