Psychiatr. pro Praxi, 2009; 10(6): 250-256 [Neurol. praxi. 2009;10(4):254-261]

Treatment of the primary insomnia from the psychiatrist point of view

doc. MUDr. Ján Praško CSc^1,3,2,4, MUDr. Lucie Závěšická¹, MUDr. Anežka Ticháčková³

¹ Psychiatrické centrum Praha, 3. LF UK, Praha

² Centrum neuropsychiatrických studií, Praha

³ Psychiatrická klinika FN a LF UP, Olomouc

⁴ 3. LF UK, Praha

Primary insomnia is characterized with difficulty initiating or maintaining sleep, or non-restorative sleep, lasting at least a month in

duration. The treatment for short term insomnia with hypnotics is recommended. The use of hypnotics in treating chronic insomnia

remains controversial. The non-benzodiazepine hypnotics zolpiden, zopiclone, and zaleplon are replacing benzodiazepines as first-line

pharmacotherapy for short-term insomnia. Hypnotics should be considered only after a thorough diagnostic assessment of secondary

causes of insomnia, after sleep hygiene has been improved and after behavioral treatments has been attempted. If these approaches

are unsuccessful, then hypnotics can be used, starting with very low doses and limiting use to short periods. Some antidepressant, such

as sedating tricyclic antidepressants, mirtazapine and trazodone, are also used as sedative-hypnotic agents for the treatment of chronic

insomnia. Low nocturnal melatonin production and secretion have been documented in elderly insomniacs, and exogenous melatonin has

been shown to be beneficial in treating sleep disturbances of these patients. There are several effective treatment approaches to primary

insomnia that do not involve the use of psychopharmacs. Education about normal sleep and counseling around habits for promoting

good sleep hygiene are a good but not sufficient intervention when used alone. Various relaxation therapies such as progressive muscle

relaxation can be helpful. Stimulus control behavior modification focuses on eliminating environmental cues associated with arousal.

Sleep restriction therapy is similarly aimed at reducing the amount of wake time spent in bed. Sleep deprivation helps consolidate sleep

on subsequent nights, thereby improving sleep efficiency.

Keywords: primary insomnia, education, non-benzodiazepine hypnotics, benzodiazepines, melatonin, antidepressants, sleep hygiene, relaxation, stimulus control, cognitive-behavioral therapy, sleep restriction therapy.

Published: December 1, 2009  Show citation