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Home > Healthcare > Health & Fitness Information

Insomnia

Introduction Insomnia is a complaint of difficulty with sleep[1] in the presence of adequate opportunity for sleep. It is characterized by one or more of the following 3 distinct features: (1) difficulty getting to sleep (sleep initiation), (2) difficulty staying asleep (sleep maintenance), and (3) waking up too early (also sleep maintenance), with these disturbances causing next-day deleterious effects.[2] These next-day effects can be perceivably minor, such as yawning and feeling tired, but often can be serious, hazardous to one’s health as well as others, and far-reaching. Thus, addressing insomnia is imperative because it can affect quality of life and have serious consequences on health and longevity. In fact, results from numerous surveys and analyses from the last few decades continue to show that insomnia has negative effects on one’s mental health, physical health, quality of life, job performance, healthcare costs, and safety.[2] In this Clinical Update, the consequences, prevalence, and causes and comorbidities of insomnia are discussed briefly, and then a series of case studies derived from the author’s practice are presented in order to differentiate 3 of the various insomnias and clarify the steps for successful diagnosis and management. Consequences of Insomnia In a study done by the National Sleep Foundation, in association with the Gallup Organization, those with insomnia had much greater difficulty with coping, accomplishing tasks, personal relationships, family and social life, and a decrement in their mood.[3] Moreover, this difficulty worsened proportionally with worsening frequency of insomnia. Those with insomnia also have a greater risk of developing psychiatric disorders.[4] Increased injuries and accidents have also been observed; those with insomnia have 3.5-4.5 times more accidents in general, 1.5 times more work-related accidents, and 2.5 times more motor vehicle accidents.[5] In terms of driving, 23% of people who were polled admitted falling asleep while driving in the past year. Sleep deprivation has been shown to play a major role in most accidents labeled "cause unknown," and an estimated 24,000 people die each year in accidents caused directly or in part by falling asleep at the wheel.[6,7] Increased healthcare costs and services are also a consequence of insomnia. Patients with moderate-to-severe insomnia see their physicians 2.5 times more often than their normal-sleeping counterparts, and are admitted to the hospital nearly twice as often as those without insomnia.[8] Finally, those with insomnia have been shown to have poorer job performance.[9] Insomnia can have unique consequences in the elderly population. Those over 65 with insomnia experience a greater number of falls. In one study of over 34,000 nursing home patients, those with insomnia had 1.52 times more falls than those without insomnia. This increase was not attributable to hypnotic use, and usage of hypnotics was not predictive of falls. Those who were treated for insomnia were less likely to fall (1.32 times compared with 1.52).[10] Prevalence of Insomnia In the latest poll by the National Sleep Foundation, 54% of adults reported having at least 1 symptom of insomnia a few times a week, with 33% experiencing at least 1 symptom every night or almost every night.[11] Moreover, based on findings from the National Institutes of Health (NIH) State-of-the Science Conference on chronic insomnia, 30% of the general population have complaints of sleep disruption and 10% have associated symptoms of daytime functional impairment consistent with the diagnosis of insomnia.[12] In terms of the elderly, 42% of those over 65 experience frequent difficulty sleeping.[11] This high percentage is not inherent to aging itself, but rather is attributed to a greater likelihood of infirmity and dissatisfaction with one’s social life.[13] When all secondary factors are removed, those over 65 have similar rates of insomnia as their younger counterparts.[14] Insomnia is very common in primary care practices. One such study showed that nearly 20% of primary care patients have chronic insomnia; 50% have occasional insomnia; and only 30% are sleeping fine.[15] What is quite concerning is that these patients are reluctant to discuss this symptom with their primary care physicians. In this study, only one fifth of patients with occasional insomnia and only one third of patients with chronic insomnia brought it up.[15] Causes and Comorbidities The NIH, in the recent consensus conference, suggested that insomnia should be thought of as either a primary entity (a disease in and of itself) or comorbid with psychiatric or medical problems.[12] Primary insomnia, or insomnia of which there is no identifiable cause, is a controversial issue. The consensus is, however, that it is somewhat hereditary, that symptoms start in the teens or 20s, and that it becomes chronic. Poor sleep hygiene, chronic stress, and behavioral conditioning are common in these patients.