Pharmacologic Treatment of Insomnia

Insomnia is a common complaint in patients with psychiatric disorders. Pharmacologic approaches to the treatment of insomnia are often recommended in combination with sleep hygiene education and cognitive behavioral therapy. Currently, the insomnia treatment medications include benzodiazepines, nonbenzodiazepines, melatonin receptor agonist, dual orexin receptor antagonists, and histamine H1 receptor antagonist. All have demonstrated efficacy in treating one or more insomnia symptoms and have been shown to have satisfactory safety characteristics in clinical trials with populations of normal subjects and individuals suffering with chronic insomnia. Therefore, the most recently approved insomnia treatment medications no longer have an implied limitation on their duration of use, and the indications specifically note efficacy for sleep onset and sleep maintenance. All of benzodiazepines, nonbenzodiazepines, and dual orexin receptor antagonists are categorized as Schedule IV controlled substances; however, ramelteon and doxepin have no abuse liability and are classed as a nonscheduled medication. Although various medications for depression, psychosis, and other psychotropic agents are prescribed with the primary intention of improving sleep onset, maintenance, and quality, generally, there is limited insomnia efficacy evidence in non-psychiatric populations, and there are significant safety concerns with all of these medications. Traditionally, insomnia caused by some underlying disease, such as a psychiatric disorder, has been referred to as secondary insomnia. However, it has become clear that in many cases insomnia can persist independently, even after the causative illness has resolved. The concept of comorbid insomnia as an alternative to secondary insomnia has been proposed, and it is appropriate to treat comorbid insomnia from the earliest stages of onset and recurrence of psychiatric disorders.