15 - Treatment of Transient Insomnia

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

Copyright 2003 Lippincott Williams & Wilkins

> Table of Contents > 15 - Treatment of Transient Insomnia

15

Treatment of Transient Insomnia

Richard I. Shader

David J. Greenblatt

Insomnia has different meanings to different people. For example, the term can refer to difficulty falling asleep because of preoccupations with worries (ruminations) or because of pain or discomfort (e.g., gastrointestinal reflux disease); waking with a full bladder and not being able to fall back to sleep readily; feeling too activated to fall asleep because of the ingestion of caffeinated beverages too close to bedtime; or waking at 5 a.m. with a sense of dread after a mere 3 hours of sleep, as sometimes occurs in disorders of mood. From an adaptive or coping perspective, insomnia simply means not getting enough restorative sleep. When total sleep time is even transiently insufficient, the consequences for daytime functioning can be clinically significant, including impaired concentration and memory, irritability, drowsiness or falling asleep without warning, or altered reaction times. A workable but nonspecific definition of insomnia is a subjective description of a person's difficulty with falling asleep or a lack of restorative or restful sleep in spite of ample time and opportunity to sleep.

Insomnia can be subdivided in many ways. Some commonly accepted but clearly arbitrary dichotomies are (a) primary (i.e., intrinsic; likely of unknown origin) and secondary (i.e., extrinsic; likely from some determinable cause, such as worry, pain, or noise); (b) short term (less than 3 weeks) or long term (longer than 3 weeks); (c) the further subdivision of short term into transient (typically less than 4 nights) and short term (4 to 21 nights); and (d) short term and situational versus chronic. Most clinicians also find that separating out sleep-onset insomnia (i.e., problems with falling asleep) from sleep-maintenance insomnia (i.e., difficulties with staying asleep) is useful. Another important form is the early morning awakening that is common in major depressive episodes (see Chapter 18). A good example of transient insomnia is the nonrestorative sleep that is commonly experienced by hospitalized patients whose sleep is interrupted by a variety of factors, including noise, intravenous lines, light, pain, and fear. Inadequately treated chronic pain is a frequent cause of insomnia.

In the United States, about 80 million adults are currently estimated to have problems with sleep. About one-third of the persons with insomnia complain that their sleep problem is persistent (chronic) or that it recurs frequently (episodic), and almost two-thirds say that their sleep is disturbed at least two nights per week. About 40% of American adults say that their impaired sleep interferes with their daily activities. Disturbed sleep is particularly frequent in the elderly and in patients suffering from psychiatric disorders. About half of patients with schizophrenia have insomnia. The estimate for patients with major disorders of mood is even higher about 75%. These estimates delineate the breadth of the population complaining of sleep disturbances; they do not address the issues of etiology or treatability.

This chapter focuses on the assessment and treatment of transient insomnia.

I. Evaluation, Diagnosis, and Sleep Hygiene

Careful evaluation and accurate diagnosis are critical first steps in responding to patients' sleep complaints. For example, some patients with daytime drowsiness, irritability, and depression are actually showing the daytime manifestations of a nocturnal problem, such as the alpha intrusions of fibromyalgia, obstructive or central sleep apnea, familial akathisia (restless leg syndrome), or nocturnal myoclonus. Treating any underlying cause (e.g., implementing continuous positive airway pressure for obstructive apnea or providing antidepressant therapy for those whose sleep difficulty is secondary to depression) is clearly more appropriate than is using sedative-hypnotic agents that, for some, may actually worsen the problem. Furthermore, some sleep problems that occur reflect grief reactions; phase-shift problems, such as jet lag (time zone changes)

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or shift work; separation anxiety; or behavioral conditioning. For example, some patients say they only have trouble sleeping when away from home. Others sleep well when they are not at home; they have difficulty sleeping at home because the bed or bedroom at home has become linked through conditioning to disquieting experiences, such as arguments or unwanted sexual experiences, or to moods, such as resentment or fear. Many complaints about disturbed sleep reflect lifestyle or stress problems. Women report a higher prevalence of disturbed sleep than men do. Further review, however, is beyond the scope of this chapter's coverage of insomnia.

