Treating Insomnia Are There Any Good Options ?
Sleep problems are associated with most psychiatric disorders. The treatment of insomnia whether primary or secondary is often difficult.
The first lines of intervention are sleep hygiene strategies, the use of a sleep diary and cognitive behavioural approaches.
When it comes to medication, commonly used drugs have many disadvantages.
Restorative sleep depends on adequate slow wave stage 3 sleep
Most medications used to aid sleep do not enhance slow wave sleep.
Benzodiazepines, zopiclone and other “Z” drugs supress slow wave sleep, produce subtle cognitive impairment and may cause depression.
In recent years there has been an increasing trend to use sedative antipsychotic medications in particular quetiapine. Quetiapine’s sedative effect may act primarily through histamine H1 receptor blockade.
The use of quetiapine, olanzapine and other antipsychotics may not be supportable based on the potential side effect burden which includes metabolic syndrome and tardive dyskinesia. Cardiovascular effects in the elderly have attracted strong warning labels. In addition the quality of the sleep is often unsatisfactory.
Sedative antidepressants are also commonly used particularly trazodone which can result in daytime sedation. It also carries a small risk of cardiac arrhythmia.
Mirtazapine can be effective but may be limited by side effects particularly weight gain.
Antidepressants are contraindicated in bipolar disorder and even small doses of trazodone can be destabilizing.
Recent research points to the role of GABA receptors in sleep regulation. Medications acting on GABA receptors may improve sleep onset and quality.
Lo et al found that gabapentin enhances slow-wave sleep in patients with primary
insomnia. It also improves sleep quality by elevating sleep efficiency and
decreasing spontaneous arousals.
Gabapentin may be a generally safer option for treatment of insomnia with less risk of adverse medical events and low risk for abuse.
Dijk DJ. Slow-wave sleep deficiency and enhancement: implications for insomnia and its management. World J Biol Psychiatry. 2010 Jun;11 Suppl 1:22-8. doi:
Lo HS, Yang CM, Lo HG et al. Treatment effects of gabapentin for primary insomnia Clin Neuropharmacol. 2010 Mar-Apr;33(2):84-90. doi:10.1097/WNF.0b013e3181cda242.
Bret J. Concerns about quetiapine. Aust Prescr. 2015 Jun;38(3):95-7. Epub 2015 Jun 1.