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Some time ago, we discussed the treatment of sleep disorders and insomnia in the live broadcast room, in which the discussion on drugs and sleep habits is very hot, today I will summarize the specific treatment of insomnia for these problems, so that everyone is no longer afraid of drug treatment, and do not ignore the very important cognitive behavioral therapy.
Text | Jiang Xueshu
This article mainly includes:
1. Classification of sleep disorders
2. Bad habits that affect sleep
3. Treatment strategies for insomnia
4. Cognitive behavioral therapy for insomnia
5. Drug treatment for insomnia
6. Frequently asked questions about drug use
Classification of sleep disorders
At present, the International Classification of Sleep Disorders (ICSD-3) divides sleep disorders into seven categories, mainly including insomnia, sleep-related breathing disorders, central narcolepsy, sleep abnormalities, circadian rhythm-wake abnormalities, sleep-related movement disorders and other sleep disorders, of which insomnia is the focus of our discussion today.
In fact, not all "can't sleep" is called insomnia, and if you want to diagnose insomnia in medicine, you must include the following points:
sleep duration or quality problems that last a certain amount of time;
Have the right sleep opportunity and environment;
Associated impaired daytime functioning.
In the vernacular, it is that you are in a very suitable environment for sleeping, and you subjectively want to sleep, but you can't sleep well for a long time, it may be poor sleep quality or insufficient sleep duration, and it affects daily work, study and life.
Insomnia can be divided into acute insomnia and chronic insomnia according to the duration of the disease, and many chronic diseases with symptoms of less than 3 months is acute insomnia, and ≥ 3 months is chronic insomnia. However, in general, if difficulty falling asleep, waking up early, or not sleeping enough persists for more than 1 month, and the seizures occur more than 3 times a week, it is necessary to pay attention to and see a doctor.
Bad habits that affect sleep
We all know that regular work and rest are closely related to health, but people always have all kinds of realities and reasons to break this rule. In the live broadcast, Dr. Wang also "named and criticized" several common bad habits that affect sleep.
1. Take the initiative to stay up late: There are many people who have nothing to do at 10 o'clock or 11 o'clock, but they often delay going to bed until very late;
2. Play in bed: There are also many people who go to bed early, but when they watch TV, listen to podcasts, chase dramas and play games in bed, and when they feel tired and sleepy, they are often late;
3. Staring at the electronic screen for a long time at night: Many people know that exposure to artificial light sources at night will disrupt the secretion of melatonin, which actually includes tablets, computers, etc. with high screen brightness, which will also lead to a delay in falling asleep and delay in sleepiness;
4. Consume a lot of excitatory foods: These foods include coffee, milk tea and alcohol. The fact that caffeine makes it difficult to sleep may be known to many people, and we will talk about alcohol separately. Although drinking alcohol before bed can help relieve tension and help you fall asleep, alcohol has a short half-life and does not last long to maintain sleep, which can lead to early awakening. At the same time, the sleep after drinking is mainly "light sleep" during the non-REM sleep period, the quality of sleep is not high, and it is easy to have the feeling of not sleeping enough after waking up the next day;
5. Think too much and move too little: There are also friends who have a lot of things in their hearts, and are accustomed to reviewing and pondering before going to bed, or take sleep problems very seriously and pay attention, and usually do not pay attention to exercise, which will actually have a negative effect on sleep.
Treatment strategies for insomnia
Before talking about treatment strategies, let's briefly talk about the diagnosis and evaluation of insomnia, doctors usually conduct detailed medical history, mainly including specific sleep conditions, medications, physical diseases and symptoms, etc., and will also use sleep diaries, assessment scales or polysomnography and other means to comprehensively assess and identify.
The treatment of insomnia mainly includes psychotherapy and drug treatment, and there are currently treatments such as transcranial magnetism, biofeedback and some herbal treatments and homeopathy, but most of them lack high-quality evidence-based medical evidence support, or it is recommended that everyone actively try psychological and drug treatment first.
