Insomnia (treatments)
The NICE (2015) Clinical Knowledge Summary provides a useful guide on the management of insomnia. It splits the management into that of short-term insomnia (<4 weeks) and long-term insomnia (>4 weeks).
Short-term insomnia:Consider a short course of a hypnotic drug only if daytime impairment is severe.
The hypnotics recommended for the treatment of insomnia are:
- Short-acting benzodiazepines temazepam, loprazolam, lormetazepam.
- Non-benzodiazepines (the 'z-drugs') zopiclone, zolpidem, and zaleplon (all are short acting).
- Diazepam is not generally recommended, but it can be useful if insomnia is associated with daytime anxiety
If a hypnotic is prescribed:
- Use the lowest effective dose for the shortest period possible. The exact duration will depend on the underlying cause, but treatment should not continue for longer than 2 weeks.
- Inform the person that further prescriptions for hypnotics will not usually be given, ensure that the reasons for this are understood, and document this in the person's notes.
- Do not issue further prescriptions without seeing the person again.
- If there has been no response to the first hypnotic, do not prescribe another.
- If the person experiences adverse effects considered to be directly related to an hypnotic, consider switching to another hypnotic.
Long-term insomniaRefer to psychological services for a cognitive or behavioural intervention.
Pharmacological therapy is generally not recommended for the long-term management of insomnia but may be considered for immediate relief of symptoms.
If prescribing medication, use the lowest effective dose for the shortest period possible. The exact duration will depend on the underlying cause but should not continue for longer than 2 weeks. Up to 4 weeks' use may occasionally be required, but continued use should always be re-assessed after 2 weeks.
For people over 55 years of age with persistent insomnia, consider treatment with a modified-release melatonin. The recommended initial duration of treatment is 3 weeks. If there is a response to treatment, it can be continued for a further 10 weeks.
Additional detail from NICE regarding evidence base:There is insufficient evidence to assess the effectiveness of sleep hygiene as a single intervention; however its use is widely supported by expert opinion in current literature and guidelines.
There is good evidence for the efficacy of hypnotic drugs in short-term insomnia; however, their use is associated with adverse effects.
Tolerance to the hypnotic effects of benzodiazepine may be rapid, and may occur within a few days or weeks of regular use.
Dependence is more likely to develop with long-term use, high doses, more potent or shorter-acting benzodiazepines, and a history of anxiety problems.
Diazepam, nitrazepam, and flurazepam are not recommended because their long half-life commonly gives rise to next-day residual effects, and repeated doses tend to be cumulative.
Sedative drugs other than hypnotics (such as antidepressants, antihistamines, choral hydrate, clomethiazole, and barbiturates) are not recommended for the management of insomnia. Expert opinion from reviews suggests that there is insufficient evidence to support their use, and that the potential for adverse effects is significant.
Modified-release melatonin (Circadin®) is only licensed for the management of primary insomnia (usually defined as more than 4 weeks' duration), and has only been studied in people with long-term insomnia.
The evidence on the efficacy of acupuncture is generally of poor methodological quality with inconsistent results. There is some evidence from single studies in a Cochrane systematic review to suggest that acupuncture and its variants (acupressure and transcutaneous electrical stimulation) may improve quality of sleep. Results for other sleep variables were inconsistent.
There is insufficient good quality evidence to make a recommendation regarding the efficacy of valerian, or any other herbal remedies, in the management of insomnia.
Good sleep hygiene includes:
- Establish fixed times for going to bed and waking up (and avoid sleeping in after a poor night's sleep).
- Try to relax before going to bed.
- Maintain a comfortable sleeping environment: not too hot, cold, noisy, or bright.
- Avoid napping during the day.
- Avoid caffeine, nicotine, and alcohol within 6 hours of going to bed. (Consider complete elimination of caffeine from the diet.)
- Avoid exercise within 4 hours of bedtime (although exercise earlier in the day is beneficial).
- Avoid eating a heavy meal late at night.
- Avoid watching or checking the clock throughout the night.
- Only use the bedroom for sleep and sexual activity.
