Managing Insomnia in Special Populations and Treatment-Resistant Cases

In an interview with Pharmacy Times, Megan Maroney, PharmD, BCPP Clinical Associate Professor Ernest Mario School of Pharmacy at Rutgers, the State University of New Jersey Piscataway, NJ, discussed her presentation at the 2024 American Association of Psychiatric (AAPP) Conference. Maroney addressed the difficulties in managing insomnia, especially the demand for quick fixes and lack of provider knowledge about alternatives like cognitive behavioral therapy. She also covered the impact of untreated insomnia on mental health conditions like depression. Non-pharmacological options like melatonin and CBT were discussed, along with risks of medication in elderly patients. Maroney also highlighted Strategies for pharmacists to improve insomnia treatment through education and expanding access to options like CBT.

Pharmacy Times

Why is managing insomnia difficult, especially in special patient groups and treatment-resistant cases?

Megan Maroney, PharmD, BCPP

Insomnia can be challenging to manage in any patient. Many times, patients are suffering, and they want something that's going to work quickly for them. Most of our treatments that do work quickly have a lot of risk to them or might not be the best for long term management of insomnia. So, trying to get patients to do things like cognitive behavioral therapy for insomnia — which is the first line treatment option really for any patient population, whether that'd be a special population, patients with comorbidities. Anyone really with insomnia, that should be the first line but accessing that can be complicated. Many times, patients aren't accepting of that, because they want that quick fix. Or it's just something that providers might not be aware of how to refer patients to that. Insomnia, in general is difficult from that way. Then when patients start to try medications and aren't seeing a good response, they can get very frustrated. It's frustrating for the clinician to try to find something that that will work for them.

Pharmacy Times

What impact does treatment-resistant insomnia have on quality of life and its connection to other mental health disorders?

Megan Maroney, PharmD, BCPP

The biggest connection is with depression. But really all mental health conditions are linked to insomnia and can be complicated by insomnia or worsened by it, but depression in particular. Even if a patient's other depressive symptoms are well managed, if they have significant insomnia symptoms, that could worsen their quality of life and increase their risk for depressive relapse as well. The link in the literature is strongest with depression, but we know that it affects all of our different mental health conditions for sure.

Pharmacy Times

How do medications help manage insomnia, especially in special patient groups, and how are they different from standard treatments?

Megan Maroney, PharmD, BCPP

Our special traditional special patient populations are older adults. We have to think about most of these drugs, because they're sedated and can increase risk of falls and fractures. There's also been links with long term data and potential risk for increasing in cognitive impairment, dementia, and delirium as well. That's a very complicated patient population in particular, but in pediatric patients as well. There are no FDA approved treatment options for insomnia in that patient population. It's really a challenge to try to manage that. Some of the guidelines recommend the use of melatonin, which can be helpful. We're not really sure about the long-term safety data and long term risks of melatonin, particularly on patients growth and development when they're young. So far, the data looks pretty clean. We have data up to 4 years, and no major safety signals have been found, but that's still always a question.

Pharmacy Times

What are the main risks and benefits of available treatments for insomnia in special populations and treatment-resistant cases?

Megan Maroney, PharmD, BCPP

If you have older adults, certainly the risk of falls is always a concern. Then in any patient too, these medications can be habit forming and they can be misused. You can build up tolerance to them, and they can cause next day impairments in driving — even if the patient doesn't feel sedated, they can have impacts on driving. They did studies with some of the drugs like zolpidem. In women in particular, they actually metabolize open a more slowly. Higher doses in particular in women can be impairing, even if they don't feel sedated, it can affect driving the next day.

Pharmacy Times

How can psychiatric pharmacists best handle the complexities of managing insomnia in these situations for better patient outcomes?

Megan Maroney, PharmD, BCPP

I think one of the big things that psychiatric pharmacists can do is try to talk to the patients— that medication is not always going to be the answer. Non pharmacologic treatments, particularly cognitive behavioral therapy for insomnia is really our best evidence-based treatment, even in those treatment resistant patients that have tried medications, it still does have evidence that it can be beneficial. There's really no harm aside from perhaps cost and accessibility. But I think with all of the different types of methods that CBTI can be delivered, such as digital applications on your phone, or people could do it on telehealth. It is more accessible now than it has been in the past. I think for pharmacists to become familiar with the different CBTI options out there, and even potentially getting trained in CBTI themselves. There are some experts that push for all frontline medical staff, really getting some training in CBTI so that it is more accessible for patients.