When hypnotics are used (particularly, benzodiazepines and nonbenzodiazepines), their use should be reassessed—every 3 to 4 weeks.3,12 Many patients with insomnia do not experience sleep disturbances nightly. Therefore, the use of hypnotics on an as-needed basis or a few times a week helps cut down on the amount and exposure to medication.27
Trazodone and mirtazapine(Drug information on mirtazapine) are also widely used for insomnia, as are atypical antipsychotics and herbal preparations. Unfortunately, these agents have not been rigorously studied for insomnia and thus their effectiveness and safety remain unclear.3
Nonpharmacological interventions
CBT-I is an important, widely accepted, multimodal treatment for insomnia and the best-studied of the nonpharmacological approaches for this disorder. It is a manualized treatment that focuses on various components of CBT (ie, cognitive restructuring and the use of psychological interventions, such as the practice of good sleep hygiene, stimulus control, sleep restriction, and relaxation therapy). These methods address negative and distorted cognitions and behaviors that initiate and perpetuate insomnia.9,28 Treatment duration is relatively short. It is administered for 5 hours divided over 4 to 6 weeks and can subsequently be used as a maintenance treatment in monthly sessions. There are approximately 12 well-designed CBT-I trials that have clearly demonstrated that it is a highly effective intervention for insomnia for 1 year or longer.29,30
Studies that compared CBT-I with pharmacotherapy found equivalent efficacy.31 This has led the NIH Consensus and State of the Science Statement to conclude that CBT-I is “as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment.”3 In contrast to hypnotics, learned CBT-I skills may persist even when active treatment ends.9 Furthermore, some patients may prefer CBT-I over hypnotic drugs because of their possible adverse effects or because of concerns about drug interactions or taking a drug during pregnancy.9
In general, CBT-I is underutilized—only about 1% of patients with chronic insomnia receive this therapy.32 To increase the availability of CBT, it can be administered via self-help strategies (eg, educational books and materials) and in group formats. In addition, the use of the Internet to provide CBT has been shown to be effective. Nonetheless, patients frequently prefer face-to-face contact.33
Besides CBT-I, a number of other nonpharmacological therapies, such as bright light, physical exercise, acupuncture, tai chi, and yoga, have been used to treat insomnia. Unfortunately, the results have been inconsistent.32,34