[16] Physiologically, elevated high frequencies on electroencephalograms (EEGs) and hypothalamic-pituitary-adrenal axis dysfunction are seen.[17] Primary insomnia is estimated to be present in 10% to 25% of the chronic insomnia population, but again, these numbers are controversial.[18] More common, and mostly what is seen in the primary care environment, is comorbid insomnia. This is a change in prior terminology, in which "secondary" was previously used.[12] However, as this latter term connotes causality -- that is to say that insomnia is a result of a psychiatric or medical condition -- comorbid implies that causality is not established. Moreover, to describe this in this way also implies that one does not have to feel compelled to identify the cause and alleviate it to eliminate the resultant insomnia. Emerging clinical evidence shows that treating the insomnia may also benefit the comorbid condition itself. This appears to be the case in major depressive disorder (MDD); when insomnia comorbid with depression is treated with a hypnotic along with an antidepressant, the outcome of depression is better compared with when the antidepressant is used alone.[19] It is with this understanding, and with the intuitive belief that treating insomnia improves quality of life and next-day function, that the primary care provider needs to identify and treat insomnia. However, it should be strongly emphasized that clinical trials are direly needed to clarify outcome measures of comorbidities after insomnia treatment. Comorbid insomnias are categorized to occur in conjunction with[20]: Inadequate sleep hygiene; Psychiatric conditions; Medical and neurologic conditions; Medications; Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD); Sleep-related breathing disorders; and Circadian rhythm sleep disorders. Diagnosis and Treatment Patients are usually eager to describe their symptoms to their primary care physicians. However, as stated above, for many reasons, patients don’t readily recount their trouble with sleep. Thus, insomnia presents a unique symptom that is not discussed is often undermined, and even at times associated with consequences that are flatly denied. The following series of case descriptions is intended to differentiate 3 of the various insomnias and exemplify the steps for successful diagnosis and management. These cases are derived directly from the author’s practice. Case Number 1 A 42-year-old, white woman comes in with a chief complaint of wanting to be checked for diabetes. Patient History and Examination. History of Previous Illness.The patient states that her older sister has had type 2 diabetes mellitus (DM-2) for years, and now she thinks that she also has it because she has been feeling tired for a while, and remembers that her sister felt this way when she was first diagnosed. On questioning, she has no polyuria, polydispsia and no recent weight loss. She had a physical exam with blood tests 2 years prior, and her fasting blood sugar was normal. After further questioning regarding her tiredness, she states that it has lasted at least 6 months. When asked whether "tired" to her is fatigue or drowsiness, she states that it is actually both: She feels a lack of energy, such that she cannot accomplish nearly as much during the day as she had in the past, but also that she feels the need to take naps. In fact, she tries to nap, and when she finds the time, it does not seem to help. She is a stay-at-home mom, caring for her 4 children -- ages 7, 10, 12, and 15 -- and her husband. Probing questions into her psychological state reveal nothing abnormal. Past Medical History. Unremarkable. Medications. Over-the-counter (OTC) aid for insomnia containing valerian root. Social History. She is a lifetime nonsmoker, with rare alcohol consumption. She used to exercise, but lately has had no energy to do so. She drinks 1-2 cups of coffee a day -- 1 in the morning and occasionally 1 in the afternoon. Family History. M: age 67. DM-2, medication controlled -- hypertension, hyperlipidemia, obesity; F: age 70. Alive and well; and S: age 45. DM-2, oral medication and insulin controlled -- obesity, hyperlipidemia, and hypertension. Review of Systems. A sleep history is obtained. The patient tries to go to bed at around 11:00 pm, after the kids are in bed, and falls into bed exhausted. However, she is unable to fall asleep for close to an hour, even when she takes her natural sleep aid. When questioned about what keeps her awake, she does not know. When asked whether there is anything on her mind keeping her from sleeping, she denies anything. When asked whether any discomfort interferes with her falling asleep, she says that she can’t find a comfortable spot for her arms and legs. She feels like she has to move them periodically or else they feel uncomfortable. Further questioning reveals that she gets these "creepy-crawly sensations" also when she is sitting and watching television at night, and her husband says that she is fidgety as she moves her