A Pragmatic Algorithm for Selecting Psychopharmacology Treatment for Secondary Insomnia

Insomnia is a symptom that can be present in many medical, psychiatric and psychological conditions, or it can occur independently as a primary disorder. Many medications are available and approved for the treatment of primary insomnia, but the evidence base for using these and other medications for treating secondary insomnia is more limited, though often under-appreciated by prescribers.

This is a new algorithm from the Psychopharmacology Algorithm Project at the Harvard South Shore Program, focusing on the management of insomnia secondary to or accompanying common psychiatric disorders. The authors reviewed content from their previous algorithms for these disorders and evaluated pertinent findings from additional controlled trials, reviews, and meta-analyses, found by searches using key words of insomnia and each disorder.

A detailed biopsychosocial evaluation of the patient with insomnia is the first step. Medical causes are managed. Suggested treatments for insomnia secondary to major depressive disorder include eszopiclone and trazodone, and for generalized anxiety disorder, eszopiclone and zolpidem; for post-traumatic stress disorder, consider prazosin; for bipolar manic episode, consider a second-generation antipsychotic. Patients may have more than one of these conditions, and if so, the one causing the greater disability will have priority for treatment. Conditioned insomnia, which can persist following resolution of other causes of insomnia, may also be present and nonpharmacological treatment is generally recommended. Treatment of primary insomnia, without any other psychiatric diagnosis being present, was not reviewed.

Insomnia is often multifactorial. When it is secondary to psychiatric disorders, there may be evidence-supported psychopharmacology approaches rather than just targeting the insomnia solely as a symptom.