Insomnia diagnosis and treatment across the lifespan
Insomnia impairs quality of life and is associated with an increased risk for physical and mental health problems and substance misuse. Here’s how you can help.
PRACTICE RECOMMENDATIONS
› Use a standard validated screening tool for the diagnosis of insomnia in all age groups. A
› Employ nonpharmacologic interventions as first-line treatment for insomnia in all populations. A
› Utilize sleep hygiene or cognitive behavioral therapy for insomnia in adolescents and all adults. A
› Initiate independent cognitive or behavioral therapies with younger children. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Melatonin is not recommended for treating insomnia in adults, pregnant patients, older adults, or most children because its effects are clinically insignificant,32 residual sedation has been reported,60 and no analysis of harms has been undertaken.32 Despite this, melatonin is frequently utilized for insomnia, and patients take over-the-counter melatonin for a myriad of sleep complaints. Melatonin is indicated in the treatment of insomnia in children with neurodevelopmental disorders. (See discussion in "Prescribing for children.")
Hypnotics are medications licensed for short-term sleep promotion in adults and can induce tolerance and dependence.32 Nonbenzodiazepine-receptor agonists at clinical doses do not appear to suppress REM sleep, although there are reports of increases in latency to REM sleep.70
Antidepressants. Although treatment of insomnia with antidepressants is widespread, evidence of their efficacy is unclear.32,62 The tolerability and safety of antidepressants for insomnia also are uncertain due to limited reporting of adverse events.32
The use of sedating antidepressants may be driven by concern over the longer-term use of hypnotics and the limited availability of psychological treatments including CBT-I.32 Sedating antidepressants are indicated for comorbid or secondary insomnia (attributable to mental health conditions, medical conditions, other sleep disorders, or substance use or misuse); however, there are few clinical trials studying them for primary insomnia treatment.62 Antidepressants—tricyclic antidepressants included—can reduce the amount of REM sleep and increase REM sleep-onset latency.71,72
Antihistamines and antipsychotics. Although antihistamines (eg, hydroxyzine, diphenhydramine) and antipsychotics frequently are prescribed off-label for primary insomnia, there is a lack of evidence to support either type of medication for this purpose.36,62,73 H1-antihistamines such as hydroxyzine increase REM-onset latency and reduce the duration of REM sleep.73 Depending on the specific medication, second-generation antipsychotics such as olanzapine and quetiapine have mixed effects on REM sleep parameters.65
Continue to: Prescribing for children