Careful history-taking is essential to elicit situational causes that the patient may be ignoring. The patient may benefit from looking at the factors that he or she can change to promote better sleep hygiene. Often patients are helped simply by hearing from the clinician that missing a few nights of sleep will not be harmful. Suggesting that they read a book, listen to restful music, or watch a movie on television instead of focusing on the fact that they are not sleeping may allow the patient to have a less distressed reaction to the loss of sleep. Some data also suggest that picturing a peaceful and quiet scene (e.g., an isolated beach) is more effective than the customary advice to visualize and count sheep. If no daytime napping is occurring, the patient may soon become tired enough to resume a normal sleep pattern. Many patients will also benefit from simple suggestions about altering their before-sleep behaviors (Table 15.1).

Polysomnographic investigation is not indicated for the typical transient sleep disturbances usually seen by clinicians.

II. Sleeping Pills

In the United States, about 15% of all persons with sleep complaints use either prescription or over-the-counter sleep remedies. With short-term use, the benefits from pharmacotherapy are usually manifested as shortening of the latency to persistent sleep or as an increase in the total time asleep; the former occurs more frequently than the latter. Although effective sleeping pills may provide these very real short-term benefits for some people, more controversy is seen with regard to the general long-term use of hypnotic agents. Some, but not all, studies suggest that some degree of tolerance typically develops after weeks or a few months of nightly use. Abrupt discontinuation of short half-life hypnotic agents, which either deliberately or inadvertently happens all too often (e.g., when a patient is admitted to a hospital and does not disclose a history of use), can result in transient rebound insomnia or a withdrawal (abstinence) syndrome when prior use has been prolonged or when in it has occurred at high doses. About 30% of insomniacs use alcohol as a hypnotic (see section II.A.4).

A. Self-Prescribed Treatments

• Over-the-counter remedies are the most widely used agents for inducing sleep. They typically contain diphenhydramine (e.g., Compoz, Dormin, Miles Nervine, Nytol, Sominex) or some other antihistamine (e.g., chlorpheniramine, doxylamine [e.g., Unisom Nighttime Sleep-Aid]) with sedating properties (Table 15.2). The resulting sedation or drowsiness may produce enough relaxation to promote sleep, but this effect may often be more subjective and indirect, rather than having a direct effect on sleep architecture. Their effectiveness has not been established by a sufficient number of carefully controlled clinical trials. Compliance with over-the-counter remedies, in general, is higher than with prescribed hypnotics. However, because antihistamines are not short acting, many people complain of next-day drowsiness or thick-headedness, a hangover, impaired coordination, reduced physical dexterity, or delayed reaction time. During sleep, diphenhydramine may increase motor activity. Anticholinergic effects, including dry mouth, urinary retention or difficulty urinating (hesitancy), or confusion, also may occur; these unwanted effects pose particular problems for the elderly, especially for men with prostatic hypertrophy. Tolerance to the sedating properties of antihistamines usually develops within days to weeks. Antihistamines should also be avoided in patients with

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  glaucoma or asthma. Some agents, such as doxylamine, may be dangerous during pregnancy.

