Chronic Insomnia

Insomnia is one of the most common medical complaints, generating over 5 million office visits per year in the US alone. Symptoms of insomnia occur in one-third to one-half of adults in the US, and are more prevalent among women and older adults. In patients with coexisting psychiatric illnesses, the incidence approaches 50% to 75%. About 1 in 10 adults has chronic insomnia – symptoms that occur at least 3 times per week for at least 3 months. Among patients with chronic insomnia, up to one-third suffer daytime consequences.

Although hypnotic medications have been considered the cornerstone of insomnia therapy for decades, recent guidelines recommend cognitive behavioral therapy as the initial treatment for chronic insomnia. In the last 10 years, new drugs have entered the marketplace for insomnia treatment: a melatonin receptor agonist, ramelteon (Rozerem®), the orexin receptor antagonist, suvorexant (Belsomra®), and low-dose doxepin (SilenorTM). Over-the-counter medications (eg, antihistamines, melatonin supplements) and other prescription medications used off label are also sought-after remedies for insomnia.

This issue focuses on updated recommendations for the management of insomnia in adults. The importance of advocating for behavioral changes (sleep hygiene and stimulus control) prior to medication use is highlighted. The medications that may be used in addition to behavioral therapy are reviewed. When advising patients, providers should take an active role in discussing medication benefits and risks, including appropriate medication choice, duration of use, tolerance, side effect management, and drug interactions.