legs to lessen these feelings. RLS comes to mind, and she is asked whether it runs in her family, but she denies it. Further review of systems reveals regular, monthly, but somewhat heavy menstrual periods -- 5 days of flow with 15 pads changed on each of the first 2 days. A gynecologist work-up 6 months prior revealed fibroids, but the patient and physician agreed to do nothing at the time. Questioning for anemia revealed mild lightheadedness lasting for a few seconds when standing up quickly, but no heart pounding, and no unusual cravings (pica). Physical Examination. Blood pressure, 100/60 mm Hg (90/50 mm Hg on standing up); heart rate, 90 bpm (105 bpm on standing up); respiratory rate, 12; temperature, 97.7 °F; height, 54 in; weight, 154 lb; skin: warm, dry, no rashes; Head/ears/eyes/nose/throat (HEENT): pale conjunctiva; neck: normal thyroid, carotids, veins; no lymphadenitis; heart; regular rate and rhythm, 1/6 systolic ejection murmur; lungs: clear to auscultation and percussion; abdomen: benign; extremities: no edema, cyanosis (pulses normal); neurologic: sensory, motor, cerebellar grossly intact. Deep tendon reflexes equal, +1. Gait normal. Evaluation and Diagnosis. At this point, the differential diagnosis for her tiredness is: Anemia, with or without iron deficiency; RLS; PLMD; and Other. The patient is advised to get a battery of tests. This is done the next day, and the following results are observed. Chem20: All within normal limits (WNL). Thyroid-stimulating hormone: WNL. CBC: Hemoglobin, 11.1, microcytic indexes; white blood cell count and differential WNL; platelets WNL. Iron/total iron-binding capacity: WNL; ferritin, 5 (normal, 20-280). Pregnancy test: Negative. Treatment and Follow-Up. The patient is informed that RLS is the probable cause of her daytime sleepiness, and that it is likely caused by iron deficiency. The latter she is told is likely also causing her fatigue. She is advised to get an OTC iron supplement and to take 27 mg of ferrous gluconate (Fergon) 2-3 times a day; she is told that it will turn her stools black, and is asked to call if any intolerable gastrointestinal side effects develop. She is also advised to take a hot bath an hour or so before retiring, if possible, and to go to bed at the same time and arise at the same time. She is advised that the findings will be faxed to her gynecologist for possible course of action to reduce her monthly bleeding. She is advised to have her iron and hemoglobin levels tested again in 2 months. After 2 months, her hemoglobin level is 12.2 and her ferritin level is 22. She reports having much more energy and an easier time falling asleep and staying asleep, although the weird feelings in her legs have not totally subsided. She and her gynecologist are discussing methods for reducing the bleeding. She understands that her ultimate relief of RLS resides on stopping the bleeding, but is ambivalent about any surgical procedures. She is advised to reduce the iron supplement to twice daily, and to have laboratory tests again in another 2 months. Discussion. RLS is a neurologic movement disorder that causes an irresistible urge to move the extremities, which results in relief. It is most common in the legs, but can also be present in the arms. It is most often bilateral. Ninety-four percent of patients have difficulty getting to sleep, but many have arousals through the night due to the discomfort. The prevalence is approximately 1% to 10% depending on the ethnic population, but is greater as one ages, with up to 50% incidence in the institutionalized elderly.[21] The diagnosis is based on patient history. The majority of cases, 75%, are idiopathic and these tend to be hereditary. However, it is necessary, as was in this case, to look into secondary causes. RLS is associated with iron deficiency (ferritin < 50, with low or even normal hemoglobin), uremia (20% to 40% of dialysis patients), pregnancy (up to 27%), Parkinson’s disease, diabetes, and certain medications (eg, tricyclics, selective serotonin reuptake inhibitors [SSRIs], lithium, dopamine blockers, and xanthines). RLS is also seen in 37% of those with fibromyalgia and seems to be associated with attention-deficit/hyperactivity disorder (ADHD).[22] Periodic limb movements of sleep (PLMS) are observed in 80% of patients with RLS, and one third of patients with PLMS have RLS.