Evie Summers
Sleep is an essential part of maintaining physical and mental health. Unfortunately, insomnia and other sleep disorders are common issues among veterans, with almost half of veterans enrolled in VA Health Care experiencing insomnia. To help veterans improve their sleep, the VA has created the Path to Better Sleep program, which offers free and anonymous online tools based on CBT-i (Cognitive Behavioral Therapy for Insomnia). While sleep medications can be prescribed, they are generally recommended for short-term use only due to significant side effects. The VA/DoD CPG guidelines suggest against the use of benzodiazepines for chronic insomnia and recommend non-benzodiazepine receptor agonists for short-term pharmacotherapy.
| Characteristics | Values |
|---|---|
| Drugs | Triazolam (Halcion, Pfizer), Estazolam (ProSom, Abbott), Temazepam (Restoril, Mallinckrodt), Quazepam (Doral, Questcor), Flurazepam, Zolpidem (Ambien, Edluar, ZolpiMist, Ambien CR), Zaleplon (Sonata, Pfizer) |
| Alternative Treatment | Path to Better Sleep program, which uses CBT-i (Cognitive Behavioral Therapy for Insomnia) |
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What You'll Learn
Insomnia and PTSD
Sleep disturbances are common in adults with PTSD, with insomnia being one of the most prevalent symptoms. An estimated nine in ten people with PTSD suffer from insomnia. Insomnia is characterised by difficulty falling or staying asleep at least three nights a week, and it continues for several months or more, causing issues in daily life.
People with PTSD may try to suppress traumatic memories during the day, which can make worries worse at night and disrupt sleep. PTSD can cause insomnia through several mechanisms. Hyperarousal, a common symptom of PTSD, can manifest as insomnia, as the individual is unable to relax and feels the constant need to be on guard and protect themselves from danger. Additionally, the stress of not being able to fall asleep can lead to maladaptive sleep behaviours such as daytime napping and substance abuse, perpetuating insomnia. Furthermore, nightmares and night terrors are common in PTSD, often related to past trauma, and can lead to frequent nighttime awakenings, making it challenging to fall back asleep.
The best treatment for insomnia in PTSD is Cognitive Behavioural Therapy for Insomnia (CBT-I), which has been shown to be effective in multiple research studies and has fewer side effects than medication. CBT-I focuses on an individual's beliefs, feelings, and behaviours that affect sleep and can be offered in one-on-one appointments or group therapy sessions. Imagery Rehearsal Therapy (IRT), a form of cognitive therapy, is also recommended for treating nightmares associated with PTSD. Clinical trials have reported positive results from combining CBT-I and IRT to address insomnia and nightmares simultaneously.
Sleep hygiene practices are also important for improving sleep in PTSD. This includes limiting caffeine intake before bedtime, reducing smartphone use and television viewing in bed, and creating a comfortable sleep environment. Early identification and treatment of sleep disturbances in trauma-exposed populations are crucial, as sleep plays a significant role in processing traumatic memories and emotions.
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CBT-i (Cognitive Behavioral Therapy for Insomnia)
Cognitive Behavioral Therapy for Insomnia (CBT-I) is a multi-component, short-term treatment for insomnia that usually takes place over six to eight sessions. It is considered effective for both short-term and chronic insomnia. CBT-I aims to address the thoughts, feelings, and behaviours that contribute to the development and perpetuation of insomnia.
The primary goal of CBT-I is to help individuals fall asleep faster, stay asleep, and feel more rested during the day. It focuses on three main factors that contribute to insomnia: identifying and eliminating ineffective habits, reducing sleep-related worry, and other sources of heightened arousal. For example, prior experiences of insomnia may lead to excessive time spent in bed in an attempt to force sleep, which can reinforce dysfunctional thoughts and make falling asleep more challenging. CBT-I helps to break this cycle by identifying, challenging, and altering unhelpful thoughts and beliefs.
CBT-I techniques include stimulus control, sleep restriction, sleep hygiene, and relaxation training. Stimulus control therapy involves associating certain stimuli with sleep, while sleep restriction therapy aims to reduce the time spent in bed to increase sleep drive. Sleep hygiene refers to practising good sleep habits, such as maintaining a consistent sleep schedule and creating a comfortable sleep environment. Relaxation training helps individuals manage stress and arousal that interfere with sleep.
CBT-I is often provided by a doctor, counsellor, therapist, or psychiatrist trained in this form of treatment. It is important for individuals undergoing CBT-I to be open to confronting uncomfortable thoughts and behaviours. While the risks of treatment are typically mild, talking about painful experiences and feelings can cause temporary stress. Working with a trained professional can help minimise these risks and provide support throughout the process.
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$11.74
Benzodiazepines
In the context of Veterans Affairs (VA), benzodiazepines have been prescribed to treat insomnia and sleep problems associated with post-traumatic stress disorder (PTSD). Sleep problems, including chronic insomnia and nightmares, are frequently reported symptoms in veterans with PTSD. While benzodiazepines can promote sleep initially, tolerance and physical dependence can develop with prolonged use. This can lead to a cycle of continued use to avoid withdrawal symptoms and rebound insomnia.
The VA has recognized the potential harms associated with benzodiazepines and has taken initiatives to emphasize their safe and effective use. As a result, there has been a decline in the proportion of veterans with PTSD prescribed benzodiazepines. Safer and more effective treatment options, such as trauma-focused psychotherapies and antidepressants, are recommended by the VA/DoD Clinical Practice Guideline for PTSD.
