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A Practical Approach to the Medication Management of Insomnia

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A Practical Approach to the Medication Management of Insomnia Dr. Bruce McGee Utah Valley Outpatient Psychiatry Disclaimer • Represent myself only • I am a psychiatrist without sleep medicine fellowship • Biases Intention/Objectives: •Quick review of how sleep works •Review of DSM-5 and ICSD [International Classification of Sleep Disorders – 3rd Ed.] •Assess benefits vs. risks of medication management •Discuss considerations in medication selection •Not to dissuade sleep hygiene, therapy, CBT-I Not covering, but important • CBT • CBT-I • Stimulus control • Sleep restriction therapy • Cognitive control • Cognitive restructuring • Thought suppression • Paradoxical intention • Relaxation • Progressive muscle relaxation But first, a quick review of sleep Simplified Examples of Sleep Architecture https://slideplayer.com/slide/9220738/ Actual Examples of Sleep Architecture https://www.researchgate.net/figure/Hypnogram-before-upper-panel- and-after-treatment-with-5-OH-tryptophan-lower- panel_fig2_42587318 Sleep Architecture • Stage 1 (5%) • Typically the first 5 minutes; transitional stage • Low arousal threshold • Stage 2 (50-55%) • Typically the next 10-15 minutes • Stage 3 (previously classified as 3 & 4) (20%) • Typically the 20-40 minutes; “delta” slow-wave sleep • REM (Rapid Eye Movement) (20-25%) • Paralyzed, except for the eyes • If you remember a dream, it happened in REM Dreaming [REM sleep] • Dreams are critical for learning and memory • Dreams often play a key role in emotional healing • Nightmares disrupt sleep and can be terrifying • Conventional treatments of disturbing dreams/ nightmares include: • Pharmacological interventions [prazosin] • Psychotherapeutic approaches • Exposure • Relaxation • Re-scripting (Rewrite the ending of a repeating dream) REM is necessary Rats denied REM sleep will die within a few weeks! Suppression of REM sleep may be caused by: • Excessive sleep deprivation • Insomnia • Most antidepressants • Excessive light • Alarm clock awakenings Sleep cycle is part of a greater cycle Circadian Rhythm Circadian Rhythm • Circa = About • Dia = Day • Literally translates as “about daily” rhythm • Its homeostasis is controlled in hypothalmus • Like most everything else… This slide is intended to demonstrate that light exposure affects physiology and behavior. Circadian Rhythm • The average circadian rhythm of humans is 24h 11min. • After LIGHT exposure, signals travel from the retina to the brain through the retinohypothalamic tract within the optic nerve. • There the signal enters the suprachiasmatic nuclei (SCN) within the hypothalmus to regulate, reset, or correct the circadian rhythm. • Each SCN is the size of a grain of rice, contains ~20k neurons each, with one on the right, one on the left. Don’t panic on the next slide… Cascading of Protein Interactions After Light Exposure in the SCN Don’t panic on this one either… It is the concept that is important. Orexin produced in DMH, LH, and PH HYPOTHALAMIC STRUCTURES (in box): LDT = Laterodorsal tegmental nucleus [midbrain] SCN = Suprachiasmatic nuclei PPT = Pedunculopontine tegmental nucleus [pons] DMH = Dorsomedial hypothalamus VTA = Ventral tegmental area [midbrain] LHA = Lateral hypothalamic area LC = Locus coeruleus [pons] PH = Posterior hypothalamus DR = Dorsal raphe [midbrain/pons] VLPO = Ventrolateral preoptic area TMN = Tuberomammillary nucleus BST = Bed nucleus of the stria terminalis SNr = Substantia nigra pars reticulata [midbrain] http://www.nature.com/nrn/journal/v8/n3/fig_tab/nrn2092_F3.html Wakefulness Melatonin through the ages… How do you keep your circadian rhythm in check? • Zeitgebers (German for “time giver”, synchronizer): External cues that synchronize the circadian rhythm • Bright light, especially blue or green light • Exercise • Temperature changes • Smells (bacon in the morning…) • Social interactions • Medication • Eating HYPOTHALAMIC STRUCTURES (in box): LDT = Laterodorsal tegmental nucleus SCN = Suprachiasmatic nuclei PPT = Pedunculopontine tegmental nucleus DMH = Dorsomedial hypothalamus VTA = Ventral tegmental area LHA = Lateral hypothalamic area LC = Locus coeruleus PH = Posterior hypothalamus DR = Dorsal raphe BST = Bed nucleus of the stria terminalis TMN = Tuberomammillary nucleus VLPO = Ventrolateral preoptic area SNr = Substantia nigra pars reticulata http://www.nature.com/nrn/journal/v8/n3/fig_tab/nrn2092_F3.html International Classification of Sleep Disorders – Third Edition 1. Insomnia 2. Sleep-related breathing disorders 3. Central disorders of hypersomnolence 4. Circadian rhythm sleep-wake disorders 5. Parasomnias 6. Sleep-related movement disorders 7. Other sleep disorders International Classification of Sleep Disorders – Third Edition • Chronic