The word insomnia comes from the Latin words in and somnus, meaning “without sleep” or “trouble sleeping.” Insomnia can be idiopathic (primary insomnia) or a symptom of several sleep, medical, and psychiatric disorders. Insomnia is characterized by persistent difficulty falling asleep (onset insomnia) and/or staying asleep (maintenance insomnia), or early morning awakening with inability to resume sleep.1

Recent sleep research has debunked the belief that insomnia is a benign malady. The research confirms that insomnia is a common condition with its own risks and consequences.2 Insomnia can cause fatigue and sleepiness during the day, as well as anxiousness, depressed feelings, and irritability.3 Patients are often unable to focus, learn, and remember.

The National Sleep Foundation reports that researchers have described brain cycles called the sleep cycle and the wake cycle. Only one of these cycles can be on at any one time. Insomnia can be the result of a problem with either of these cycles.4

Classifications
Primary insomnia is not due to medical issues, medications, or other substances.5 The cause of this type of insomnia is often life changes such as stress about work, school, health, or family.6 Travel or work schedules that disrupt sleep routines may also foster insomnia.3

Secondary insomnia is the consequence of another problem such as an emotional, neurologic, medical, or sleep disorder.3 Insomnia can result from emotional factors such as depression, anxiety, and posttraumatic stress disorder, as well as neurologic disorders such as Alzheimer’s disease and Parkinson’s disease. Other causative maladies include nasal/sinus issues, gastroesophageal reflux disease, hyperthyroidism, diseases that cause chronic pain (eg, arthritis, headache disorders), and conditions that make breathing difficult (eg, asthma, heart failure).3,4 Secondary insomnia can also result from sleep apnea or certain medications. Medications causing insomnia can include decongestants, weight loss products, corticosteroids, stimulants (Adderall or Ritalin), some heart and blood pressure medications, antidepressants, and combination pain medications.

Insomnia can be further classified as acute or chronic. Acute insomnia is brief, usually manifests as primary insomnia, and often resolves without treatment. Chronic insomnia occurs when a patient experiences insomnia at least 3 days per week for at least 3 months. Chronic insomnia has many causes and usually requires some form of intervention or treatment.7

Signs and Symptoms
Obviously, not being able to sleep is a sign of insomnia—either taking too long to get to sleep or waking too early, and not being able to get back to sleep. Symptoms include waking up feeling tired or not well rested. Other common symptoms include fatigue, cognitive impairment, mood disturbances, behavior problems, difficulty at work or school, and difficulty in personal relationships.8

Diagnosis
Although there is no definitive test for insomnia, a physician can diagnose insomnia based on medical history and a physical exam. The patient may be asked to keep a sleep diary to record sleep history. The physician may also order a sleep study.3,5,9

The Pharmacist’s Role
The first step to treating insomnia is to practice good sleep hygiene. Sleep hygiene is a combination of good sleep practices that are purely behavioral. As pharmacists, we can ask patients about their sleep hygiene and advise them to go to bed at the same time each night and wake up at the same time each morning, even on days off. We can advise patients to make sure their bedroom is quiet, dark, relaxing, and a comfortable temperature. The bed should be comfortable and used for sleeping, not other activities such as reading, using the computer, watching television, or listening to music. Advise patients with insomnia to avoid napping.10

Other actions that can help to reduce insomnia include refraining from eating large meals close to bedtime, limiting caffeine and alcohol intake, and not using nicotine. Activity helps promote sleep; therefore, advise patients to get daily exercise, but at least 5 hours before bedtime.11 Cognitive therapy can be used to promote good sleep hygiene and relaxation and to reduce struggles with anxiety, depression, or a major life event.12 Alternative methods of dealing with insomnia that some small studies have found to be helpful include acupuncture, yoga, and meditation.11

Medications may also help. As always, check the patient’s profile for any allergies, drug interactions, or contraindications before recommending an OTC product. The FDA does not require manufacturers to show proof of the effectiveness or safety of OTC dietary supplement sleep aids,11 and the dose and purity of these substances can vary.3 Advise patients to read all package labeling and follow dosing instructions carefully.

Antihistamines such as diphenhydramine and doxylamine are the main ingredients in OTC insomnia drugs and are also found in many cold and headache combination products.13 A list of prescription insomnia medications can be found in the Online Table.13

Table: Prescription Sleep Aids
Brand Name Generic Name
Ambien, Ambien CR Zolpidem tartrate
Ativan Lorazepam
Belsomra Suvorexant
Butisol sodium Butisol sodium
Carbrital Pentobarbital and carbromal
Dalmane Flurazepam hydrochloride
Desyrel Trazodone
Doral Quazepam
Edluar Zolpidem tartrate
Elavil Amitriptyline
Halcion Triazolam
Intermezzo Zolpidem
Lunesta Eszopiclone
Pamelor Nortriptyline
Placidyl Ethchlorvynol
Prosom Estazolam
Restoril Temazepam
Rozerem Ramelteon
Seconal Secobarbital sodium
Silenor Doxepin
Sonata Zaleplon
Xanax Alprazolam
Zolpimist Zolpidem tartrate