[21] PLMS are stereotyped, periodic, jerking movements typically consisting of intermittent extension of the big toe and dorsiflexion of the ankle, with occasional flexion of the knee and hip that can fragment sleep and result in daytime sleepiness. Whereas RLS is diagnosed by clinical history, PLMS is suspected when the patient has unexplained daytime sleepiness and sleep laboratory testing reveals the disorder on polysomnography. Treatment of RLS, as with all sleep difficulties, begins with education and good sleep hygiene. Because RLS was secondary in this case, medications to treat the cause, in this case an iron supplement, are used. If RLS is primary, dopaminergic medications are most often prescribed, including carbidopa-levodopa, bromocriptine, pergolide, pramipexole, and ropinirole; only the latter is US Food and Drug Administration (FDA)-approved for this condition. Opioids, benzodiazepines, and anticonvulsants are also used, again off-label. Case Number 2 A 20-year-old, white man comes in for follow-up of ADHD. Patient History and Examination. History of Previous Illness. This college student came in 2 weeks prior, wanting to be diagnosed and treated for ADHD. He is a sophomore at a local, small college, and had reported an inability in keeping his grades up since leaving high school; he was getting mostly B’s and C’s when he was used to getting B’s and occasional A’s. He never had to study to get those grades, but his workload as a premedicine major demanded studying, with which he was having difficulty. He scored 25 on the Adult Self-Report Scale screen for ADHD at the last visit, and did not have any secondary causes of inattention. The symptoms dated back to his elementary school days, when he was admonished by his teacher for being disruptive in class. A telephone call to his parents confirmed inattention since age 6, continuing throughout his educational career, without abatement; the parents had been frustrated with his never studying and never living up to his potential, and as well his lack of responsibility with household chores. His 2 younger siblings had not been diagnosed, but the middle brother was faltering in 11th grade. A week ago, the patient returned; the diagnosis of ADHD was confirmed; and the patient was prescribed long-acting methylphenidate. He now reported moderate improvement in inattention parameters. When questioned about his sleep, he reported trouble getting to sleep on a nightly basis, and had been that way off and on for years. This insomnia had actually predated the administration of methylphenidate. He had already tried acetaminophen (Tylenol PM) unsuccessfully, and continued to struggle for over an hour every night before falling asleep at around 2:00 am. He would get up at 8:00 am on weekdays when he had morning classes, but would sleep until 11:00 am on weekends. This catching up on sleep didn’t really help, because he still felt sluggish on weekends. He experienced daytime sleepiness especially during his first 2 classes, but also after lunch. The methylphenidate had helped a bit with this, but not much. Past Medical History. Negative. Medications. As above. He reported no side effects from the medication. Family History. Noncontributory, but reports that his mother has always been a poor sleeper. Social History. Nonsmoker, denied drug use, denied alcohol use. Caffeine: a few colas a day, none after supper. Review of Systems. Brief psychiatric inventory revealed nothing positive. Physical Examination. Blood pressure, 110/70 mm Hg; heart rate, 64; respiratory rate, 12; temperature, 97.6°F; height, 70 in; weight, 145 lb (no change from previous). General. Well-developed, typically dressed young man, pleasant, cooperative, bouncing his one foot rapidly on the floor. Heart/Lung. WNL. Evaluation and Diagnosis. At this point, the differential diagnosis is primary or chronic insomnia: Primary insomnia; Delayed sleep phase syndrome (DSPS); Chronic insomnia possibly comorbid with ADHD; Chronic insomnia possibly comorbid with as yet undiagnosed psychiatric problem; and Other. Treatment and Follow-Up. The patient is asked to try to go to bed at 1:00 am, and to try to keep the room dim and quiet, which he believes is possible. He is asked to read something pleasant and noneducational for around 15 minutes before going to bed. He is asked not to have his clock in his view. He is also asked not to try to catch up on weekends, but to try to get up no later than 9:00 am. He is asked whether there is a possibility of regular napping in the afternoons, and he states that there may be a time between 2:00 and 3:00 pm when the dorm is quiet, and he can have that time to sleep. He is asked to limit the nap to no more than 1 hour. The patient calls in a week reporting an improvement in daytime sluggishness, mainly because of napping an hour in the afternoons, but still is struggling to fall asleep at night. He says that many thoughts are going through his head, and he can’t stop thinking. He is taking the medication as directed, and has followed the sleep-hygiene measures. He continues to show no evidence of psychiatric comorbidity. The most likely diagnosis is primary insomnia, DSPS, or chronic insomnia secondary to ADHD. DSPS is quite common in adolescents and young adults. It results from a disconnection between the patient’s internal biological clock and the external environment, thus the patient’s propensity to fall asleep is simply "delayed" in relation to that of the general public. Subsequently, a patient who is experiencing DSPS is out of phase with the routine that governs most of his or her life. At this point, possible courses of action include reinforcing sleep-hygiene methods, referral to the school psychologist for cognitive behavioral