insomnia disorder • Narcolepsy type 1 • Exploding head syndrome • Short-term insomnia disorder • Narcolepsy type 2 • Sleep-related hallucinations • Other insomnia disorder • Idiopathic hypersomnia • Sleep enuresis • OSA, adult • Kleine-Levin syndrome • Parasomnia due to a medical disorder • OSA, pediatric • Central sleep apnea with Cheyne-Stokes • Hypersomnia due to a medical disorder • Parasomnia due to a medication or breathing • Hypersomnia due to a medication or substance • Central sleep apnea due to a medical substance • Parasomnia, unspecified disorder without Cheyne-Stokes breathing • Hypersomnia associated with a psychiatric • Restless legs syndrome • Central sleep apnea due to high altitude- disorder • Periodic limb movement disorder periodic breathing • Insufficient sleep syndrome • Sleep-related leg cramps • Primary central sleep apnea • Delayed sleep-wake phase disorder • Sleep-related bruxism • Primary central sleep apnea of infancy • Advanced sleep-wake phase disorder • Sleep-related rhythmic movement • Primary central sleep apnea of prematurity • Irregular sleep-wake rhythm disorder disorder • Treatment-emergent central sleep apnea • Non-24-h sleep-wake rhythm disorder • Benign sleep myoclonus of infancy • Obesity hypoventilation syndrome • Shift work disorder • Propriospinal myoclonus at sleep onset • Congenital central alveolar • Jet lag disorder • Sleep-related movement disorder due to a hypoventilation syndrome • Circadian sleep-wake disorder not medical disorder • Late-onset central hypoventilation with otherwise specified • Sleep-related movement disorder due to a hypothalamic dysfunction • Confusional arousals medication or substance • Idiopathic central alveolar Sleepwalking Sleep-related movement disorder, hypoventilation • • • Sleep-related hypoventilation due to a • Sleep terrors unspecified medication or substance • Sleep-related eating disorder • Sleep-related hypoventilation due to a • REM sleep behavior disorder medical disorder • Recurrent isolated sleep paralysis • Sleep-related hypoxemia disorder • Nightmare disorder 73>57 DSM-5 Sleep-Wake Disorders • Insomnia disorder • Hypersomnolence disorder • Narcolepsy • Breathing-related sleep disorders: • • • • Circadian rhythm sleep-wake disorders • Parasomnias: • • • • DSM-5 Sleep-Wake Disorders • Insomnia disorder • Hypersomnolence disorder • Narcolepsy • Breathing-related sleep disorders: • Obstructive sleep apnea hypopnea • Central sleep apnea • Sleep-related hypoventilation • Circadian rhythm sleep-wake disorders • Parasomnias: • Non-rapid eye movement sleep arousal disorders • Nightmare disorder • Rapid eye movement sleep behavior disorder • Restless legs syndrome ~11 Dx DSM-5 Sleep-Wake Disorders • Insomnia disorder • Substance/medication- induced sleep disorder • Hypersomnolence disorder • Other specified insomnia • Narcolepsy disorder • Breathing-related sleep disorders: • Unspecified insomnia • Obstructive sleep apnea hypopnea disorder • Central sleep apnea • Other specified • Sleep-related hypoventilation hypersomnolence disorder • Unspecified • Circadian rhythm sleep-wake disorders hypersomnolence disorder • Parasomnias: • Other specified sleep-wake • Non-rapid eye movement sleep arousal disorders disorder • Nightmare disorder • Unspecified sleep-wake • Rapid eye movement sleep behavior disorder disorder • Restless legs syndrome 18 Dx Insomnia Disorder A) A predominant complaint of dissatisfaction with sleep quantity or quality 1. Difficulty initiating sleep [DFA] -OR- 2. Difficulty maintaining sleep [DSA] -OR- 3. Early-morning awakening with inability to return to sleep [EMA] B) Distress or impairment C) 3+ nights/week D) 3+ months already E) Adequate opportunity for sleep F) Not due to other sleep disorder G) Not due to a substance or medication H) Not explained by coexisting mental disorders or medical conditions Insomnia Disorder Subtypes • With non-sleep disorder mental comorbity • With other medical comorbity • With other sleep disorder • Episodic • Persistent • Recurrent Hypersomnolence Disorder A) Excessive sleepiness despite a main sleep period lasting at least 7h 1. Recurrent periods of sleep or lapses into sleep within the same day -OR- 2. A prolonged main sleep episode of more than 9h/day that is nonrestorative -OR- 3. Difficulty being fully awake after abrupt awakening B) 3+ nights/week for 3+ months C) Distress or impairment D) Not due to other sleep disorder E) Not due to a substance or medication F) Not explained by coexisting mental disorders or medical conditions Hypersomnolence Disorder Subtypes • With mental disorder • With medical condition • With another sleep disorder • Acute [<1m] • Subacute • Persistent [>3m] • Mild • Moderate • Severe Narcolepsy Narcolepsy Sleeping with dead people, right? Narcolepsy Comes from Greek narkē-lambanein, later narkē-lepsia,
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