In a Word document, please paraphrase the writeup below with the subheadings.  

“Sleep disorders only come in two diagnostic categories, one related to sleep apnea and the other related to the failure to stay awake due to stress.”

Broadly, there are three main categories of sleep disorders. Insomnia describes inadequate sleep duration or quality; hypersomnia describes excessive daytime sleepiness, and parasomnia describes unusual events at night (Wilson and Nutt, 2013). It is therefore inappropriate and incorrect to categorise sleep disorders into the two categories in the statement. Sleep disorders include insomnia, parasomnias, restless leg syndrome, narcolepsy and sleep apnea and can be co-occuring. Sleep disorders are complex and may have medical or psychiatric causes (Leahy, 2017). Various medications can be utilised in treating people who struggle to stay awake and alert in the daytime. Atomoxetine (Strattera) is a non-stimulant, selective norepinephrine reuptake inhibitor (SNRI) which increases dopamine in the pre-frontal cortex, increasing alertness (Limandri, 2018). This is often useful for people with daytime sleepiness. Psychostimulants such as Methylphenidate (Ritalin) and Amphetamine (Adderall) are dopamine-norepinephrine reuptake inhibitors which improve motivation, alertness, attention, concentration, cognition, energy, and wakefulness (Wilson and Nutt, 2013). Orexin agonists Modafinil (Provigil) and Armodafinil (Nuvigil) are wakefulness-promoting medications which activate the excitatory neurochemical Orexin, increase glutamate and decrease GABA (Limandri, 2018).

“The use of over-the-counter sleep aids should be encouraged over prescription drugs because OTC aids are safer and not habit forming.”

Many people find OTC medications to be helpful in treating sleep disorders, however, many people overuse or inappropriately use OTC medications. Other common substances which people use to aid sleep include alcohol (ethanol); however, many people with chronic insomnia report using alcohol as a sleep aid (Rhoads, 2021). Health concerns associated with regular use of alcohol include dependence, hepatotoxicity, and poor sleep quality. Diphenhydramine is a Histamine (H1) receptor antagonists which is commonly used off-label to treat insomnia (Wilson and Nutt, 2013). Melatonin supplements effect the body’s hormonal system and help to regulate the circadian rhythm (National Sleep Foundation, 2017) although in many European countries is a prescription-only medication. Ramelteon and Tasimelteon are Food and Drug Administration (FDA) approved to treat insomnia. It is an unhelpful blanket statement to group drugs together in such broad statements such as “OTC aids are safer” as there are many variables to this. Furthermore, many OTC drugs are unregulated by the FDA and quality is not always assured.

“Menopause has no impact on insomnia.”

According to Shieu et al (2023) the relationship between menopause, sleep, and overall brain health should be studied further, although it is acknowledged that menopause may lead to insomnia, worsening cognitive function. Women experiencing menopause may have difficulties falling asleep, awakening at night and early in the morning, and often experience non-restorative sleep (Carmona et al., 2022). The physiological changes involved with menopause contributes to insomnia. Cognitive-behavioral, behavioral, and mindfulness-based (CBBMB) therapies may be useful in the treatment of insomnia in peri-menopausal women (Carmona et al., 2022).

“As a backup to over-the-counter sleep aids, benzodiazepines are the most useful.”