  TABLE 15.1. HELPFUL HINTS FOR BETTER SLEEP

  Do not go to bed to try to sleep when you are not tired.
  Avoid evening naps.
  Pain interferes with sleep. If possible, take an appropriate medication to reduce any physical pain you may be having.
  Eat selectively. Being hungry when you go to bed may disrupt your sleep. Avoid a heavy meal too close to bedtime. Avoid caffeine and other methylxanthines (e.g., chocolate, colas, coffee, tea) after 4 p.m. A warm noncaffeinated beverage and a small carbohydrate snack before bedtime may be soothing, and they may enhance drowsiness.
  Exercise at least two to three times per week. Avoid vigorous and sustained exercise close to bedtime (i.e., within the 2 3 hours before trying to go to sleep). A short early evening walk or bicycle ride may be relaxing.
  Try to keep stress and conflict out of the bedroom; whenever possible, resolve the stresses of that day and enter the bedroom with a clean slate.
  Enhance relaxation whenever possible (e.g., a warm unhurried bath; a massage; comforting sexual experiences; meditation; reading a good, but not too exciting, book). Try deep breathing methods (e.g., abdominal breathing in which slow inhalation is linked to the downward movement of the diaphragm and slow exhalation is linked to the upward movement of the diaphragm). Do this for 10 breaths, working to slow your breathing rate progressively. Repeat as necessary while trying to relax the rest of your body. Focus on a relaxing image and try to capture the whole scene including scents and temperature.
  Develop comfortable and easily doable nighttime rituals or routines. Try to go to bed at a consistent time. Darken the room whenever possible.
  If you do not fall asleep after a half hour or so, read a book or watch a pleasant television program for awhile. With this in mind, watching the late (e.g., 11 p.m.) news is probably not a good habit. When possible, leaving the bedroom if you do not readily fall asleep and returning only when you feel tired may be better. Keep your arising time as regular as possible as well.
  Keep the room temperature comfortable for you. A hot room may increase awakenings (>24 C [75 F]), and a cold room may promote an increase in unpleasant dreams (<12 C [54 F]). Some fresh air may be helpful. Humidify your bedroom if it is too dry.
  Try to use a supportive, preferably firm, mattress and pillows of comfortable thickness and density. Sometimes an adjustable bed should be considered because having the knees bent may decrease lower back muscle strain and pain.
  Avoid noise, unless it is a form of white noise that is soothing to you.
  For most people, alcohol use when kept to a minimum (i.e., one to two drinks with dinner) does not disrupt sleep. Alcohol use of any amount close to bedtime may be disruptive to the sleep of some.

  TABLE 15.2. SOME OVER-THE-COUNTER SLEEP AIDS^a COMMONLY AVAILABLE IN THE UNITED STATES

  Product Name	Active Ingredientb
  Benadryl	Diphenhydramine
  Compoz	Diphenhydramine
  Sleepinal	Diphenhydramine
  Sominex	Diphenhydramine
  Miles Nervine Nighttime Sleep-Aid	Diphenhydramine
  Nytol	Doxylamine
  Nytol QuickCaps	Diphenhydramine
  Unisom	Doxylamine
  Unisom SleepGels	Diphenhydramine
  aOther sedating antihistamines include triprolidine, clemastine, and promethazine. bVarious strengths and formulations contain between 25 and 50 mg of the active antihistamine.

  Remembering that antihistamines may also be present in combination products, such as Alka-Seltzer PM, Aspirin Free Excedrin PM, Extra Strength Bayer PM Caplets, and Extra Strength Tylenol PM Gelcaps, is important.

• L-Tryptophan was used, usually on a nonprescription basis, to help with sleep-onset insomnia until contamination problems led to its withdrawal from the market in the United States and many other countries in 1990. (Note: Some dietary supplements and enteral nutrition products may contain L-tryptophan.) Although the available data on the efficacy and safety of this drug are neither extensive nor conclusive, the clinical consensus is that l-tryptophan is a weakly effective hypnotic agent without significant risks in the absence of contaminants. The eosinophilic-myalgia syndrome reported with its use has been linked to a contaminant in the manufacturing process. No acceptable reformulation has been introduced into the market in the United States. The folk remedy of warm milk with crackers before bedtime probably has its basis in the facilitation of L-tryptophan absorption from milk by the accompanying carbohydrate or through mediation by cholecystokinin. Some people believe that the soporific effects of L-tryptophan seen after eating turkey or bananas are also predictable.

