Treatment Options

Medication & Behavioral Treatments

Medication

Sleep medications are recognized as effective and safe treatments for insomnia. Medications that currently are available by prescription are known to improve sleep by reducing the amount of time it takes to fall asleep, increasing sleep duration, and/or reducing the number of awakenings during sleep. Sleep medications also have been shown to improve self-reports of sleep quality. The newest prescription medications for insomnia are zolpidem (Ambien) and zaleplon (Sonata). These medications are now considered "first line" therapies for insomnia, and appear to have advantages over older medications (the benzodiazepines), which are associated with problems of tolerance, dependence, and next-day impairment. Many people who suffer from insomnia find that occasional or short-term use of sleeping pills provides significant relief from their symptoms. Other people may require longer-term use.

While the use of sleep medicines is a common treatment, it is not a cure for insomnia. Sometimes sleep medications can be dangerous when treating insomnia symptoms that may arise from another disorder, such as one resulting from breathing disorder. Insomnia needs to be properly diagnosed and treatment options discussed with a healthcare professional before treatment with medications is undertaken.

Prescription
There are several types of prescription sleeping pills that have been approved for the treatment of insomnia. These include medications in the class known as benzodiazepines, such as temazepam (Restoril), newer medications that are known as benzodiazepine receptor agonists, such as zolpidem (Ambien) and zaleplon (Sonata), and some other sedating drugs, such as trazodone (Desyrel). Some may be short-acting and work best for trouble initially falling asleep. Others may be long-acting and work best for maintaining sleep in the middle of the night.

Over-the-counter
Over-the-counter medications are available for the treatment of insomnia. These medications are mainly sedating antihistamines. Such medications certainly may be useful for some individuals, but others find that they are not effective, and are associated with unwanted side effects or lose their effectiveness over time.

Sleep medications are recognized as effective and safe treatments for insomnia. Medications that currently are available by prescription are known to improve sleep by reducing the amount of time it takes to fall asleep, increasing sleep duration, and/or reducing the number of awakenings during sleep. Sleep medications also have been shown to improve self-reports of sleep quality. The newest prescription medications for insomnia are zolpidem (Ambien) and zaleplon (Sonata). These medications are now considered "first line" therapies for insomnia, and appear to have advantages over older medications (the benzodiazepines), which are associated with problems of tolerance, dependence, and next-day impairment. Many people who suffer from insomnia find that occasional or short-term use of sleeping pills provides significant relief from their symptoms. Other people may require longer-term use.

While the use of sleep medicines is a common treatment, it is not a cure for insomnia. Sometimes sleep medications can be dangerous when treating insomnia symptoms that may arise from another disorder, such as one resulting from breathing disorder. Insomnia needs to be properly diagnosed and treatment options discussed with a healthcare professional before treatment with medications is undertaken.

For more information, refer to the section on medication.

Behavioral Treatments

Insomnia is a highly common and significant health problem resulting from varied causes. Often, misconceptions and worry about sleep, as well as many sleep-disruptive habits, serve important roles in causing and maintaining insomnia problems. When this is the case, behavioral therapies designed to address these causes are often required to eliminate the observed sleep difficulties. The nature of these treatments varies significantly in that some are composed of fairly formalized "exercises" designed primarily to reduce anxiety and tension at bedtime, whereas others are fairly regimented programs designed to eliminate sleep-disruptive habits. There are several behavioral treatments that are effective and commonly used to treat insomnia.

Relaxation Therapies:
Since the late 1950's, a host of formal relaxation therapies, including progressive muscle relaxation training, autogenic training, imagery training, biofeedback, and hypnosis have all been used to treat insomnia. These approaches are designed to reduce anxiety and excessive tension at bedtime. Regardless of the specific relaxation strategy employed, treatment entails teaching the insomnia sufferer a formal exercise or set of exercises designed to reduce anxiety and arousal at bedtime, so that going to sleep becomes less of a problem. Typically, multiple weekly or biweekly treatment sessions are required to teach relaxation skills, which the patient is encouraged to practice at home in order to gain mastery. The goal of all such treatments is to assist the insomnia sufferer in gaining sufficient relaxation skills in order to eliminate insomnia due to anxiety and tension.

