This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
Medication for Insomnia – Is It Worth the Risks? by Katie Muniz
Insomnia Disorder can be described as the complaint of insufficient sleep, both in amount and quality, which interferes with an individual’s functioning in social, academic, occupational, and other realms. This sleep disturbance causes the individual distress, usually leading to anxiety and further distress surrounding these sleep difficulties. This can lead to a vicious cycle, possibly creating more maladaptive sleep patterns and perpetuating the course of the disorder. As can be seen, insomnia can be an extremely taxing sleep disorder. Lack of good quality or quantity of sleep can also lead to significant impairments within daily functioning, which as just described, can be apparent across several areas of an individual’s life. Furthermore, 40 to 50% of those that meet the diagnosis for Insomnia also meet diagnosis for at least one more mental disorder. Although only about 6–10% of adults are diagnosed with Insomnia Disorder, at least 1/3 of the general population reports experiencing symptoms of insomnia. In actuality, most of us will experience at least one bout of insomnia within our lifetimes. It sometimes seems unavoidable, considering the daily stressors that many of us face. Especially within such a fast-paced society, people are often on-the-go, with little downtime to relax and get sufficient sleep. It’s understandable as to why the experience of insomnia can be so prevalent, and at times harmful.
Insomnia Disorder is the most commonly diagnosed problem in Sleep-Wake Disorder class within the general population. Within specific populations, such as young adult college students, insomnia tends to be even more prominent. Young adulthood is usually the time of onset for Insomnia Disorder, according to the DSM-5. Often the transition to college can be a difficult adjustment. In addition to living in a new environment and the stressors of schoolwork, adolescents and young adults often experience physiological and behavioral changes that could contribute to a change in sleep-wake patterns. In one study conducted in 2014, college students reported several factors that contributed to less than sufficient sleep, including: stress, environmental noise, restricted sleep duration, and variability in sleep schedules. Of these students, 14.3% met criteria for a diagnosis of Insomnia Disorder (Journal of Adolescence). This rate is higher than that in the general population, putting young adults more at risk for developing further psychological and health problems.
Of these problems, those with insomnia disorder are more at risk of developing a substance use disorder. These individuals may abuse medication, take anxiolytics or drink alcohol as sleep aids, and drink caffeine to fight the daytime fatigue experienced. Ironically, young adults aged 18-24 years have a much higher prevalence rate for the use of every substance. Usually this substance use begins in adolescence, in which teenagers often experiment with illicit drugs. One research study published in The American Journal of Psychiatry concluded that by the senior year of high school, 50% of high school students had used at least one substance. The risk of experiencing insomnia during young adulthood coupled with the increased risk of substance use can make treatment of insomnia difficult, especially within a society that often relies on pharmaceutical interventions to help treat mental disorders.
Although there are several evidence-based treatments for Insomnia Disorder, pharmaceutical treatments are still commonly prescribed. I’m sure we have all seen commercials advertising sleep aids – Lunesta, Ambien, Sonata. In addition to these medications, other hypnotics, such as benzodiazepines are prescribed, as well as anti-depressants such as Trazadone. I have personally experienced insomnia for many years, and in times of severe insomnia bouts, I found sleep medications readily available. I suppose it does seem easier at times to simple medicate a problem, whether than address its roots. Unfortunately, with the medicalization of mental disorders within society, the rates of prescription drug use continue to increase. The Centers for Disease Control and Prevention examined these rates between 1999 and 2008, and discovered that the use of one prescribed medication increased from 44% to 48%. In addition to this, 1 out of 5 children and 9 out of 10 adults reported using at least one prescription medication in the last month. Although medications for insomnia aren’t as commonly prescribed as, let’s say, asthma and stimulant medications, they still warrant a certain amount of attention and concern, especially to the public eye.
Anxiolytics are a common class of medicines that have been used for the treatment of insomnia for many years. These include benzodiazepines, barbiturates, and alcohol. These medications act as Central Nervous System depressants, and are commonly prescribed for anxiety disorders as well. They act on the GABA receptors, and decrease feelings of tension and stress. Interestingly enough, the very medications that are used to treat insomnia, are the ones that are more commonly abused by individuals with insomnia. As mentioned before, those with Insomnia Disorder are at an already increased risk of developing substance use disorder. Benzodiazepines are known to develop tolerance and physical dependence in its users, and the side effects can include mental clouding, restlessness, amnesia, and insomnia. Because of this physical dependence, withdrawal symptoms can also be severe, and can lead to seizure and death.
Zolpidem (more commonly known as Ambien), another commonly prescribed sleep medication, is considered a non-benzodiazepine but displays the same pharmokinetics in binding to GABA receptors. Its popularity increased when it appeared to create less of a dependence than benzodiazepines, although current research seems to suggest otherwise. Withdrawal from Ambien can also lead to more serious adverse health outcomes, such as coma (although this is normally at much higher doses). Ambien still seems to have a moderate abuse potential, and some users report feelings of euphoria and energy at high doses. At lower doses, Ambien can cause amnesia and vision problems. Cases have been reported in which individuals under the influence of Ambien sleep-eat, sleep-drive, and even cases of murder have been reported. Despite these possibly serious and fatal side effects of these medications, the risk of dependence and abuse potential of anxiolytics is already increased when taking into account the population that will most likely be prescribed them- adults with insomnia. As this population is already at a much higher risk for substance use disorder, as well as depressive and anxiety disorders, it seems more harmful than beneficial to treat insomnia with pharmaceuticals.
Although pharmaceutical intervention is common in insomnia, several evidence-based therapies have shown to be more effective in the long-term. Cognitive-behavioral therapy (CBT) is used widely across clinics, and 80% of individuals who receive CBT experience a reduction in symptoms in the long-term. Methods that are used in this type of therapy include changing dysfunctional beliefs about sleep, education in sleep-hygiene, learning relaxation techniques, and restriction of time in bed. CBT is very successful in treating Insomnia Disorder, and should be considered firstly when developing a treatment plan.
Because Insomnia Disorder is as prevalent as it is (it is the most common sleep disorder), it is crucial to understand the pros and cons of treatments, especially when you or a loved one is experiencing severe impairments because of disturbed sleep. The use of sleep medications may be more well-known in the public view, but before initiating treatment, individuals should pause and assess the negative side effects of medication vs. the long-term and seemingly successful effects of other types of therapy such as CBT.