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.

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.