Insomnia in the Psychiatric Context
Vernon M Neppe MD, PhD, FFPsych, MMed, FRCPC, BCFE
Director, Pacific Neuropsychiatric Institute, Seattle;
Adjunct Professor of Psychiatry and Human Behavior,
St Louis University School of Medicine and
Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle.
To educate in the area of sleep and insomnia and to discuss
classifications, causes, diseases and differentiation of
To discuss the clinical implications with regard to management
options and problems.
The development of a broader theory of innovative
psychopharmacotherapy and the understanding of concepts such as
- To educate in the nonpharmacologic management of insomnia.
To discuss the clinical and theoretical frameworks for the
current hypnotic agents.
To develop a profile of the ideal insomnia management compound
based on a pharmacologic and clinical model.
Of all the problems in psychiatry, possibly the most common is the nonspecific
symptom of sleep disturbance. One out of three people has occasional sleep
difficulty, and one out of every six have chronic insomnia. Disorders of
sleep can be hypersomnia, insomnia or parasomnia with insomnias classified
under DIMS, Disorders of Initiating and Maintaining Sleep in which etiologies
vary: psychophysiologic, e.g. 'jet lag' or shift work. ; psychiatric, e.g.,
depression, mania or anxiety; drugs e.g. caffeine, alcohol, cigarettes
and nicotine, "pleasure drugs", certain medications; other
medical conditions and toxic and environmental conditions e.g. respiratory
compromise, urinary or pain syndromes; childhood onset disorder of initiating
or maintaining sleep; and other associated conditions, not specified. The
treatment of these is the treatment of the causes. There are a variety of
other confounding variables. Common are the perception of disturbed sleep
may be different from objectively disturbed sleep; increased difficulties
with age; and disruption by ones partner.
Our society perceives great credit and great relevance to sleeping less
than one needs to. The negative impacts in psychomotor responsiveness and
cognitive awareness are enormous. The chronic insomnia patient particularly
is at risk in relation to these kinds of phenomena.
There are three fundamental facets to insomnia - difficulty falling asleep,
initial insomnia, difficulty maintaining one's sleep, so called fragmented
sleep or paroxysmal awakenings, and early morning awakening, terminal
insomnia as opposed to the first phase of initial insomnia. These reflect
different symptom complexes but overlap. The nonpharmacologic approach to
better sleep hygiene are highly relevant.
The pharmacologic aspects of insomnia is particularly important in
medicine. A sedative antidepressant such as amitriptyline or
trazodone differs markedly from an activating antidepressant such as
fluoxetine or sertraline. Some drugs actually cause depression - e.g.
alpha-methyldopa, reserpine, steroids. Various treatment options are
now of limited suitability because of reasons - lack of maintained
efficacy (e.g. chloral hydrate), to anticholinergic and other
side-effects ( e.g. antihistamines), to bizarre responses in the second
half of the night (e.g. controversially triazolam), to possible
psychomotor impairments during the day because of maintained effects
(e.g. flurazepam), to potential dependence, addiction, withdrawal,
abuse and craving (e.g. benzodiazepines). The emergence of a rapid
onset, effective, safe, short acting, low side-effect profile, apparently
non-addictive drug which seems to have maintained efficacy over
time and which works selectively on only part of the benzodiazepine
receptor complex is an exciting advance. The first such drug is
zolpidem tartrate which seems to be a valuable advance.