• Melatonin is a naturally occurring pineal gland peptide hormone. When purified or synthesized and taken orally, it alters circadian rhythms, lowers the core body temperature, and reduces daytime alerting phenomena originating in the suprachiasmatic nucleus. Although it has been found to be effective for the treatment of insomnia in a number of populations and settings, the results are inconsistent and some degree of controversy remains about its efficacy and long-term safety. One factor that may influence efficacy studies has been a lack of information about dose-response relationships. Efficacy has been reported with doses as low as 0.3 mg at bedtime. Others believe that 6 mg is the necessary dose. The authors have had some inconsistent success with melatonin for the treatment of transient insomnia at doses of 6 mg per night.

  Some data suggest that the endogenous melatonin levels increase in patients receiving monoamine oxidase inhibitors or selective serotonin reuptake inhibitors and that they decrease during the use of some -adrenergic receptor antagonists (e.g., atenolol, propranolol).

  Side effects attributed to melatonin use include pruritus, tachycardia, headache, and daytime drowsiness.

• Alcohol is probably even more frequently used to induce sleep than are over-the-counter remedies. What most alcohol users do not realize, however, is that, although alcohol may promote sleep onset, it then fragments the subsequent sleep architecture. This means that most alcohol-induced sleep will not be as restorative as unaided sleep is. Many persons who consume alcohol at bedtime sleep quite deeply and soundly for a few hours but then awaken; they are then unable to fall back to sleep. Alcohol use may pose additional risks for those who are sleep deprived. For example, in a driving simulation test conducted after a night of sleep deprivation, volunteers performed poorly after the ingestion of small amounts of alcohol, some at levels that were insufficient to result in detectable blood alcohol levels.

• Kava, as kavalactones and kavapyrones, is sometimes used as a sleep aid. Called the intoxicating pepper by the sea-going James Cook, kava is derived from the roots of a shrub (Piper methysticum) grown on some South Pacific islands. Kava-kava is called kavain in some other countries. A typical dose of kavalactones 15 have been isolated and 6 are thought to be -aminobutyric acid (GABA)ergic is 200 to 500 mg. Curiously, despite its putative GABAergic mode of action, kava is not thought to potentiate the sedative effects of alcohol.

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  As the controlled or long-term assessment of kava is insufficient at this time, it cannot be endorsed as either an effective or safe substance; more rigorous trials are being conducted currently. Some side effects attributed to its use include headache, gastrointestinal distress, fatigue, and so-called kava dermopathy (a fish scale like change in the skin seen in some persons after chronic use). Recently, the United Kingdom Medicines Control Agency advised prudence regarding kava-kava use and recommended discontinuation of products containing kava-kava because of serious adverse hepatic events. Switzerland has discontinued sales of these products, and Germany and the Food and Drug Administration in the United States are reviewing data at the time of the writing of this chapter. At least one case on file at the United States Food and Drug Administration involved hepatic failure requiring liver transplantation.

• Valerian was described by Samuel Taylor Coleridge as a gentle thing, beloved from pole to pole. It is approved by the German Commission E as a prescription sleep aid. Many varieties of valerian exist, and, as with many herbal extracts, standardization problems and inconsistent potency are rampant. Some of valerian's sleep-inducing activity is attributed to valerenic acid and various valpotriates. Dosages usually range from 300 to 900 mg. Side effects are not common at these dosage levels; headache, gastrointestinal distress, and palpitations have been noted. Tolerance, physical dependence, and withdrawal reactions have not been substantiated. Systematic assessments of efficacy and safety that meet American research design standards are still lacking.

• Aromatherapies are also available. One such product simply called SLEEP (by Essence of Vali) contains lavender flowers, cedar wood, marjoram leaves, and ylang-ylang petals. The manufacturer's recommended strategy is to place a few drops of the oil on the corner of the pillowcase or on a separate cloth that is placed under the pillowcase. Curiously, this product contains a warning cautioning against use during pregnancy or in persons treated for low blood pressure.

