DƯỢC LÍ Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th, 2010

476 Controversy in the management of insomnia
revolves around two issues:
SECTION II
NEUROPHARMACOLOGY
• Pharmacological versus nonpharmacological
treatment
• Use of short-acting versus long-acting hypnotics
The side effects of hypnotic medications must be
weighed against the sequelae of chronic insomnia,
which include a 4-fold increase in serious accidents
(Balter and Uhlenhuth, 1992). In addition to appropriate
pharmacological treatment, the management of insomnia
should correct identifiable causes, address inadequate
sleep hygiene, eliminate performance anxiety
related to falling asleep, provide entrainment of the biological
clock so that maximum sleepiness occurs at the
hour of attempted sleep, and suppress the use of alcohol
and OTC sleep medications (Nino-Murcia, 1992).
Categories of Insomnia. The National Institute of
Mental Health Consensus Development Conference
(1984) divided insomnia into three categories:
• Transient insomnia lasts <3 days and usually is
caused by a brief environmental or situational stressor.
It may respond to attention to sleep hygiene
rules. If hypnotics are prescribed, they should be
used at the lowest dose and for only 2-3 nights.
However, benzodiazepines given acutely before
important life events, such as examinations, may
result in impaired performance (James and Savage,
1984).
• Short-term insomnia lasts from 3 days to 3 weeks and
usually is caused by a personal stressor such as illness,
grief, or job problems. Again, sleep hygiene education
is the first step. Hypnotics may be used
adjunctively for 7-10 nights. Hypnotics are best used
intermittently during this time, with the patient skipping
a dose after 1-2 nights of good sleep.
• Long-term insomnia is insomnia that has lasted for
>3 weeks; no specific stressor may be identifiable. A
more complete medical evaluation is necessary in
these patients, but most do not need an all-night
sleep study.
Insomnia Accompanying Major Psychiatric Illnesses. The insomnia
caused by major psychiatric illnesses often responds to specific pharmacological
treatment for that illness. In major depressive episodes
with insomnia, e.g., the selective serotonin reuptake inhibitors,
which may cause insomnia as a side effect, usually will result in
improved sleep because they treat the depressive syndrome. In
patients whose depression is responding to the serotonin reuptake
inhibitor but who have persistent insomnia as a side effect of the
medication, judicious use of evening trazodone may improve sleep
(Nierenberg et al., 1994), as well as augment the antidepressant
effect of the reuptake inhibitor. However, the patient should be monitored
for priapism, orthostatic hypotension, and arrhythmias.
Adequate control of anxiety in patients with anxiety disorders
often produces adequate resolution of the accompanying insomnia.
Sedative use in the anxiety disorders is decreasing because of a
growing appreciation of the effectiveness of other agents, such as
β adrenergic receptor antagonists (Chapter 12) for performance
anxiety and serotonin reuptake inhibitors for obsessive-compulsive
disorder and perhaps generalized anxiety disorder. The profound
insomnia of patients with acute psychosis owing to schizophrenia
or mania usually responds to dopamine-receptor antagonists
(Chapters 13 and 16). Benzodiazepines often are used adjunctively
in this situation to reduce agitation; their use also will result in
improved sleep.
Insomnia Accompanying Other Medical Illnesses. For long-term
insomnia owing to other medical illnesses, adequate treatment of the
underlying disorder, such as congestive heart failure, asthma, or
COPD, may resolve the insomnia.
Adequate pain management in conditions of chronic pain,
including terminal cancer pain, will treat both the pain and the
insomnia and may make hypnotics unnecessary.
Many patients simply manage their sleep poorly. Adequate
attention to sleep hygiene, including reduced caffeine intake, avoidance
of alcohol, adequate exercise, and regular sleep and wake
times, often will reduce the insomnia.
Conditioned (Learned) Insomnia. In those who have no major psychiatric
or other medical illness and in whom attention to sleep
hygiene is ineffective, attention should be directed to conditioned
(learned) insomnia. These patients have associated the bedroom with
activities consistent with wakefulness rather than sleep. In such
patients, the bed should be used only for sex and sleep. All other activities
associated with waking, even such quiescent activities as reading
and watching television, should be done outside the bedroom.
Sleep-State Misperception. Some patients complain of poor sleep but
have been shown to have no objective polysomnographic evidence
of insomnia. They are difficult to treat.
Long-Term Insomnia. Nonpharmacological treatments are important
for all patients with long-term insomnia. These include education
about sleep hygiene, adequate exercise (where possible),
relaxation training, and behavioral-modification approaches, such
as sleep-restriction and stimulus-control therapies. In sleeprestriction
therapy, the patient keeps a diary of the amount of time
spent in bed and then chooses a time in bed of 30-60 minutes less
than this time. This induces a mild sleep debt, which aids sleep
onset. In stimulus-control therapy, the patient is instructed to go
to bed only when sleepy, to use the bedroom only for sleep and
sex, to get up and leave the bedroom if sleep does not occur within
15-20 minutes, to return to bed again only when sleepy, to arise at
the same time each morning regardless of sleep quality the preceding
night, and to avoid daytime naps. Nonpharmacological treatments
for insomnia have been found to be particularly effective
in reducing sleep-onset latency and time awake after sleep onset
(Morin et al., 1994).