Stimulus Control:
This approach, introduced by Richard Bootzin in 1972, is based on the assumption that both the timing (bedtime) and setting (bed/bedroom) associated with repeated unsuccessful sleep attempts, over time become cues that maintain the insomnia. As a result, the goal of this treatment is to re-associate the bed and bedroom with successful sleep attempts. Stimulus control achieves this by curtailing sleep-incompatible activities in the bed and bedroom and by establishing a consistent sleep-wake schedule. In practice, stimulus control requires that insomnia sufferers:

	go to bed only when sleepy
	establish a standard wake-up time,
	get out of bed whenever awake for more than 15-20 minutes,
	avoid reading, watching TV, eating, worrying and other sleep-incompatible behaviors in the bed and bedroom
	refrain from daytime napping

From a practical viewpoint, this treatment has appeal since it is easily understood and can usually be administered in one visit. However, follow-up visits are generally conducted to help the insomnia sufferer achieve optimal success.

Sleep Restriction:
Sleep restriction therapy (SRT) is a treatment that aims to shrink the margin between bedtime and morning wake time so that the sleep period follows your own biological sleep requirement. This treatment, first introduced by Arthur Spielman and colleagues in 1987, grew out of the observation that many people with insomnia stay in bed hoping this will produce more sleep time. Instead, excess time in bed spreads sleep over a longer period, breaks up sleep, and increases frustration. Typically this treatment begins by having the insomnia sufferer maintain a sleep log to record each night of sleep. After the insomnia sufferer has maintained sleep record for about two weeks, the average total sleep time (ATST) is calculated from the information recorded. Subsequently, an initial time-in-bed (TIB) prescription may be set at a value no greater than the ATST +30 minutes. The TIB prescription is increased by 15-20 minute increments following weeks during which the insomnia sufferer sleeps relatively well but continues to report daytime sleepiness. Conversely, TIB is usually reduced by similar increments following weeks during which the individual continues to have difficulty sleeping. Since TIB adjustments are usually necessary, SRT typically requires an initial office visit to introduce treatment instructions and follow-up visits to alter TIB prescriptions.

Cognitive-Behavioral Therapy:
This treatment strategy might best be regarded as a second generation behavioral insomnia treatment, which evolved from the above described strategies. Cognitive-Behavioral Insomnia Therapy, or CBT, typically consists of some form of therapy to eliminate the misconceptions and faulty beliefs about sleep that many insomnia sufferers have. For example, it would not be useful for a person who needs only 6½ hours of sleep each night to believe that everyone should try to get 8 hours of sleep on a nightly basis. For such an individual, cognitive therapy designed to challenge this faulty belief often proves useful. In CBT, such cognitive therapy strategies are used in combination with both stimulus control and sleep restriction therapies. One presumed advantage of this treatment is that it includes treatment components which address the range of cognitive and behavioral factors that perpetuate insomnia. As a result, this treatment may be more universally effective across insomnia sufferers regardless of their presenting complaints (e.g., sleep onset complaints vs. sleep maintenance difficulty). Admittedly, CBT is a multi-component and seemingly more complex treatment than those previously described. Nonetheless, in practice, this intervention usually requires no more therapist or patient treatment time than do the less complex first generation treatments reviewed above. Often, CBT's cognitive therapy and behavioral instructions can be provided in no more than eight sessions, and some forms of CBT require as few as 2 to 4 sessions.

Where to Get Behavioral Treatment for Insomnia

Healthcare practitioners who offer behavioral treatment for insomnia usually have specialized training in the field of sleep medicine, and many are board certified sleep specialists. You often can locate a therapist in your area by contacting your local sleep center.