B. Prescription Medications

• Benzodiazepines are more consistently effective than self-prescribed treatments. They shorten sleep latency, decrease stage 1 sleep, and increase stage 2 sleep. Slow-wave sleep (stages 3 and 4) generally is reduced. Patients believe that their sleep experience is more restorative. Five benzodiazepines are currently marketed as hypnotics in the United States (Table 15.3). No convincing evidence that is currently available consistently distinguishes among them in terms of efficacy or safety with proper usage (i.e., dosages, dosing intervals, and duration of use). Some differences among the benzodiazepines have been suggested on the basis of stage 3 and stage 4 effects and possible variations in receptor binding,

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  but no basis for any clinically relevant variability has been established. Data suggest that all currently marketed benzodiazepines bind to cortical ( ₁, ₂), cerebellar ( ₁), and spinal ( ₂) benzodiazepine receptor sites on GABA_A-chloride channels.

  TABLE 15.3. BENZODIAZEPINE RECEPTOR AGONISTS MARKETED IN THE UNITED STATES AS HYPNOTICS

  Generic Name	Trade Name	Dosage Strength(s) (mg)	Relative Duration of Action
  Triazolam	Halcion and generics	0.125, 0.25	Short
  Zolpidem	Ambien	5, 10	Short
  Zaleplon	Sonata	5, 10	Short
  Temazepam	Restoril and generics	7.5, 15, 30	Intermediate
  Estazolam	ProSom	1, 2	Intermediate
  Flurazepam	Dalmane and generics	15, 30	Long
  Quazepam	Doral	7.5, 15	Long

  Any benzodiazepine, including those not marketed as hypnotics, could be used to induce sleep as long as an appropriate dose is chosen. The basic issues are rapidity of absorption from the gastrointestinal tract, rapid uptake into the brain, adequate duration of action, duration of activity of any active metabolites, and the elimination of the parent compound and any active metabolites at a rate that significantly reduces brain concentrations before the patient awakens the next morning. From this perspective, one can imagine the possibility that certain agents would be good for sleep-onset problems and that others might be good for maintaining sleep. Problems with benzodiazepines when they are used in appropriate dosages and for brief courses (e.g., a few nights to several weeks) are infrequent. Unfortunately, some patients mix benzodiazepines and alcohol, which can enhance the sedation or adverse effects from both and can produce, for example, excessive and prolonged sedation, dizziness, or falls. Cross-tolerance among benzodiazepines and between benzodiazepines and alcohol has not been adequately clarified, even though benzodiazepines are successfully used in the treatment of alcohol withdrawal (see Chapter 12). Some problems seen shortly after starting a patient on a new benzodiazepine hypnotic may actually reflect a withdrawal syndrome from a prior benzodiazepine, particularly if the former was a shorter half-life type, or from alcohol that was abruptly stopped.

  Rebound insomnia is common with abrupt discontinuation after several nights of use of shorter half-life benzodiazepine hypnotics, and some patients find that this seems worse than their original problem. Rebound insomnia may in fact be more marked or exaggerated than the original insomnia problem. However, it rarely lasts for more than a few nights, and it generally can be avoided either by dose tapering rather than by abrupt stoppage or by using lower dosages during treatment. Individual susceptibility to rebound insomnia is variable. Some evidence suggests that the likelihood of rebound is greater in those who experience a greater hypnotic efficacy.

  Some patients receiving shorter half-life benzodiazepines complain of increased wakefulness during the terminal hours of sleep (i.e., the last 2 to 3 hours). This is similar to what may happen when alcohol is used as a hypnotic. Another concern experienced by some patients taking shorter half-life benzodiazepines is increased daytime anxiety, particularly during the morning.

  Benzodiazepines are relatively safe when they are used as directed. A small proportion of patients, usually persons who have a tendency to abuse other substances, becomes involved in dosage escalation and abuse. Daytime drowsiness may be a problem, particularly with longer-acting benzodiazepines (Table 15.4). Falls¹ occur and confusion may develop, particularly in the elderly. Anterograde amnesia is not uncommon, particularly with triazolam or in phase-shifted persons. Any consideration of comparative safety claims among benzodiazepines must take into consideration dosage, the activity of the metabolites, the timing of use, age, and concomitant diagnoses.