therapy (CBT), the addition of short-acting methylphenidate several hours prior to bedtime, and/or prescribing a sleep medication. The patient is given a prescription for ramelteon 8 mg, and advised to take it every night about a half hour before getting into bed. He is advised that it is nonaddictive, and not a controlled substance, but nonetheless, that he still needs to keep it and the other medication locked securely in his desk. The patient returns a week later to be seen in the clinic. He reports continued usage of the methylphenidate as directed, once every morning. He has followed the sleep-hygiene methods more often than not, and is happy to report success with getting to sleep easily with the sleep medication prescribed. He believes that his daytime function has improved as well. Discussion. As in all cases of insomnia, proper sleep hygiene is recommended. Sleep-hygiene measures include[23,24]: Waking up at the same time of day; obtaining morning light exposure; Restricting napping; educating about impact of naps, if taken; Discontinuing caffeine 4-6 hours before bedtime; Avoiding alcohol and heavy meals close to bedtime; Exercising in the afternoon, but not within 3-5 hours of bedtime; Minimizing noise, light, and excessive temperature in the bedroom; If reading in bed is relaxing, use low light level and read "appropriate materials"; Avoiding working, emotional stress, and computers in the bedroom; Working to reduce arousal in the hours before bedtime; Using the bedroom only for sleeping and sexual activity; and Moving the alarm clock out of sight; set the alarm for morning awakening. CBT has been shown to be highly effective in treating chronic insomnia. In these patients, a trained professional, either individually or in a group setting, helps interrupt the cycle of insomnia by altering faulty beliefs about sleep and setting realistic expectations regarding sleep.[23] Sleep hygiene is usually also reviewed. Studies have shown that CBT alone is as good, if not better, than medication for chronic insomnia, but the combination of medication and CBT is best.[25] Of the many prescription medications that are FDA-approved for insomnia, the most useful are the selective benzodiazepine agonists (sBZRAs) and the one melatonin receptor agonist, ramelteon. The former include, in order of appearance on the US market, zolpidem, zaleplon, and eszopiclone. These induce sleep by modulating selectively the GABAA receptors located throughout the brain. Ramelteon, the newest sleep medication, induces sleep by selectively binding to the MT1 and MT2 receptors located on the suprachiasmatic nucleus (SCN). The latter, located in the hypothalamus, contains a circadian oscillator that functions as the master clock for the entire body. Its neurons exhibit a predictable, rhythmic firing cycle or "oscillation," with a periodicity that is slightly longer than 24 hours, a circadian process.[26] As one is awake throughout the day, one accumulates a "sleep debt," an amount of sleep that is needed to "recharge" oneself. This increasing tiredness, a homeostatic drive, is counterbalanced by the increased firing of the SCN, resulting in alertness throughout the day.[27] With ramelteon, a drug with a mode of action similar to melatonin but 17 times more potent, SCN firing is dampened, and the circadian drive is lessened, allowing for the homeostatic drive to have a greater proportionate effect, thereby facilitating sleep. Studies have shown ramelteon to be effective in sleep induction in transient (acute) and chronic insomnia in all adult ages, including over 65.[28] Unlike the sBZRAs (except eszopiclone, which does not have FDA restriction for long-term use), it is FDA-approved for long-term use, and is not a scheduled substance. There is no addiction potential, abuse potential, tolerance, or withdrawal problems.[28] Its main side effects are somnolence (5% vs 3% for placebo), dizziness (5% vs 3% for placebo), and fatigue (4% vs 2% for placebo).[28] Case Number 3 A 52-year-old, African-American nurse comes in wanting something for her headaches. Patient History and Examination. History of Previous Illness. This pleasant, quiet woman describes experiencing headaches for close to 2 months. She indicates that they feel like tightness around her head. They are present most of the time, worse when she awakens, better during the day, and intensify at night. They are rarely severe, but rather mild and at most moderate. Trauma, fever, neurologic symptoms, and visual disturbances are not observed. On 2 occasions, the headaches turned into migraines that she had not had in 2 years; these involved a throbbing pain behind her left eye, nausea, and light sensitivity that lasted a day; this was typical and exactly like previous ones. OTCs have been of little help. When probing into her life and being asked about her problems, she begins to sob. Ever since separating from her husband with the intent to divorce, she had been doing well, but she was now distraught that he was getting serious with another woman. For the past few