[gajendra][7x10 Tight][D:/informa_Publishing/DK7319_Kushida_112082/z_production/ z_3B2_3D_files/978-0-8493-7319-0_CH0010_O.3d] [2/11/08/13:51:3] [107–118] 10 Special Considerations for Treatment of Insomnia Allison G. Harvey, Ilana S. Hairston, Anda Gershon, and June Gruber Department of Psychology, University of California, Berkeley, California, U.S.A. SPECIAL CONSIDERATIONS FOR TREATMENT OF INSOMNIA Several of the preceding chapters have already raised important issues that require consideration when treating patients with insomnia. The aim of this chapter is to address a number of additional special considerations including side effects, gender, age, comorbidity, reasons insomnia may be treatment resistant (e.g., presence of unhelpful beliefs or worry, daytime distress), and legal issues. SIDE EFFECTS OF TREATMENT Aside from some sleep deprivation in the first one to two weeks of stimulus control and sleep restriction, cognitive behavior therapy for insomnia (CBT-I) has no known side effects. The side effects associated with medication treatments for insomnia depend on the half- life, target receptor, and specificity to that receptor site. For example, benzodiazepines (such as temazepam and flurazepam) have the most side effects and are associated with tolerance and rebound (1), as they have the longest half-life and the least specificity (targeting the GABA A receptor complex broadly). The newer non-benzodiazepine hypnotics (such as zolpidem and zalelpon) have a shorter half-life and specific targets within the GABA A receptor site. Hence, they have fewer associated side effects relative to the benzodiazepines (2,3). Although much less researched Ramelteon, a newer medication targeting the melatonin receptors, appears to be associated with relatively few side effects (4). Research investigating other receptor targets (such as orexin, leptin, and serotonin) is ongoing in the hope of developing additional medications with low side effect profiles. GENDER EFFECTS OF TREATMENT Gender Differences in Rates of Insomnia It is well documented that women meet diagnostic criteria for insomnia at higher rate than men. A meta-analysis investigating these sex differences reported that insomnia is approx- imately 1.4 times more prevalent among women than among men (95% confidence interval: 1.28–1.55) (5). This female-to-male ratio has been shown to increase slightly after the age of 45 (6). Before examining possible implications of this gender difference for treatment, we first briefly review two possible explanations for the difference. Biological Sex Differences in Sleep Patterns While a large number of studies have assessed gender (or sex) differences in sleep patterns, a reliable pattern is yet to emerge. This may relate to the cyclic nature of the female hormonal profile as well as the interaction of gender with age-related changes. For example, an examination of gender differences comparing patients diagnosed with insomnia (n = 86) and good sleepers (n ¼ 86) found no evidence of gender-related differences in objective measures of sleep continuity and amounts of rapid eye movement (REM) or non-REM (NREM) sleep. The authors concluded that the increased prevalence of insomnia among women compared to men is not due to sex-related differences in sleep parameters (6). By contrast, Carrier et al. (7) assessed the spectral signature of different NREM sleep stages in 100 healthy men and women Handbook of Sleep Disorders Downloaded from informahealthcare.com by IBI Circulation - Ashley Publications Ltd on 02/28/14 For personal use only.