Insomnia is recognized as a difficulty with falling asleep or staying asleep. This condition affects approximately more than half of Americans. It is considered to be one of the most common sleep problems. It is reported that 30% of the population suffer from insomnia, with one and three people suffering from some type of insomnia during their lifetime. Individuals who suffer from insomnia can experience feelings of dissatisfaction and can generally experience one or more of the following that can include low energy, concentration difficulty, decreased performance either in academics or in the workplace or fatigue.
The evaluation and characterization of insomnia is typically based on duration, with acute insomnia being brief, circumstantial and based on life events. Chronic insomnia can happen at least three nights per week and last for at least three months. Some of the causes of insomnia can stem from depression, anxiety, stress, or pain being experienced at night.
While acute insomnia may not require treatment given its brief occurrence the treatment of chronic insomnia is different. The first line is to attempt to treat the underlying condition or issue that is the cause of the insomnia. However, if the symptoms continue and individuals often turn to nonpharmacological and pharmacological interventions. Nonpharmacological interventions can come in the form of cognitive behavioral therapy, relaxation exercises, reconditions, or sleep restriction therapy as well as the adoption of sleep hygiene techniques. Pharmacological interventions can come in the forms of prescription medications such as Suvorexant, Lunesta, and Trazodone. Over-the-counter sleep supplements, like melatonin, are also commonly used for the treatment of insomnia.
One of the newer sleeping agents for insomnia approved in 2014 was Belsomra (Suvorexant) (which is a new class of drug called an orexin receptor antagonist. There is currently no other drug in the market like Belsomra which makes it a novel treatment aid. Belsomra blocks the orexin receptor which is believe to suppress the sleep drive. The benefits of Belsomra is that it can help to treat insomnia that is characterized by difficulty with sleep onset and /or maintenance. The disadvantages of Belsomra, which is similar to other central nervous system depressants in that is can impair daytime wakefulness and impair one’s driving skills and increases the risk of falling. It is important to carefully monitor during the initial stages of therapy to see how one reacts to the medication.
Another medication that has existed for some time is the hypnotic eszopiclone (Lunesta) that is indicated for the treatment of insomnia. While the exact mechanism of action for Lunesta is not known it is believed to interact with GABA receptors with is important in sleep induction. In adults with chronic insomnia that took Lunesta it was found that they were able to fall asleep each night for six months faster and longer but safety communications by the FDA within the last two years have reported concerns of next day impairment with Lunesta and the recommendation was made for lower starting doses of 1mg for men and women. There continues to be ongoing evaluation of the risk of impaired mental alertness not only with Lunesta but with the entire class of sleep aid drugs including over the counter medications.
Lastly, trazodone is an antidepressant that was originally indicated for the treatment of depression in 1981 and with time it effects for the treatment of insomnia led to its off-label indication. There were a few studies that reported improved sleep during the first two weeks of treatment. Trazodone works to inhibit the reuptake of neurotransmitter and blocks histamine and alpha1 adrenergic receptors to can contribution to the induction of sleep. Treatment guidelines have recommended trazodone for chronic insomnia without depression only when other drugs such as Lunesta have failed to produce the desired effect.
Insomnia continues to be a prevalent condition for most Americans but there are current and up and coming agents that are being developed to help manage and potentially treat this condition that has an impact on so many individuals. With ongoing research and clinical trials, newer agents that can help to effectively treat insomnia can be identified.
Author: Abimbola Farinde
Dr. Farinde is a healthcare professional who has gained experience in the field and practice of psychopharmacology/mental health, and geriatric pharmacy. She has worked with active duty soldiers with dual diagnoses of a traumatic brain injury and a psychiatric disorder providing medication therapy management and disease state management.
© 2020 American Sleep Association.