months, this has caused her to be deeply despondent, and to question her decision to divorce. She is often tearful when alone, has stopped taking walks, and has lost interest in pleasurable things, such as dining and going to church. She has low energy and motivation, but she is still able to work and explains that work takes her mind off her problems. She has no suicidal thoughts, although she does not have happy thoughts, either. She admits to having trouble sleeping. She falls asleep easily, but 2 hours later she awakens with her mind racing and worrying, and struggles to fall back asleep for an hour or so. She also awakens too early. She goes to bed at 10:00 pm, but needs to be up at 6:00 am to be at work at 7:00 am. She awakens at 4:00 am, again unable to fall back to sleep, and often remains awake until her alarm goes off. Past Medical History. Obesity, prehypertension, and total abdominal hysterectomy with bilateral salpingo-oophorectomy 10 years prior. Medications. None, having stopped hormone replacement therapy 3 years prior. Supplements with OTC multivitamins and calcium. Social History. Quit smoking over 20 years ago. No alcohol, no drugs. Diet and exercise as above. Caffeine: 2 cups of tea per day, no other sources of caffeine. Family History. Noncontributory. Review of Systems. Negative other than above in history of previous illness. Physical Examination. Well-developed, well-nourished woman, tearful, poor eye contact. Blood pressure, 136/88 mm Hg; heart rate, 84; RR, 14; temperature, 98.0°F; height, 65 in; weight, 188 lb. HEENT, atraumatic. PERRLA, EOMI. Fundi normal. Temporomandibular joints normal. Turbinates and oral normal. Neck: nontender, full AROM with no pain. Carotids, veins, thyroid, nodes normal. Heart/lungs: WNL. Neurologic: sensory, motor, and cerebellar intact. Deep tendon reflexes equal. Gait normal. Evaluation and Diagnosis. At this point, the likely diagnoses are: MDD; Chronic insomnia comorbid with depression; Headaches, most likely tension type, with few migraines; and Prehypertension. The patient is diagnosed with chronic insomnia comorbid with MDD. She is knowledgeable about her condition, and knows she is depressed. She wanted reassurance about her headaches, and this is provided; she is told that they are most likely tension-type, with few migraines. She agrees to forego any imaging tests for now, and needs no further reassurance. She accepts an invitation to see a psychologist, but needs to check her insurance for providers in her area. She also agrees to undergo a baseline set of tests because she had not had any for over 3 years. Treatment and Follow-Up. The patient adamantly refuses to take any antidepressants because she has heard that they all cause weight gain. She is eager, however, to take something to help her sleep. Sleep-hygiene measures are reviewed and reinforced, and she is prescribed eszopiclone 3 mg. She seems glad and confident of this because she recounts a television commercial advertising the drug. She is asked to take it nightly right as she gets into bed. She is advised to make sure that she is in bed by 10:00 pm, and that she has the opportunity for a full 8 hours of sleep. She is advised that if she gets an unusual metal taste in her mouth when she wakes up, that her morning oral hygiene measures will remedy this. She is asked to return in 2 weeks, but also to call in 1 week to provide an update. The patient calls in 1 week and states that she is sleeping much better, with no middle-of-the-night awakenings, and that she gets up with her alarm clock at 6:00 am. She feels a bit groggy when she first gets up, but this quickly dissipates after her shower. She did notice the metal taste, but it disappeared after brushing her teeth. She is thankful for the improvement in her sleep, but still feels quite low; as a result, she is having second thoughts about taking antidepressants. All the psychologists in her area who would take her insurance are booked for months, but she did make an appointment to be seen. Information is given on several of the SSRIs, serotonin/norepinephrine reuptake inhibitors, and bupropion. The patient returns in another week, reporting little change from her phone call a week prior. She is still sleeping well, but still feels quite down. She has been following the sleep-hygiene measures, and taking the medication as directed. She is ready to take an SSRI, and indicates that she prefers to take fluoxetine, as her prescription plan copayment is very low when generic medications are prescribed. She is prescribed 20-mg tablets, and told to take half a tablet initially in the morning and then that this should be increased to 1 full tablet. She is asked to call in another week, and to return in another. When she calls a week later, she says that she is still sleeping well, and maybe that she is also feeling a bit less depressed. Her visit a week later shows her to be noticeably improved. Her demeanor and visage are more upbeat, and she reports feeing 50% better. She has more energy, and feels brighter. She reports