Newer agents with short duration of effect are changing the pharmacologic treatment of insomnia.

Insomnia negatively affects as many as 10% of the U.S. population, and its impact on medical illnesses, work productivity, and quality of life is only recently being fully appreciated. The need to effectively treat insomnia means pharmacists must understand the relative role of nonpharmacologic and pharmacologic treatment options. Drug treatment options continue to evolve, with benzodiazepine hypnotics being challenged by the newer nonbenzodiazepine drugs zolpidem and zaleplon. In addition, many patients are increasingly turning to alternative treatments such as melatonin.

Diagnosis and Epidemiology

Insomnia is diagnosed when an individual has measurable difficulty initiating or maintaining sleep. There are many causes of insomnia, including stress, environmental changes (new surroundings, temperature, and noise), medical and psychiatric illness, medications, and substance use or abuse.

Two Gallup surveys of representative samples of the adult U.S. population asking if respondents “ever had difficulty sleeping” found prevalence rates of 36% and 49%, while 9% and 12% reported “regular” or “frequent” sleep difficulty.

A screening of nearly 2,000 primary care patients in a large health maintenance organization found that 10% reported current major insomnia, defined as taking at least two hours to fall asleep nearly every night.

By definition, transient insomnia lasts for a few days; short-term insomnia persists for up to three weeks, and chronic insomnia is diagnosed when insomnia continues for greater than three weeks. Investigating potential causes and duration of insomnia is necessary to develop an effective treatment plan, and to decide whether medication and/or behavioral interventions should be utilized.

Societal Impact

Insomnia has a profound impact on society and public health in many ways. Chronic insomnia can indicate untreated illness. Additionally, the condition contributes to injury and illness and may cause loss of productivity and diminished quality of life.

In a study of 10,778 men and women aged 35–59 years, poor sleepers were more than twice as likely as good sleepers to have ischemic heart disease in the following six years after onset of poor sleep. Insomnia is associated with gastrointestinal, renal, and musculoskeletal disorders, in addition to primary sleep disorders such as sleep apnea and periodic limb movements (PLMS) during sleep. Primary insomnia patients have been shown to have impaired immune system function due to reduced natural killer cell activity. Insomnia and excessive daytime sleepiness in the elderly is one of the leading predictors of institutionalization.

Health screening surveys have shown that insomnia sufferers of all ages experience excessive daytime sleepiness, predisposing them to diminished cognitive ability, poor attention, lower productivity and decreased quality of life. One study assessing work and daily activities showed insomniacs reporting 10 times as many days absent from work than those without insomnia. Other U.S. surveys on insomnia describe difficulty completing simple tasks, coping with stress, making decisions, and functioning in family and social relationships.

Driver sleepiness is a causative factor in at least 2% of U.S. motor vehicle crashes. Peaks of driver sleepiness occur in the early morning and late afternoon, the natural circadian pattern for drowsiness. Long-haul truck drivers are perhaps the most extensively studied group of sleep-deprived drivers. In one study, 45 drivers had at least one six-minute interval of drowsiness while driving, as judged by analysis of video recordings of their faces. Eight drivers were objectively assessed as drowsy, and two drivers fell into the initial stage of sleep, as detected by polysomnography. Polysomnography is the measurement of physiologic sleep through EEG (electroencephalogram), EOG (electrooculogram) and EMG (electromyelogram).

Polysomnography objectively observes and measures sleep parameters in the laboratory; it is particularly useful in determining drug effects on sleep.

Absenteeism at work, higher rates of chronic illness, traffic accidents and overall diminished quality of life create significant indirect costs of insomnia, which are difficult to measure. Those aside, the direct cost of insomnia (including healthcare system utilization, prescription and nonprescription medication, and alcohol, which some patients use in an attempt to remedy insomnia) is estimated at $13.9 billion for 1995.

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1. Sleep Disorders: Insomnia. Part 2 Physiology of Sleep An understanding of normal sleep is essential in recognizing and effectively treating insomnia. Although individual sleep needs vary, between six and nine hours of total sleep are necessary to feel rested and refreshed and to have optimal daytime functioning. Polysomnography...
2. Sleep Disorders: Insomnia. Part 4 Nonprescription Hypnotic Agents Antihistamines: Most over-the-counter drug treatments for insomnia contain the antihistamines diphenhydramine, doxylamine or hydroxyzine. Individuals with insomnia report that these agents cause drowsiness and help them fall asleep. The most prominent disadvantage is the next-day “hang-over” effects of psychomotor impairment...
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