Review Article

Pharmacologic Management of Chronic Insomnia

Authors: James R. Taylor, PharmD, Cristina M. Vazquez, PharmD, MPH, Kendall M. Campbell, MD

Abstract

Chronic insomnia is a common disorder that is under recognized, under diagnosed and under treated. Initial assessment should focus on identifying and treating, if present, any secondary causes of insomnia. Primary insomnia can be treated with behavioral and/or pharmacological therapy. A thorough sleep history can identify the type of insomnia present, its severity, and can consequently guide therapy. Behavioral therapy has been shown to be equivalent to or superior to pharmacologic therapy, at least in some patients. It is a reasonable initial approach, although there are barriers to its use. There are several pharmacologic agents available, some of which are more effective at reducing time to fall asleep and others for maintaining sleep. There is some evidence to indicate that combining the approaches may impair outcomes. There is little data on the long-term use of pharmacologic agents.


Key Points


* Physicians should routinely inquire about patients' sleep habits as patients may not report these on their own.


* Any secondary causes of insomnia should be investigated and treated before a diagnosis of primary insomnia is made.


* Behavioral therapy has been shown to be equivalent to, or superior to pharmacologic therapy, at least in some patients, and is a reasonable initial approach, although there are barriers to its use.


* Zolpidem, zaleplon or ramelteon should be considered for patients primarily suffering from sleep-onset insomnia.


* Eszopiclone or an intermediate-acting benzodiazepine (eg, estazolam, temazepam) would be appropriate for insomnia that is predominantly associated with sleep maintenance. Zaleplon can also be used for those suffering from sleep maintenance insomnia when taken in the middle of the night.

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