no side effects. She is asked to return in a month. When she returns as scheduled, she believes that she is all but back to her usual self. She tried stopping the sleep medication a few times, and ended up with sleepless nights, so she has continued to take it nightly. She is advised that it is optimal for first-time MDD patients to continue the SSRI for 6 months after remission. Also, she is advised that she might need to be weaned off the sleep medication, but at this point, she is unwilling to try that. She is advised to return in 2 months. Discussion. Insomnia is quite pervasive in psychiatric disorders. Eighty percent of outpatients[29] and 90% of inpatients[30] with depression report disturbed sleep. Oddly enough, this disturbance does not seem to result from depression, as insomnia precedes depressive symptoms in nearly half of patients with first-time MDD, is concurrent with it 20% of the time, and follows depression 30% of the time.[31] Moreover, in recurrent MDD, insomnia appears before depressed symptoms 56% of the time.[31] This pattern is also seen in the elderly.[13] Of all the symptoms that patients complain about when depressed, sleep seems to be the most concerning. In fact, patients will go to unwise extremes to ensure that their sleep is restored, including consuming excessive amounts of alcohol and taking others’ medications. Results from a study of MDD patients with insomnia, in which one group was given a SSRI alone and the other an SSRI plus adjunctive eszopiclone for sleep, suggest that there are benefits of controlling insomnia in depressed patients.[32] Patients in the latter group had significantly lower Hamilton Depression Rating Scale scores (excluding sleep items) from week 4 of treatment until the end of the study, and were significantly more likely to be both responders and remitters in terms of overall depression.[33] These findings suggest that coadministration of eszopiclone not only treated the insomnia in these patients but also significantly augmented the antidepressant effect of fluoxetine. Most importantly, this study questions the long-held view that insomnia is caused by depression and should be treated by alleviating the depression with antidepressant therapy, and not with therapy directed at insomnia. On the other hand, it suggests that chronic insomnia may also have a causal role in the course of depression and that treating the insomnia improves depression treatment outcomes. It is yet to be determined whether this is a class effect to sBZRAs or whether it will also be observed with other types of medications for insomnia. When choosing a medication for insomnia in depression or otherwise, one can pick from the 3 available sBZRAs based on their duration of action, matching it to the specific symptom of insomnia, or ramelteon. Fifty-seven percent of patients with insomnia have difficulty going back to sleep after waking up; 56% have trouble getting to sleep; and 44% wake up too early.[34] Many insomniacs have 2 or more of these symptoms. sBZRAs differ primarily in duration of action, with onset of action being acceptably rapid for all. The half-lives of zolpidem, zolpidem CR, zaleplon, and eszopiclone are 1, 2.5, 5, and 6-9 hours, respectively.[35-38] This suggests that the shorter duration medication, zaleplon, is preferential for sleep-initiation insomnias. Because of its short duration of action, it is also preferential in situations in which only a short period of sleep is needed, such as a transatlantic flight. Also preferential here is ramelteon, as sleep induction is its only indication, and its nonscheduled characteristic makes it especially attractive. This consideration of half-life also suggests that zolpidem is ideally suited for those with sleep-initiation needs, who also wake up soon after they fall asleep. Zolpidem CR, with its longer duration of action, is especially attractive for patients who have awakenings at any time in the night. Eszopiclone, with its longest half-life, is best for those who wake up too early and can’t fall asleep. Thus, when all the insomnia types are considered, all the currently available medications have a specific and definite place in treating the various faces of insomnia. Conclusion Insomnia is a symptom, or a clue, rampantly occurring in our primary care patients. It is often overlooked or undermined, both by patients and physicians. Inquiring about sleep problems and extracting the details can be invaluable in arriving at the accurate diagnosis expeditiously. Moreover, questions about patients’ sleep habits are also best incorporated in their annual screening exams. Treatment of insomnia, as with most medical problems, begins with advice on lifestyle changes. Treatment also needs to be directed at comorbidities if the insomnia is comorbid and not primary. Finally, the use of medications to relieve sleep difficulties provides palliation and improvement of quality of life, and is emerging as adjunctive treatment of the comorbid condition itself. 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