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Insomnia – Assessment and Treatment

Insomnia –

Treating insomnia improves patient satisfaction, compliance, and medical care. Insomnia is often under-reported and under-treated since patients are often focusing on other medical issues when they visit their doctor or they haven’t found relief from their insomnia from previous treatment.

Insomnia and chronic sleep deprivation can have a significant impact on many areas of a person’s life including.

– Decreased job performance
– Impaired focus and concentration
– More frequent car accidents
– Increased risk of suicide
– Worsening health condition
– Poor medication compliance

By addressing and treating a person’s insomnia, you can make a great impact on the quality of life. There are many causes of insomnia and many of them are overlapping. Some of the most frequent causes include:

– Working late
– Computer, Internet, IPAD before bed
– Exercising in the late evening
– Depression and anxiety
– Reflux
– Restless leg syndrome
– Sleep Apnea
– Substance abuse
– Medications ex. antidepressants, stimulants, steroids

In addition, insomnia is very common in psychiatric problems such as depression and anxiety. “A useful rule of thumb is that insomnia more commonly precedes a depressive episode, and more commonly follows an episode of anxiety”1.

When a patient presents with a pharma problem, it is crucial to understand the potential cause(s) of the pharma problem.

Here are ten essential questions to ask:

When did your pharma problem start?

Are there any changes at work or home?
Have you started any new medications or supplements?
When do you work out?
Do you snore or kick your partner?
Have you had this problem before?
What treatments have helped in the past?
What medical problems do you have?
Do you have a history of depression, anxiety or ADHD?
How many times a week do you drink? What do you like to drink?

There are numerous treatments available for insomnia. A key principle to keep in mind is that “…[N]onpharmacologic therapy for insomnia should be attempted first, and benzodiazepines should probably be reserved for patients not responding to nonpharmacologic combined with nonbenzodiazepine pharmacologic therapy.”2

Here are some tips on medications that I have found helpful for my patients:

1. Ambien is an intermediate acting medication. It should be taken on an empty stomach. It is recommended to use for only 2 weeks, but often I have found that patients require longer periods of use.

2. Sonata has a very short half-life. Thus, it is useful for the patients that are able to fall asleep but wake up at 4 or 5 am and need an additional 2-3 hours of sleep without a hangover. This also should be taken on an empty stomach.

3. I rarely use Lunesta because it has a high rate of the side effect of a metallic taste. This occurs in 40% of patients.

4. Another medication that I often like for patients is Trazodone. This is an off-label use. I prescribe 25- 100 mg at night. There is a risk of hypotension and thus a risk of falls. I rarely use it in men because of the risk of a priapism. If it is used with men, this risk must be discussed with the patient prior to prescribing.

5. Seroquel is another medication that I prescribe off-label. Even though there is a risk of metabolic syndrome and other side effects, I have found this medication to be very help, especially in patients with PTSD, bipolar disorder or chronic insomnia.

6. I try to avoid benzodiazepines such as Klonopin (clonazepam) and Xanax (alprazolam) because they often help with anxiety and insomnia initially; however, the sedative effect often wears off over time.

7. Tricyclic antidepressants such as Tofranil may also be helpful in small doses. Some of the common side effects include dry mouth and constipation.

8. Clonidine 0.1-0.2 mg can be an effective off-label treatment for insomnia, especially in patients with Adult ADD/ADHD and PTSD.

Insomnia is very common and a careful history and assessment along with effective treatments can greatly help your patient have a better quality of life.

Scott Shapiro, MD is a Harvard-educated psychiatrist in New York City. He specializes in Adult ADD/ADHD.


1. Flaherty, Kelleen. The Carlat Report, November 2011, Vol 9, Issue 11.
2. Smith, Howard, et. al. American Journal of Therapeutics. 18 (3): 227-40, May 2011.

The material contained here is not intended in any way to replace proper medical supervision or advice. All decisions which may impact your health should be discussed with your physician.
If you are under the care of a physician or are taking medication, consult your physicians before changing or discontinuing any medication or current medical treatment. Implementing new items may alter your medication needs. Adjustments of prescribed medications should only be done under the direct supervision of your physician.

Information in this article is provided for informational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. If you have or suspect that you have a medical problem, promptly contact your health care provider.

Source by Scott Shapiro

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