Somatic Symptoms: Mental Health Approach and Differential Diagnosis

IV. Insomnia

A. Assessment and Diagnosis

Recommendations:

Clinicians should ask patients at routine monitoring visits about quality of sleep and difficulty initiating or maintaining sleep.

Clinicians should determine whether a patient's insomnia is acute, chronic, primary, or secondary.

Insomnia, or "problem sleeping," is a common complaint among people with HIV. Insomnia can be multifactorial and, therefore, a complex condition to treat. Insomnia involves not only how many hours a patient sleeps at night but also how a patient feels upon waking and the patient's perception of his/her quality of sleep. Insomnia can be acute or chronic and can be a primary or secondary condition attributable to a physiologic or mental health disorder. Patients who suffer from insomnia tend to have impaired daytime cognitive function,³ which can lead to increased absenteeism from work and other disruptions in life,⁴ including missed appointments. Other problems associated with insomnia include the following:

• Insomnia may be associated with nonadherence to ARV therapy⁵
• Physical and mental health disorders, including acute episodes of most severe mental illnesses, can cause insomnia and/or worsen preexisting primary insomnia
• Insomnia can be an early sign of relapse in patients with a history of mental health disorders⁶
• Insomnia may become even more severe in advanced HIV infection⁷
• A patient with insomnia has greater risk of a first episode of depression than a patient without insomnia⁸

Possible medical, mental health, and substance use etiologies of insomnia are listed in Table 2.

B. Management

A careful evaluation of the possible causes of insomnia should be conducted before initiating treatment. Lack of response to treatment after a reasonable period may require a mental health referral to assess for an underlying mental health disorder.

1. Nonpharmacologic Treatment

Recommendations:

Clinicians should use nonpharmacologic approaches for treating insomnia before prescribing medications.

Clinicians should discuss sleep hygiene with patients with insomnia (see Table 3).

Behavioral therapy may benefit some patients with insomnia. Techniques may include cognitive therapy, relaxation training, sleep restriction, and phototherapy. When possible, patients with insomnia should be evaluated at least once by a psychiatrist or clinical psychologist, who may be more likely to identify an underlying mental health disorder that warrants more aggressive monitoring and management.

Clinicians should offer practical nonpharmacologic methods of improving sleep. Table 3 lists specific strategies.

2. Pharmacologic Treatment

Recommendation:

Medications that have narrow therapeutic ranges and potential for abuse, including barbiturates, choral hydrate, and meprobamate, should not be used as first-line agents for treating insomnia.

The medications described below are commonly used to treat insomnia. Barbiturates, choral hydrate, and meprobamate were previously prescribed to treat insomnia; however, because of their narrow therapeutic windows and potential for abuse, they are no longer drugs of choice. All of these drugs should be prescribed with caution because patients may develop tolerance within a short period of time, and withdrawal symptoms may be severe.

Sedative/Hypnotic Agents

Pharmacologic therapy with benzodiazepines has been used successfully to treat insomnia. Benzodiazepines with long half-lives, such as flurazepam, may be most beneficial for use in patients whose insomnia is associated with anxiety. However, some primary care clinicians are wary of prescribing this class of agents because of the addiction potential and the residual drowsiness patients may experience the following day. Temazepam (Restoril) has been used with success and has an intermediate half-life. Although protease inhibitors (PIs) may prolong the duration of many benzodiazepines because of inhibition CYP3A4 enzyme activity, resulting in excessive daytime somnolence, this effect does not apply to temazepam, which is metabolized by glucuronidation.

The newer hypnotic agents, zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta), are benzodiazepine receptor agonists with shorter half-lives and are not likely to result in the day-after drowsiness. They may have decreased addiction potential compared with older agents. Patients can be educated about using hypnotics on an as-needed basis rather than nightly; it is easier for patients to discontinue a drug that they are not taking every day. The inhibition of CYP3A4 enzyme activity by PIs is also a concern when prescribing benzodiazepine receptor agonists, particularly eszopiclone.

Refer to Interactions Between HIV-Related Medications And Psychotropic Medications: Indications And Contraindications.

Antidepressants

Recommendations:

Clinicians who prescribe tricyclic antidepressants to induce sleep should obtain routine blood levels in patients receiving long-term treatment. Assessment of blood levels may not be necessary for patients without liver disease who are receiving low doses of these agents.

Clinicians should perform a routine electrocardiogram before prescribing tricyclic antidepressants and should not prescribe this class of drugs to patients with cardiac conduction problems.

Antidepressants have been used to induce sleep.

• Trazodone can promote sleep and is widely used for this purpose. However, trazodone levels are increased by PIs, especially when they are boosted; therefore, lower doses should be used in patients receiving PIs. Trazodone may cause priapism, but the incidence is low.
• Tricyclic antidepressants are beneficial but have longer half-lives than short-acting hypnotic agents, and potential adverse effects include cardiac dysrhythmias and pulmonary complications. A routine electrocardiogram should be performed before prescribing tricyclics, and this class of drugs should not be prescribed to patients with cardiac conduction problems. However, tricyclic antidepressants also have characteristics that may benefit some patients, including treatment of chronic pain, promotion of weight gain, and reduction of diarrhea. Routine blood levels of tricyclic antidepressants should be obtained in patients receiving long-term treatment. However, assessment of blood levels may not be necessary for patients without liver disease who are receiving low doses of these agents (e.g., 10 to 25 mg/day amitriptyline, nortriptyline, doxepin, or desipramine).

The SSRI antidepressants are not sufficiently sedating to be used as sleeping agents.

Antihistamines

While many clinicians continue to prescribe antihistamines for sleep, side effects that should be taken into consideration include the following:

• Daytime drowsiness
• Diminished daytime cognitive abilities
• Uncomfortable anticholinergic effects

Melatonin and Melatonin-Agonist Drugs

Recommendation:

Clinicians should advise patients of the potential side effects, particularly severe hypersensitivity reactions such as anaphylaxis and angioedema, of melatonin and melatonin-agonist therapy.

Clinicians should be familiar with doses and potential adverse reactions associated with melatonin therapy, including over-the-counter preparations. The melatonin agonist ramelteon (Rozerem), the first of a new class of melatonin agonists to receive FDA approval, has been approved for the treatment of insomnia and may have some advantages over sedative/hypnotic agents with regard to dependence and overuse. However, patients should be cautioned about potentially severe adverse reactions, including hypersensitivity reactions such as anaphylaxis and angioedema. Importantly, long-term interactions with ARV agents are unknown at this time.