Melatonin is another OTC supplement marketed for treating insomnia. Melatonin is a naturally occurring hormone the body produces. The main purpose of melatonin is to regulate day and night sleep cycles. The body makes more melatonin when individuals are exposed to darkness, signaling the body to sleep; exposure to light decreases melatonin production.14

Valerian is a dietary supplement sold as a sleep aid because of its sedating effect. If used at high doses or for long periods, it may increase the risk of liver damage. Valerian must be tapered down to prevent withdrawal.11,15

Other supplements marketed to help with insomnia have significant safety concerns; these supplements include L-tryptophan, kava, and 5-hydroxytryptophan.11,16-18

Conclusion
Insomnia is a common problem in the United States. It occurs more frequently in women than in men and increases with age. Pharmacists are asked many times daily for their recommendations to help patients sleep better. Instead of automatically suggesting a drug, help patients find the cause of the problem and recognize lifestyle changes they can make. Always refer patients to a physician if they are experiencing chronic insomnia, as it may be due to something more serious.


Dr. Kenny earned her doctoral degree from the University of Colorado Health Sciences Center. She has 20+ years’ experience as a community pharmacist and works as a clinical medical writer in Colorado Springs, Colorado. Dr. Kenny is also the Colorado education director for the Rocky Mountain Chapter of the American Medical Writers Association.

References
  1. Key sleep disorders. Centers for Disease Control and Prevention website. cdc.gov/sleep/about_sleep/key_disorders.html. Accessed October16, 2015.
  2. Recent advances in the understanding of insomnia. Psychiatry Online website. focus.psychiatryonline.org/doi/abs/10.1176/appi.focus.12.1.3?journalCode=foc. Accessed October 22, 2015.
  3. Insomnia. National Heart, Lung, and Blood Institute website. nhlbi.nih.gov/book/export/html/4926. Accessed October 16, 2015.
  4. What causes insomnia? National Sleep Foundation website. sleepfoundation.org/insomnia/sleep-disorders-problems/insomnia/causes. Accessed October 24, 2015.
  5. An overview of insomnia. WebMD website. webmd.com/sleep-disorders/guide/insomnia-symptoms-and-causes. Accessed October 16, 2015.
  6. Stress and insomnia. National Sleep Foundation website. sleepfoundation.org/ask-the-expert/stress-and-insomnia. Accessed October 24, 2015.
  7. What are different types of insomnia? National Sleep Foundation website. sleepfoundation.org/insomnia./content/what-are-different-types-insomnia. Accessed October 16, 2015.
  8. Insomnia: symptoms. National Sleep Foundation website. sleepfoundation.org/insomnia./content/symptoms. Accessed October 16, 2015.
  9. Insomnia: diagnosis. National Sleep Foundation website. sleepfoundation.org/insomnia./content/diagnosis. Accessed October 16, 2015.
  10. Sleep hygiene tips. Centers for Disease Control and Prevention website. cdc.gov/sleep/about_sleep/sleep_hygiene.html. Accessed October 16, 2015.
  11. Insomnia. Mayo Clinic website. mayoclinic.org/diseases-conditions/insomnia/basics/definition/con-20024293. Accessed October 16, 2015.
  12. Insomnia: treatment. National Sleep Foundation website. sleepfoundation.org/insomnia./content/treatment. Accessed October 16, 2015.
  13. Sleep disorder (sedative-hypnotic) drug information. FDA Website. fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm101557.htm. Accessed October 22, 2015.
  14. Melatonin. WebMD website. webmd.com/vitamins-supplements/ingredientmono-940-melatonin.aspx?activeIngredientId=940&activeIngredientName=MELATONIN&print=true. Accessed October 24, 2015.
  15. Valerian. WebMD website. webmd.com/vitamins-supplements/ingredientmono-870-valerian.aspx?activeIngredientId=870&activeIngredientName=valerian&source=1. Accessed October 24, 2015.
  16. L-tryptophan. WebMD website. webmd.com/vitamins-supplements/ingredientmono-326--tryptophan.aspx?activeIngredientId=326&activeIngredientName=-tryptophan&source=1. Accessed October 24, 2015.
  17. Kava. WebMD website. webmd.com/vitamins-supplements/ingredientmono-872-kava.aspx?activeIngredientId=872&activeIngredientName=kava&source=1. Accessed October 24, 2015.
  18. 5-HTP. WebMD website. webmd.com/vitamins-supplements/ingredientmono-794-5-HTP.aspx?activeIngredientId=794&activeIngredientName=5-HTP&source=2. Accessed October 24, 2015.