Additionally, the newly issued VA/DoD CPG for Insomnia Disorder and Obstructive Sleep Apnea recommends against the use of benzodiazepines for chronic insomnia. Instead, it suggests using a non-benzodiazepine benzodiazepine receptor agonist, such as zolpidem, for short-term pharmacotherapy. Zolpidem has a shorter half-life and a lower risk of dependency compared to older benzodiazepines. However, concerns have been raised about its potential interference with next-day cognition and performance, particularly for veterans reintegrating into civilian life.
While benzodiazepines may still be prescribed in certain cases, the VA is moving towards alternative treatments for sleep disorders and PTSD. This shift is driven by a growing body of research highlighting the risks associated with benzodiazepines and the need to adapt to the changing demographics of VA health care users, including an increasing number of women veterans.
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Non-benzodiazepine benzodiazepine receptor agonists
Non-benzodiazepine receptor agonists, sometimes referred to as 'Z-drugs' or hypnotics, are a class of psychoactive drugs that act on the GABA-A receptor complex. They are chemically unrelated to benzodiazepines but have similar pharmacological mechanisms of action. Non-benzodiazepines selectively bind to subtypes of GABA-A receptors, specifically the alpha 1 subtype, which is responsible for sedative effects. This includes the Z-drugs zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta), which are commonly prescribed for insomnia and sleep disorders. These drugs have a short half-life of 2-6 hours and are generally well-tolerated, with a lower risk of addiction and physical dependence compared to benzodiazepines. However, they can cause side effects such as amnesia and, more rarely, hallucinations, especially in large doses.
The Z-drugs act as positive allosteric modulators of the GABAA receptor, enhancing the inhibitory effects of GABA on wake-promoting regions of the brain, such as the lateral hypothalamus and the locus coeruleus. This results in a decrease in excitatory neurotransmitters, leading to sedation and sleep promotion. Non-benzodiazepines have high pharmacologic specificity, with clinical effects primarily attributed to their modulation of the GABAA receptor complex. Their selectivity for specific subtypes of GABA-A receptors may contribute to their efficacy in treating sleep disorders with fewer side effects than benzodiazepines.
While non-benzodiazepines have shown efficacy in treating insomnia, they are not without disadvantages. In addition to the risk of amnesia and hallucinations, these drugs can cause impairments in body balance and standing steadiness upon waking, leading to an increased risk of falls and hip fractures, especially in older patients. The combination of non-benzodiazepines with alcohol can further increase these impairments. Additionally, there is limited data on the long-term effects of non-benzodiazepines, and further research is needed to assess their safety and effectiveness.
It is important to note that non-benzodiazepine sedative-hypnotics do not have reversal agents in the event of an overdose. Treatment in such cases primarily involves supportive measures while the drug is metabolized, including monitoring the patient's hemodynamics and respiratory status. While non-benzodiazepines may offer advantages in treating insomnia, particularly in the elderly, they should be used with caution due to the potential side effects and risks associated with their use.
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Short-term medication
The VA has a program called Path to Better Sleep, which was created to help veterans improve their sleep. The program is free, anonymous, and mobile-friendly, and uses CBT-i (Cognitive Behavioral Therapy for Insomnia) to help retrain the brain to get a full night's rest. CBT-i has been proven to be more effective than medication in treating insomnia.
However, there are several medications that can be prescribed to help with insomnia and other sleep disorders. These include:
- Zolpidem (Ambien, Edluar, ZolpiMist, Intermezzo, Ambien CR) - The FDA recommends a lower dose for women and that health care professionals consider prescribing lower doses for men.
- Zaleplon (Sonata, Pfizer) - This drug has a rapid onset of action and a significantly shorter duration of action, making it advantageous for patients who wake up in the middle of the night.
- BZDs (benzodiazepines): triazolam (Halcion, Pfizer), estazolam (ProSom, Abbott), temazepam (Restoril, Mallinckrodt), quazepam (Doral, Questcor), and flurazepam. These are Schedule IV controlled substances due to their potential for abuse or dependence. Temazepam is the most commonly prescribed BZD for insomnia. BZDs are generally not recommended for long-term use due to the risk of patients developing a rapid tolerance to their sedative effects.
- Doxepin - FDA-approved for treating insomnia marked by difficulty with sleep maintenance.
- Sedating TCAs (e.g., amitriptyline, nortriptyline, imipramine) - Used off-label to treat insomnia, but they carry an increased risk for anticholinergic effects, orthostatic hypotension, and slowed cardiac conduction. Safer treatment options have diminished their use.
- Atypical antipsychotics (quetiapine, olanzapine, risperidone) - Commonly prescribed for sleep disorders, but not FDA-approved for this purpose.
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Frequently asked questions
The VA does not publish a list of prescribed medications online. However, the VA/DoD CPG for Insomnia Disorder and Obstructive Sleep Apnea suggests using non-benzodiazepine benzodiazepine receptor agonists for short-term pharmacotherapy.
The VA recommends Cognitive Behavioral Therapy for Insomnia (CBT-i) as a first-line treatment for sleep problems. The VA's Path to Better Sleep program is a free, anonymous, and mobile-friendly resource that uses CBT-i to help veterans improve their sleep.
Yes, sleep medications carry significant side effects and are recommended for short-term use only. There are few clinical trials examining the efficacy and safety of these medications, especially for veterans with PTSD. Benzodiazepines, for example, are not recommended for treating PTSD.
Sleep disorders, such as insomnia and obstructive sleep apnea, are common among veterans, with nearly half of those enrolled in VA Health Care experiencing insomnia. Sleep problems can significantly impact both physical and mental health.
