The goals of the treatment of Insomnia are;
1) To improve related daytime impairments
2) To improve sleep quality.
Cognitive-behavioral therapy (CBT) is also considered the most appropriate treatment for patients with insomnia. The components of CBT are;
1) Sleep hygiene education
2) Cognitive therapy
3) Relaxation therapy
4) Stimulus-control therapy
5) Sleep-restriction therapy
Phytotherapy for the treatment of insomnia is an exciting new therapeutic option, which might benefit patients suffering from different degrees of insomnia. Insomnia or sleeplessness is a disorder characterized by difficulty initiating or maintaining sleep. It affects sleep quality and quantity leading to increased morbidity. Sleep disturbances are thought to be caused by abnormalities of the circadian system as indicated by misalignments of the endogenous circadian cycle and the sleep-wake cycle. Several contributory factors may be involved such as stress, health status, and medicines (e.g. caffeine).
Treating insomnia is a big challenge as the available medications are associated with several side-effects. Herbal medicines are being looked at as an ideal replacement for these medications. Among the ethnobotanicals used for sleep disorders, only Valeriana officinalis and Ziziphus jujuba have been evaluated for pharmacological or clinical efficacy against insomnia. Sedative-hypnotics are the most commonly prescribed drugs for insomnia. Though not usually curative, they can provide symptomatic relief when used alone or adjunctively:
Short- and intermediate-acting benzodiazepines (triazolam, temazepam, estazolam)
A physical illness is uncommon with the sleep issue. An off and on sleeplessness need to dig the cause for underlying anxiety, depression or other related issue. A thorough evaluation by the history is done to reach to a conclusion. Accordingly the medical treatment is commenced. The precipitating factors can be;
3) sleep-wake schedule changes,
5) other sleep disorders,
6) medical conditions
7) work-related issues
8) family problem,
9) health events.
All these in isolation or in combination play problems in sleep issues. Good sleep cycle, handling the specific problem, counseling, cognitive-behavioral therapy, medications are employed for the treatment.
Following measures are helpful;
1) Avoid if you do;
a) caffeine or alcohol use,
b) environmental noise,
c) inappropriate room temperature,
d) watching TV in bed.
e) avoid large meals in dinner.
2) Relaxation techniques
3) Acupressure and acupuncture.
A study comparing zolpidem with CBT showed continued efficacy for the patients treated with CBT. Please see the reference;
Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. Sep 27 2004;164(17):1888-96. [Medline].
Dietary measures which are useful:
1) Avoid caffeinated beverages in the late afternoon or evening.
2) Avoid alcohol in the evening.
3) Avoid large meals near bedtime.
Acupressure on the Shenmen points of both wrists significantly decreased insomnia, with the benefit persisting for up to 2 weeks afterward. Please see the reference;
Sun JL, Sung MS, Huang MY, Cheng GC, Lin CC. Effectiveness of acupressure for residents of long-term care facilities with insomnia: a randomized controlled trial. Int J Nurs Stud. Jul 2010;47(7):798-805. [Medline].
The following is the guideline when using medications:
1) Try the lowest dose of the medication.
2) Use the medication for not more than 2-4 weeks in a single stretch.
3) Medications with a rapid onset of action, such as zolpidem or zaleplon, are preferable when the problem is falling asleep.
4) If the problem is staying asleep, temazepam, estazolam, flurazepam are more useful.
5) If one is depressed, an antidepressant with sedative properties, such as trazodone, mirtazapine, or amitriptyline, may be preferable.
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