Insomnia Disorder in Adults

Occasional sleep difficulties are fairly common in adults.  Therefore, insomnia disorder is diagnosed only when the sleep difficulty occurs at least three nights per week for a period of three months or longer.  Insomnia disorder often co-occurs with medical conditions and other mental disorders.  However, insomnia disorder should only be diagnosed if the insomnia is not adequately explained by the co-occurring condition and if the insomnia is severe enough to warrant independent clinical attention.  Finally, insomnia disorder is diagnosed only if the individual is significantly distressed or impaired by the insomnia or resulting daytime symptoms.

Most individuals with insomnia disorder experience comorbid physical and/or mental health conditions, some of which may be exacerbated by the insomnia disorder or share a bidirectional causal relationship with insomnia.

Insomnia disorder has been linked to abnormalities of brain function which are thought to contribute to symptoms.  In particular, evidence points to hyperarousal in the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and central nervous system.  In addition, cognitive factors (such as worrying excessively about sleep or its negative consequences) and behavioral factors (such as arousal-related conditioning of sleeping areas) have been proposed to maintain insomnia.  The disorder has a genetic component, although having a genetic predisposition to insomnia disorder does not necessarily mean that someone will develop insomnia disorder.

First Line Treatments

Clinical research and practice guidelines suggest that the following treatments are effective:

• Cognitive-behavioral therapyrefers to one or more of a set of cognitive and/or behavioral interventions that have demonstrated efficacy in treating insomnia.  These include stimulus control, relaxation training, sleep restriction, and paradoxical intention.
• Biofeedback involves giving the patient visual or auditory feedback to promote muscle relaxation and other sleep-promoting physical parameters.
• Pharmacotherapy can be prescribed short-term and should ideally be used in combination with cognitive-behavioral therapies.  Specific medications for insomnia include short- or intermediate-acting hypnotics and benzodiazepine receptor agonists such as:
• Ramelteon
• Zolpidem
• Eszopiclone
• Zaleplon
• Temazepam

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• Sedating antidepressant medications such as trazodone, amitriptyline, doxepine, and mirtazapine

• Combination treatment with a benzodiazepine receptor agonist and sedating antidepressant

• Other sedating agents, including anti-epilepsy medications such as gabapentin and tiagabine or atypical antipsychotics such as quetiapine and olanzapine

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered.

• Cognitive therapy
• Acupressure/acupuncture
• Tai chi
• Yoga
• Herbal therapies such as melatonin