Treatment

The main aim of insomnia management is to improve sleep quantity and quality, improve daytime function (greater alertness and concentration), and cause minimal adverse drug effects

Acute insomnia

Remember that acute insomnia is very common, often transient, and does not always require treatment (1)

• address the trigger factors which might have resulted in insomnia e.g. – ill health, stress, medication, change in time zone etc.
• provide with or review sleep hygiene practices
• educate and reassure the patient that the symptoms are usually self limiting and are usually caused by a precipitant factor
• a short term hypnotic can be considered if symptoms are severe and causes distress about lack of sleep (the Committee on Safety of Medicines, the Medicines and Healthcare products Regulatory Agency (MHRA), and the Royal College of Psychiatrists advise that hypnotic drugs should be limited to the lowest effective dose for the shortest time possible, with a maximum two-week treatment period, and avoided where possible in the elderly.)
• if there is no improvement consider comorbid conditions

Chronic insomnia

• healthcare professionals should address any relevant, underlying problems :
  • prescribed drugs (eg some antidepressants, withdrawal of sedatives) and non-prescribed drugs (eg caffeine, alcohol)
  • physical - pain, respiratory and cardiovascular disorders, neurological disorders, movement disorders, restless leg syndrome and other sleep disorders
  • psychiatric disorders - depression, anxiety, dementia and substance misuse
  • disruption of circadian rhythm e.g. shift work
• first-line therapy should be non-drug therapy - cognitive behavioural therapy (CBT) (1). There is randomised controlled trial evidence that a single session of CBT is effective compared with treatment as usual for acute insomnia (2), and also good evidence for the effectiveness of digitally delivered CBT. (3)
• in patients with significant distress and impact on waking function due to insomnia consider pharmacological treatment (this should be used in parallel with non drug treatment and needs regular review of medication)
• manage comorbid conditions and refer to a specialist if indicated

Whether acute or chronic insomnia, the following non-pharmacologic and pharmacologic treatments can be utilised for treatment (depending on the individual patient and circumstances).

Non pharmacological therapy

• cognitive behavioural therapy (CBT)
  • sleep hygiene
  • stimulus control
  • sleep restriction
  • relaxation training
  • cognitive restructuring (2,3,4)
  • the National Institute for Health and Care Excellence (NICE) has recently recommended the use of the Sleepio app for treating insomnia. People can get Sleepio through self-referral, or through primary care or IAPT services and clinical evidence shows that Sleepio reduces insomnia symptoms compared with sleep hygiene and sleeping pills. (5)

Pharmacological therapies include (4,6)

• benzodiazepines and Z drugs
• prolonged-release melatonin
• antidepressants
• antipsychotics
• sedating antihistamines
• daridorexant - an orally administered dual orexin type 1 and type 2 (OX1 and OX2) receptor antagonist (DORA) developed for the treatment of insomnia

It should always be remembered that there is little evidence to support the pharmacological treatment for the management of long-term insomnia and it should be avoided if possible (7). The use of long-acting benzodiazepines and some Z drugs seems to be associated with an increased risk of falls and hip fractures in elderly patients (8). NICE also has evidence that past benzodiazepine use is associated with an increased risk of Alzheimer's (9)

Herbal remedies (10)

• there is insufficient evidence to support the use of herbal medicine for insomnia, though there is a clear need for further research in this area

NICE have recommended daridorexant for insomnia in adults with symptoms lasting >=3 nights per week for >=3 months, where daytime functioning is considerably affected, only if cognitive behavioural therapy for insomnia has been tried but not worked, or is not available or unsuitable (11).

References:

1. Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017 Dec;26(6):675-700.
2. Ellis JG, Cushing T, Germain A. Treating acute insomnia: a randomized controlled trial of a "single-shot" of cognitive behavioural therapy for insomnia. Sleep. 2015 Jun 1;38(6):971-8.
3. Luik AI, van der Zweerde T, van Straten A, et al. Digital Delivery of Cognitive Behavioural Therapy for Insomnia. Curr Psychiatry Rep. 2019 Jun 4;21(7):50
4. Kay-Stacey M, Attarian H. Advances in the management of chronic insomnia. BMJ. 2016;354:i2123
5. NICE MTG70 Sleepio to treat insomnia and insomnia symptoms
6. Wilson S et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol. 2019 Aug;33(8):923-947
7. Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307-349
8. Donnelly K, Bracchi R, Hewitt J, et al. Benzodiazepines, Z-drugs and the risk of hip fracture: A systematic review and meta-analysis. PLoS One. 2017 Apr 27;12(4)
9. Hypnotics (KTT6) Evidence Context. NICE Advice, 2015 (Last updated: January 2019)
10. Leach MJ, Page AT. Herbal medicine for insomnia: A systematic review and meta-analysis.Sleep Med Rev. 2015 Dec;24:1-12
11. NICE (October 2023). Daridorexant for treating long-term insomnia.