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C HAPTER 8 / Sleep 195
Cognitive Behavioral Therapy Medications Associated with Insomnia
for Sleep Disturbances DISPLAY 8-4
Dysfunctional beliefs and attitudes about sleep contribute to
SPD. In particular, cognitive processes such as worry over sleep Antidepressants
and its consequences and automatic or altered beliefs are thought Tricyclics
to play a critical role in the development and maintenance of Amitriptyline
SPD. An example of an altered belief system is the belief in need Doxepin
for 8 hours of sleep per night to feel refreshed. Since the amount Imipramine
of sleep varies among individuals, this belief can exacerbate or Trimipramine
worsen SPD when this expectation is not met. These cognitive Desipramine
processes increase physiological and emotional arousal and in Nortriptyline
some individuals lead to a downward and cyclic trajectory that Protriptyline
perpetuates the underlying. 305–310 Selective Serotonin Reuptake Inhibitors
Nonpharmacologic approaches to management of SPD, par- Fluoxetine
ticularly those emphasizing cognitive behavioral therapy to di- Paroxetine
rectly target faulty beliefs and negative thoughts about sleep, have Sertraline
increased in popularity over the past decade. 306,311 Conceptually, Fluvoxamine
the basis for CBT is that dysfunctional thinking and behaviors as- Serotonin and Norepinephrine Reuptake Inhibitors
sociated with SPD are cognitively mediated. The cognitive com- Venlafaxine
ponent of CBT is tailored to the individual needs of the partici- Monoamine Oxidase Inhibitors
pant to identify, challenge, and change stressful, distorted sleep Phenelzine
thoughts that contribute to SPD. 285,305,310,311 The behavioral as- Tranylcypromine
pects include sleep restriction therapy, modified stimulus control,
and use of relaxation techniques which are described in greater Antihypertensives
detail in the section “Sleep Education and Hygiene”. -Blockers (Lipophilic Blockers)
Evidence from SPD research suggests that CBT results in Propranolol
short-term improvements that are as effective as pharmacotherapy Timolol
with sedative-hypnotics. This effect is especially relevant given the
adverse events and side effects associated with sedatives and hyp- Others
notics, especially among the elderly. The potentially greatest ad- Hypolipidemic Drugs
vantage of CBT is over time, since it may be more durable than Atorvastatin
pharmacotherapy because the beneficial effects persist after ther- Lovastatin
apy has ended. Therefore, although CBT may be a more costly ap- Simvastatin
proach than pharmacotherapy in the short run, it becomes cost- Nasal Decongestants
effective over 6 months or longer. 312–314 Pseudoephedrine
Previous studies of psychological interventions for insomnia Phenylpropanolamine
have primarily used behavioral approaches such as stimulus con-
trol and sleep restriction, which focused on modifying maladap- Bronchodilators
Theophylline
tive sleep habits. 308 The addition of cognitive restructuring that
targets factors known to perpetuate SPDs (i.e., consequences of Antiparkinsonian Medications
not falling asleep), or that reduce compliance with behavioral Levodopa
therapy may improve treatment effectiveness for SPDs. 305 Corticosteroids
Prednisone
Pharmacological Interventions Adapted from Schweitzer, P. K. (2005). Drugs that disturb sleep and wakefulness. In
M. H. Kryger, T., Roth, & W. C., Dement (Eds.), Principles and practice of sleep
to Promote Sleep medicine (pp. 499–518). Philadelphia: Elsevier Saunders.
The consequences and impact of insomnia (difficulty initiating
and/or maintaining sleep, early morning awakenings, or unrefresh- patient should be carefully examined as many have the potential to
ing sleep) are associated with a significant negative impact on day- disturb sleep (Display 8-4). Simply discontinuing, or advising that
time function including increased fatigue, decreased motivation the patient take these medications that interfere with sleep in the
and vigilance, reduced concentration, and impaired psychomotor morning rather (or visa versa) than at bedtime, may improve sleep.
function. Chronic sleep problems may also increase the risk of psy- There are a number of pharmacologic agents currently used to en-
chiatric disorders, such as depression and anxiety. In addition, the hance sleep and specific information regarding dose, action, and
effects of poor sleep impact, not only the patient, but on family, side effects appear in Table 8-1. As with all medications, follow-up
friends, and caregivers. In many situations, the judicious use of and further evaluation of patient response to treatment is critical.
pharmacologic agents to enhance sleep is indicated—often in con-
junction with behavioral therapy. An assessment of the type and du- Over-the-Counter Medications
ration of the sleep problem within the context of the underlying The major over the counter medications include antihistamines,
cardiac disease should dictate which agent is used. 315 However, be- melatonin, and herbal therapies, such as valerian. There are insuffi-
fore initiating pharmacologic therapy, the medications taken by the cient data to documents the effectiveness of the use of these agents.