"Non-pharmaceutical strategies like behavioral interventions are key to every patient with insomnia," said Dr. Zee. "There are individuals where that is not sufficient or they need to have sleep more quickly than the six to eight weeks that behavioral interventions sometimes require. There is a role for combining behavioral and pharmaceutical therapies."

When deciding which medication to prescribe, she said, consider whether the problem is delayed sleep onset or sleep maintenance. Some medications are indicated only for short-term use while others have no restrictions. Also, keep in mind that some are Schedule IV controlled substances and others are non-scheduled.

Zolpidem, for example, has shown improvements in latency, number of awakenings, and wakefulness after sleep onset versus placebo. Ramelteon significantly reduced patient-reported time to sleep versus placebo. Neither tolerance nor rebound is a problem with either one, Dr. Zee said.

A National Institutes of Health State-of-the-Science statement said that both benzodiazepine and non-benzodiazepine medications have demonstrated efficacy in managing insomnia, Dr. Zee noted. The non-BZD medications have a lower frequency and severity of adverse events. The same group raised significant concerns about using over-the-counter and herbal preparations, antidepressant, and antipsychotic use in this group.

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