• Chloral hydrate is viewed by many clinicians as an obsolete agent. However, it is reasonably effective in dosages of 0.5 to 1.5 g (Table 15.5). The elimination half-life of 6 to 8 hours for its active metabolite, trichloroethanol, is consistent with a minimal likelihood of next-day

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  performance impairment. In many clinical drug studies, particularly those of antidepressants, it is used for the initial 7 to 10 days to give the patients some relief while the study drug begins to become effective. This is actually an arbitrary decision, because little research has been done on the molecular basis of chloral hydrate's mode of action or on its interactions with study drugs. Chloral hydrate's drawbacks include a narrow therapeutic index (toxic dose to therapeutic dose), gastric irritation leading to nausea and vomiting, and gastric necrosis with high dosages. As with other sedative-hypnotics, dependence and tolerance may develop. It may also displace other drugs from their protein-binding sites, and, during prolonged dosage, it may be a hepatic microsomal enzyme-inducing agent.

  TABLE 15.4. SOME UNWANTED EFFECTS COMMON TO MOST BENZODIAZEPINE RECEPTOR AGONIST SEDATIVE-HYPNOTIC AGENTS^a

  Motor impairment and falls
  Anterograde impairment of memory and new learning (recall)
  Discontinuation syndromes (e.g., rebound insomnia, withdrawal reactions)
  Tolerance and physical dependence
  Respiratory depression
  Interactions (additive or synergistic) with alcohol (ethanol)
  Architecture of sleep altered
  Daytime drowsiness and other carryover effects

  ^aThe unwanted effects have been ordered to produce the mnemonic MAD TRIAD.

  TABLE 15.5. SOME NONBENZODIAZEPINE RECEPTOR AGONIST SEDATIVE-HYPNOTIC AGENTS AVAILABLE BY PRESCRIPTION IN THE UNITED STATES

  Generic Name	Trade Name	Dosage Range (mg)	Class
  Butabarbital	Butisol	50 100	III
  Phenobarbital	Luminal	100 300	IV
  Mephobarbital	Mebaral	32 400	IV
  Chloral hydrate	Noctec	500 1,500	IV
  Meprobamate	Miltown Equanil	400 1,600	IV
  Hydroxyzine hydrochloride	Atarax	50 400
  Hydroxyzine pamoate	Vistaril	50 400

• Zolpidem, an imidazopyridine compound, is currently the most widely prescribed hypnotic in the United States. Although it is promoted as a nonbenzodiazepine, its activity is based on its binding to central ( ₁) benzodiazepine receptors. The assumption made is that the more restricted binding of zolpidem confers a more limited range of unwanted effects. To some extent, this is borne out by clinical experience, but more time and data across a spectrum of dosages in different age groups are needed before adequate comparisons can be made.² Zolpidem's half-life typically is 2.5 to 3 hours. Zolpidem's hypnotic activity can be reversed by the benzodiazepine antagonist flumazenil (Romazicon). Based on its

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  extensive use, zolpidem appears to have a somewhat reduced likelihood of producing tolerance or withdrawal syndromes. Its abuse potential also seems lower than that seen with some benzodiazepines, but it does have some cross-tolerance with alcohol at higher than standard hypnotic dosages. See Table 15.3 for available dosage forms. The use of lower dosages is usually important for elderly patients. Rebound insomnia has been reported with its discontinuation.

• Zaleplon is another nonbenzodiazepine that acts by binding to central ( ₁) benzodiazepine receptors; its hypnotic effects can also be antagonized by flurazepam. Zaleplon is classified as a pyrazolopyrimidine compound (Table 15.3 details the available dosage forms). The usual starting dose in adults is 10 mg; 5 mg is a typical dose for the elderly. Although it is currently less popular in the United States than zolpidem, it is similar in most respects; one notable difference is its even shorter elimination half-life, which is approximately 1 to 2 hours. Some clinicians find this quality useful for patients who awaken during the middle of the night and who want to fall asleep again. Many clinicians limit the consecutive nights of use to two to three nights, which is then followed by an interruption in use of one to several nights. Rebound insomnia has been reported with discontinuation.