So-called psychotherapy includes sleep hygiene education and cognitive behavioral therapy (CBT-I). Sleep hygiene education sounds quite profound, but in fact, it is to correct incorrect sleep concepts, change bad sleep habits, and give you examples:
1) Don't be lazy in bed, get up immediately after feeling energetic;
2) Regular schedule, go to bed and get up at the same time every day;
3) Don't force yourself to sleep, when you can't fall asleep, you can get up first, and then try to fall asleep;
4) Eat only excitatory drinks and foods in the morning;
5) Do not drink alcohol in the evening, evening and before going to bed;
6) Do not smoke, especially at night;
7) Keep the bedroom dark, cool, quiet and free of reminders about work or other stressful things;
8) Try to solve problems during the day, do not delay until sleep;
9) Get enough exercise, but do not engage in strenuous activities before going to bed;
10) Do not look at your phone, computer screen, or illuminated reading device (such as an e-book) before going to bed.
In addition, correction of precipitating factors and comorbidities that interfere with ideal sleep should not be overlooked, such as chronic pain or increased nocturia, which requires treatment for the primary condition, or long-term use of hormones, aldosterone, theophylline, or caffeine-containing medications.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
Cognitive behavioral therapy is the preferred modality for chronic insomnia in adults, and it is also a first-line treatment recognized by international and domestic guidelines, even insomnia patients who have received medication should actively try CBT-I under the guidance of a doctor. CBT-I is a combination of cognitive therapy and behavioral therapy, and the sleep hygiene education we mentioned above is often also included.
1
Cognitive therapy
It aims to eliminate the fear of insomnia itself, thereby changing the vicious cycle of fear and other bad emotions caused by insomnia. The basic content includes:
Do not attribute all physical and emotional discomfort and problems to insomnia;
Fall asleep naturally and avoid forcing yourself to sleep;
Don't pay too much attention to sleep, don't get frustrated by a single insomnia;
Develop a tolerance for insomnia and get used to it.
2
Behavioral therapy
There are many methods of behavioral therapy, such as relaxation therapy including abdominal breathing training, progressive muscle relaxation and mindfulness meditation, sleep restriction therapy based on adjusting bed time, and stimulation control therapy that can rebuild sleep-wake biorhythms, etc., which will not be described in detail here, if you are interested, we can write a specific guide later.
Drug treatment for insomnia
In clinical practice, many people with insomnia may still need medication after actively trying CBT-I. These drugs mainly include the following categories, namely benzodiazepine receptor agonists, melatonin receptor agonists, some antidepressants with hypnotic effects, and some antipsychotic drugs.
If there are no special contraindications, new non-benzodiazepines (non-BZDs) are generally preferred to correct insomnia, and if they are ineffective or intolerable, drugs such as short-acting benzodiazepines (BZDs) and melatonin receptor agonists can be selected. However, it is necessary to remind you that the drugs described below need to be used under the guidance of a specialist, and must not be blindly purchased and used by yourself.
1. Benzodiazepine receptor agonists
These include traditional benzodiazepines (BZDs) and newer non-benzodiazepines (non-BZDs), which may be more familiar.
1) Benzodiazepines (BZDs)
In fact, it is everyone's impression of "sleeping pills" or "tranquilizers", short-acting preparations are mainly midazolam, intermediate and long-acting preparations are mainly eszolam, alprazolam and diazepam. This class of drugs is characterized by a certain dependence, and after long-term application, rebound insomnia and withdrawal symptoms may occur after discontinuation of the drug.
The half-life of this drug is about 10~24 hours, it is an intermediate preparation, can be taken orally before bedtime, the commonly used dose is 1~2mg, if chronic insomnia patients need long-term medication, it is not recommended to prefer such drugs.
2) Novel non-benzodiazepines (non-BZDs)
Such drugs include zolpidem tartrate, zopiclone, dexzopiclone, etc., which have a similar sleeping effect than traditional BZDs, but have a shorter half-life, generally do not cause daytime sleepiness, and have a lower risk of drug dependence. Because it is safe, effective, low dependence and low adverse reactions, it is generally used as the first choice for treatment.
