EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS (FRONTLINE MEDICAL NEWS) – For patients who present with complaints of insomnia, consider using the principles of the Brief Behavioral Treatment of Insomnia tool as your frontline approach.
“It’s a pragmatic approach to treating insomnia complaints but also provides a useful foundation for the behavioral management of sleep disorders generally, when combined with other pharmacologic approaches,” Dr. Charles F. Reynolds III said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “It involves relatively little time on the part of the clinician to apply.”
Part of the Brief Behavioral Treatment of Insomnia (BBTI), which was developed by Dr. Daniel J. Buysse and his colleagues at the University of Pittsburgh ( Arch Intern Med. 2011;171:887-95 and Behav Sleep Med. 2012;10:266-79 ), involves education about lifestyle choices and practices that can be helpful to sleep, such as physical activity, stability of daily routines, treating medical problems that can interfere with sleep, having a comfortable sleep environment, and keeping the bed only for sleep and sexual intimacy.
The BBTI also educates the patient about practices that can be harmful to sleep, including alcohol, caffeine, worries, a poor sleep environment, or using the bed for things other than sleep or sex. “You can go a long way toward helping people with sleep-wake problems if they’re well educated about these issues, and if they keep a diary so that they can engage in self-monitoring,” Dr. Reynolds said.
He went on to note that the principles of the BBTI are grounded within an understanding of the physiological factors that regulate sleep. “One factor that controls sleep is how long you’ve been awake, the so-called homeostatic drive to sleep,” said Dr. Reynolds, Endowed Professor of Geriatric Psychiatry at the University of Pittsburgh. “Another factor is the biological clock, the circadian rhythms deep within the brain stem that govern the timing of sleep onset and offset. These two physiological processes provide the basis for the behavioral prescriptions that we make in brief behavioral treatment for insomnia.”
The four steps of the BBTI involve the following:
• Reduce time in bed. This doesn’t mean decreasing the amount of sleep per se, but rather the amount of wakefulness that can occur during a night. “By reducing time in bed we’re trying to increase the homeostatic drive to sleep,” said Dr. Reynolds, also director of the University of Pittsburgh Medical Center Aging Institute . “Being awake longer leads to quicker, deeper, more solid sleep.”
• Get up at the same time every day of the week. This practice “provides a kind of circadian anchor to the brain’s sleep wave rhythms, and reinforces those rhythms, and hence the efficiency of sleep,” he explained. “Even if you’ve slept poorly, getting up at the same time helps you to sleep better the next night.”
• Don’t go to bed unless sleepy. This strategy helps to increase sleep drive by keeping you awake longer. “Going to bed when you’re not sleepy can lead to frustration and gives your brain the wrong message,” he said. “The principles of stimulus control and temporal control are at the behavioral root of BBTI prescriptions.”
• Don’t stay in bed unless asleep. “We are teaching patients how to associate lying in bed with sleeping, and not with worrying or other activities that may lead to frustration or hyperarousal,” he said.
Studies have demonstrated that BBTI produces improvement in 70%-80% of patients. “It is a briefer, less complicated approach than traditional cognitive-behavioral therapy for insomnia,” Dr. Reynolds said. “BBTI also provides a wonderful behavioral foundation for intelligent evidence-based pharmacotherapy for common sleep disorders.”
If it’s determined that pharmacologic treatment for insomnia is indicated, Dr. Reynolds cautioned that the margin of safety for benzodiazepines such as temazepam is wide. Contraindications include obstructive sleep apnea, substance abuse disorders, and advanced liver disease. Side effects may include daytime sedation, anterograde amnesia, sleepwalking, sleep-related eating disorder, respiratory depression, and in some cases, rebound insomnia.
“In my practice, I tend to use shorter-acting agents often as an augmentation pharmacotherapy,” he said. “For example, if I’m treating an older adult with depression, I may use an antidepressant as the primary pharmacotherapy and then add a low-dose benzodiazepine to help keep them more comfortable and help them sleep better during the initial phases of treatment.”
Studies of the orexin receptor antagonist suvorexant have shown improved sleep time, falling asleep faster, staying asleep longer, and sleeping more throughout the night. However, “there are some possibilities for daytime hangover,” Dr. Reynolds said. “I’m also not clear on how well suvorexant’s effects on breathing during sleep have been evaluated. In my view, that remains a somewhat open question.”
The two most widely used sedating antidepressants for insomnia problems include doxepin and trazodone. “They can be particularly helpful in patients with co-occurring depression,” he said. Doxepin in low doses is approved for sleep maintenance insomnia.
Ramelteon is the first melatonin receptor agonist approved for the treatment of insomnia. Contraindications include a history of angioedema with concurrent use of fluvoxamine.
“In general, I recommend to my colleagues not to use sedative antipsychotics like quetiapine or olanzapine, particularly in the context of elderly with dementing disorders and sleep-wake disturbances,” he said.
Dr. Reynolds reported having no relevant financial conflicts.