Selecting a pharmacotherapy regimen for patients with chronic insomnia

ABSTRACT

Introduction

Chronic insomnia, whether it is primary or in combination with another medical or psychiatric disorder, is a prevalent condition associated with significant morbidity, reduced productivity, increased risk of accidents, and poor quality of life. Pharmacologic and behavioral treatments have equivalent efficacy with each having its own advantages and limitations.

Areas covered

The purpose of this perspective is to delineate the limitations encountered in implementing cognitive behavioral therapy (CBT) and to review the pharmacological treatments designed to target the different phenotypes of insomnia. The discussions address how to choose the optimal medication or combination thereof based on patients’ characteristics, available medications, and the presence of comorbid conditions. Selective nonbenzodiazepine sedative ‘Z-drug’ hypnotics, melatonin receptor agonist-ramelteon, and low-dose doxepin are the agents of choice for treatment of primary and comorbid insomnia.

Expert opinion

A pharmacological intervention should be offered if cognitive behavioral therapy for insomnia is not available or has failed to achieve its goals. Increasing evidence of the significant adverse consequences of long-term benzodiazepines should limit the prescription of these agents to specific conditions. Testing novel dosing regimens with a combination of hypnotic classes augmented with CBT deserve further investigation.

KEYWORDS:

• Pharmacotherapy
• cognitive behavioral therapy
• hypnotics
• antidepressants
• off-label

Article Highlights

• Insomnia is the most prevalent sleep disorder that can present independently (primary insomnia) or associated with another medical or psychiatric disorders (comorbid insomnia).

• CBT is the recommended first line of therapy for insomnia but barriers to implementation include the scarce availability of qualified providers and perceived stigma by those seeking treatment.

• The choice of drug for insomnia treatment should be based on the pharmacological properties of the agent and the clinical attributes of the patient.

• Use of antidepressants, antipsychotics, and over the counter sedating agents for the treatment of chronic insomnia is not supported by empirical evidence.

• Future research should evaluate targeted therapy based on specific phenotypes using CBT as an augmentation therapy.

Declaration of Interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was partially funded by a Merit Review Award from the Department of Veterans Affairs [CX 001656].