Cognitive-behavioural therapy for insomnia (CBT-I) is recommended as a first-line treatment by the American Academy of Sleep Medicine (Reynolds & Ebben, 2017). CBT-I may provide significant improvements in sleep quality and duration. Whilst benzodiazepines hold sedating and calming properties and are very effective at treating insomnia short-term, they should not necessarily be considered a first-line treatment due to their addictive qualities. Benzodiazepines are contraindicated in people with a history of substance abuse disorder, depression, suicidal ideation, bipolar disorder, and neurocognitive disorders (Rhoads, 2021) and tolerance, dependence, and rebound insomnia are significant adverse effects. Other prescription medications for treating insomnia include those which act as H1 antagonists, including antidepressants and antipsychotic agents. Trazodone blocks H1 receptors and antagonist at serotonin-2 which improves sleep. Mirtazapine some tricyclic antidepressants (TCAs) can improve sleep although may suppress REM sleep. Orexin receptor antagonists include Suvorexant (Belsomra) which suppresses the wake drive. Prazosin (Minipress) is an alpha-adrenergic antagonist which treats nightmares associated with PTSD. Many medications such as benzodiazepines stimulate the inhibitory neurochemical GABA. Z-drugs and gabapentin also work in this manner. Benzodiazepines suppress REM sleep, which can affect memory and learning. Benzodiazepine withdrawal may lead to rebound REM sleep.  Z-drugs such as Zolpidem (Ambien), Eszopiclone (Lunesta), and Zaleplon (Sonata) increase the frequency of chloride channel opening, which induces sleep. These are not as likely as Benzodiazepines to cause rebound REM sleep on withdrawal. The Beers Criteria notes that Benzodiaepines and Z-drugs should ideally not be prescribed to older adults due to a prolonged half-life which can affect the patient during the daytime (Leahy, 2017).

 â€œWhat is the best practice for insomnia assessment?”

A comprehensive physical exam should be conducted together with a full history of symptoms, medical and psychiatric history (Boland et al., 2021). The patient should be asked about all medications, OTC drugs, the use of alcohol/cannabis and illicit substances, and should be asked about timings of waking versus sleeping, about timings of consuming stimulants such as caffeine and nicotine (Boland et al., 2021). The patient should be asked about exercise, light exposure, overall diet and lifestyle. Specific questions should include enquiring about mood symptoms, restless legs, daytime sleepiness and snoring. Testing may include a Polysomnography, which is a sleep study evaluating oxygen levels, bodily movements, and brain waves. A home sleep study is similar although conducted in the home rather than in a lab. An electroencephalogram (EEG) investigates electrical activity within the brain. A multiple sleep latency test (MSLT) involves investigating daytime napping in relation to diagnosing narcolepsy. Assessment should culminate in correlating symptoms with DSM-IV criteria in order to make an accurate diagnosis.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Wolters Kluwer.

Carlat, D.J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Carmona, N. E., Millett, G. E., Green, S. M., & Carney, C. E. (2022). Cognitive-behavioral, behavioural and mindfulness-based therapies for insomnia in menopause. Behavioral Sleep Medicine. https://doi.org/10.1080/15402002.2022.2109640

Centers for Disease Control and Prevention. (2023). CDC’s Developmental Milestones. Available through: https://www.cdc.gov/ncbddd/actearly/milestones/index.html

Leahy, L.G. (2017). In Search of a Good Night’s Sleep (PDF). Journal of Psychosocial Nursing and Mental Health Services, 55(10), 19–26.

Limandri, B.J. (2018). Insomnia: Will medication bring rest? (PDF). Journal of Psychosocial Nursing and Mental Health Services, 56(7), 9–14.

Shieu MM, Braley TJ, Becker J, & Dunietz GL. (2023). The Interplay Among Natural Menopause, Insomnia, and Cognitive Health: A Population-Based Study. Nature and Science of Sleep, ume 15, 39–48.

Wheaton, A., Jones, S., Cooper, A., & Croft, J. (2015). Short sleep duration among middle school and high school students. MMWR: Morbidity and Mortality Weekly Report, 67, 85-90.

Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse. A how-to guide for evidence-based practice (3rd ed.). Springer.

Wilson, S., & Nutt, D. (2013). Sleep disorders: (2nd ed.). Oxford University Press.

In a Word document, respond to each of the following statements succinctly, but with detail.

• Sleep disorders only come in two diagnostic categories, one related to sleep apnea and the other related to the failure to stay awake due to stress.
• The use of over-the-counter sleep aids should be encouraged over prescription drugs because OTC aids are safer and not habit forming.
• Menopause has no impact on insomnia.
• As a backup to over-the-counter sleep aids, benzodiazepines are the most useful.
• What is the best practice for insomnia assessment?