Treating insomnia: pharmacological and nonpharmacological approaches

Insomnia is a commonly encountered condition in clinical practice. The prevalence of self-reported poor sleep increases with age and is more common in women. There are clear associations between poor sleep and psychiatric disturbance; however, causality in this regard may be complex, and there are at least some insomniacs who show high somatic tension without marked psychopathology. The development of chronic insomnia can be conceptualized as involving predisposing, precipitating, and perpetuating factors. Pharmacological treatments for insomnia most typically involve judicious and intermittent usage of a benzodiazepine hypnotic. A variety of such medications are available, with varying absorption and elimination characteristics. Benzodiazepines are preferred over antidepressants in the treatment of insomnia in individuals without major psychiatric disorder because of fewer side effects and a larger margin of safety. Nonpharmacological treatments typically rely on elements of sleep hygiene, stimulus control, sleep restriction, and chronotherapy. The establishment of good patient-clinician rapport and the working through of unfounded beliefs and unrealistic expectations of the sleep experience are also important components of the behavioral treatment of insomnia. Use of such techniques, particularly when combined in a treatment package, has shown appreciable benefits in improving sleep.