• A variety of other prescription hypnotics, particularly oral hypnotic agents, remains available, including the barbiturates (e.g., butabarbital [intermediate duration of action], mephobarbital [because of long duration of action it is used mainly for anxiety]) and meprobamate (Table 15.5). These agents do not have either efficacy or safety profiles that are comparable with those of the benzodiazepines, zolpidem, or zaleplon. Their use is not encouraged by the authors, even though health care cost pressures and other forces have led to a resurgence in their use in some locations.

• Trazodone, a triazolopyridine compound marketed as an antidepressant, is frequently used as a hypnotic. Given in doses of 25 to 150 mg at bedtime, it appears to be effective as a hypnotic for many patients. One of trazodone's common uses is to counter the insomnia associated with selective serotonin reuptake inhibitor use. Daytime drowsiness can usually be minimized by choosing the lowest effective hypnotic dose. Tolerance development is not common, so trazodone is frequently used for patients with chronic insomnia. Because anticholinergic side effects and postural hypotension are not common with its use, trazodone has some advantages over other sedating antidepressants.

• Other sedating antidepressants are still used by some clinicians in small doses (i.e., 25 to 50 mg); these include sedating antidepressants, such as amitriptyline or trimipramine. These may be appropriate alternatives, especially for patients with depression, but the risks from the antiadrenergic and anticholinergic properties of these agents must also be considered.

III. Suggested Guidelines for Prescribing Medications

Universally accepted guidelines for the dosing and duration of use for hypnotics are not established. Both must be individualized, with the goal of finding the lowest dose and minimizing the duration to the shortest possible. Generally, between one and three tablets or capsules per night of the lowest dosage strength is appropriate. Short-term treatment (i.e., one to two nights to 1 to 2 weeks) is reasonable for most patients. However, some patients with chronic insomnia may benefit from longer term use, as long as the prescribing clinician provides careful monitoring. Because no criteria are presently available to identify this subpopulation, considering several short-term trials, with gradual tapering at the end of each period and a drug-free interval between each period, seems reasonable for establishing the patient's need for, and the appropriateness and value of, continued therapy. The drug-free time interval between the initial periods should be from 1 to 3 weeks, depending on the half-lives of

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the agent and its active metabolites and the rapidity of the taper schedule. Reevaluation of such a patient's continued need for hypnotic medication at 3-month to 6-month intervals is also reasonable. Because the elderly are particularly susceptible to falls or confusion from hypnotic use, using the lowest available dosage strength is advisable.

When insomnia is of the primary and chronic form, controversy exists about continuous long-term use of hypnotics. Although many patients do benefit from long-term use, to establish whether the occurrence of rebound insomnia or withdrawal has been the deciding factor in convincing the patient of the continued value of the hypnotic agent is important.

For those individuals who hope to benefit from behavioral or nonpharmacologic approaches to their insomnia, prescribing hypnotics two to three times per week while they are working out such modifications may be beneficial. For patients with chronic, persistent, sleep-maintenance insomnia, some evidence exists that suggests that cognitive-behavior therapy is more helpful than either muscle relaxation exercises or a sham form of behavior therapy. Unfortunately, the comparative benefits of cognitive-behavior therapy as compared with the use of hypnotic agents and of the combined use of cognitive-behavior therapy and hypnotic agents has been insufficiently studied.

IV. Overdosage and Abuse of Sedative-Hypnotics

These important topics are covered in Chapters 3, 9, 11, and 12.

V. Internet Sites

Some useful sites for persons with sleep disorders include http://www.sleepfoundation.org/ and http://www.nhlbi.nih.gov/about/ncsdr/. These sites provide facts about research, contact telephone numbers, a sleep diary for tracking actual sleep patterns that can be helpful to both clinicians and patients, and other useful information.

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¹Factors increasing susceptibility to falls include impaired visual contrast sensitivity, decreased visual acuity, and decreased sensation in the legs. In addition, sedative-hypnotic use may augment any existing decrements in reaction time, muscle strength, or postural stability.