Taking zolpidem as an example, its oral dose for adults is 10mg, and it is generally recommended to take it 5~10 minutes before going to bed. The time of taking the drug can be adjusted according to the sleep needs under the guidance of the doctor, such as when you cannot fall asleep 30 minutes after going to bed, you can take the drug immediately, or if you wake up at night and cannot fall asleep again, and the expected time to get up is longer than 5 hours, you can also take it temporarily.
Although non-BZDs are relatively safe and the drug of choice, it is recommended that patients with long-term medication needs be revisited for evaluation in about 4 weeks. In addition, it is also reminded that such drugs may cause transient insomnia aggravation after sudden discontinuation, so it is necessary to stop the drug under the guidance of a doctor.
2. Melatonin receptor agonists
This class of drugs is not equal to the "melatonin" that everyone understands, mainly including ramerton (ramemotin) and agomelatine. Among them, Ramerton is not dependent on drugs and does not produce withdrawal symptoms, and is approved by the FDA for long-term insomnia drug treatment. However, these drugs are still not the first choice of treatment clinically, but as an alternative treatment for patients who cannot tolerate other sleeping drugs and who have developed drug dependence.
3. Antidepressants
It mainly includes tricyclic antidepressants represented by doxepine and amitriptyline, selective serotonin reuptake inhibitors (SSRIs) represented by paroxetine, fluoxetine and sertraline, serotonin and norepinephrine reuptake inhibitors (SNRIs) represented by venlafaxine and duloxetine, and other antidepressants with sedative effect such as low-dose mirtazapine and trazodone. These drugs can usually correct anxiety and depression, and exert a certain sedative effect, which plays a role in treating insomnia.
4. Antipsychotics
These drugs mainly include low-dose quetiapine and olanzapine second-generation antipsychotics, which exert a sedative effect by antagonizing histamine receptors, and these drugs are used more cautiously and require detailed evaluation by a doctor.
Answers to frequently asked questions about drug use
1. Do sleeping pills have many side effects? Will there be dependencies?
Dr. Wang replied: All drugs, in fact, will have certain adverse reactions, but compared with the trouble and harm of insomnia, these adverse reactions are relatively small and acceptable, in fact, it is necessary to weigh the pros and cons of medication.
We have talked about dependence before, traditional benzodiazepines (BZDs) do have drug dependence problems, but new non-benzodiazepines (non-BZDs) dependence is very low, and there are also non-dependent drugs like Remelton.
As for side effects or adverse reactions, I will also give you examples. The most common side effects of benzodiazepine agonists are drowsiness, drowsiness, and dizziness, in addition to ataxia and secondary risk of falls. Common side effects of other drugs include drowsiness, dizziness, nausea, fatigue, etc.
In addition, it is necessary to remind everyone that insomnia in adolescents and adults needs to consider the problem of anxiety and depression, and must be evaluated by a doctor before treatment. In addition, while drug treatment, it is also necessary to cooperate with bad behavior correction and cultivate healthy sleep habits. Everyone should have this psychological expectation that insomnia, like all chronic diseases, can have a long treatment cycle.
2. Can sleeping pills be stopped on their own?
Dr. Wang replied: It is not recommended that everyone stop the drug by themselves, whether it is a single drug treatment or a combination of multiple drugs, you must avoid sudden withdrawal to reduce insomnia rebound. The method of dose reduction is actually similar to glucocorticoid reduction, that is, reducing the dose of each drug under the guidance of a doctor, or switching to intermittent treatment.
Typesetting | beautiful
Bibliography:
[1] UpToDate: Overview of the treatment of insomnia in adults
[2] UpToDate: cognitive behavioral therapy for insomnia in adults
[3] UpToDate: Patient Education - Insomnia
[4] Keyou Live Room No. 19