Insomnia symptoms can indicate underlying medical conditions

THE NATIONAL SLEEP FOUNDATION recommends that healthy adults sleep seven to nine hours per day. However, many people aren't getting the sleep they need. The Centers for Disease Control and Prevention recently reported that 30% of workers sleep less than six hours per day.

Many different situations can lead to short or interrupted sleep, including predisposing factors such as anxiety, depression and worry about sleep; precipitating factors such as stressful life events, medical or psychiatric illness; shift work; and prescription or nonprescription drugs.

MEDICATIONS TO TREAT INSOMNIA

More recently, a class of medications called benzodiazepine receptor agonists has been developed. They include Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon).

"Benzodiazepine receptor agonists, benzodiazepines, the melatonin agonist ramelteon and low doses of the antidepressant doxepin are effective and generally safe for treatment of insomnia," says Mark Abramowicz, MD, editor-in-chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs.

The benzodiazepine receptor agonists are not structural benzodiazepines, but bind to benzodiazepine receptors. All act rapidly to decrease sleep latency and do not affect deep sleep; the primary differences between them are in their duration of action.

"However, these agents may impair performance in the morning, including driving," says Dr. Abramowicz. "Complex sleep-related behaviors may occur without conscious awareness."

Over-the-counter sleep aids containing antihistamines such as Benadryl (diphenhydramine) are widely available.

"Over-the-counter antihistamines marketed as sleep aids are not recommended," he says. "They can cause next-day sedation, impairment of performance skills such as driving, and troublesome anticholinergic [dry eye and/or dry mouth] effects."

A wide variety of psychiatric medications, are commonly prescribed for insomnia even though they are not FDA-approved for this condition. The most common are antidepressants such as trazodone (Desyrel, and others), mirtazapine (Remeron) or amitriptyline (Elavil, and others).

"There is little evidence that these agents are effective in treating insomnia not associated with depression," Dr. Abramowicz says.