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
Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle.
Educational Objectives
- To educate in the area of sleep and insomnia
and to discuss classifications, causes, diseases
and differentiation of conditions.
- 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 receptor complexes.
- 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.