Most adults have difficulty sleeping at some time in their lives, with problems falling asleep, staying asleep, or having nonrestorative sleep. When these symptoms continue for ≥1 month and are associated with daytime dysfunction or distress, they reach the status of an insomnia disorder. Roughly 10% of adults in the United States have an insomnia disorder (hereafter referred to as insomnia), ie, that which is present on most nights and lasts ≥4 weeks. Insomnia can be primary, in which the sleep disturbance exists in the absence of co-existing medical or psychiatric disorders, or comorbid, when it is accompanied by one of these disorders.

Although a diagnosis of insomnia requires difficulty with sleep, insomnia is a 24-hour disorder. Individuals with insomnia describe difficulties with concentration, fatigue, and mood, which both influence, and are influenced by, the sleep disturbance. In addition, insomnia is associated with a substantially elevated risk of incident major depressive disorder (MDD), panic disorder, and substance abuse disorders. There is also emerging evidence that insomnia increases the risk for incident hypertension and diabetes.

There are a several therapies available for the treatment of primary insomnia, most notably cognitive-behavioral therapy (CBT) and pharmacologic treatment. The benzodiazepines are a group of chemically related compounds represented by medications such as triazolam, temazepam, and lorazepam. Non-benzodiazepines, such as zaleplon, zolpidem extended-release (ER), eszopiclone and zopiclone, act via a mechanism similar to the benzodiazepines but have a different chemical structure. Also available is the melatonin receptor agonist, ramelteon, as well as several antihistamines such as diphenhydramine, doxylamine, hydroxyzine.

Medications, such as the antidepressants trazodone, mirtazapine, doxepin, and amitriptyline as well as the antipsychotics, quetiapine, olanzapine, and risperidone, have been used off-label for the treatment of insomnia. Patients often turn to alcohol, over-the-counter agents, and melatonin for relief of their sleep problems (Slide 1).

Given these treatment options, there are several questions faced in clinical practice concerning when to treat patients for insomnia, what treatments should be used, and how long treatment should continue. CBT is typically continued for a fixed length of time. Generally, the greater the functional impairment a person experiences, the more there is to be gained from treatment. The decision about whether to treat and which treatments should be used, should consider the risks and expected benefits of all treatment options. CBT for insomnia has relatively minimal risks, with the only downsides being cost, access, and convenience. CBT should always be a therapeutic option.

There are many new findings in the area of comorbid insomnia. Almost 50% of all cases of chronic insomnia are due to a mental disorder, with depressive illness explaining the majority of cases related to mental disorder (Slide 1). Other common causes of comorbid, or secondary, insomnia include chronic respiratory disease such as asthma and chronic obstructive pulmonary disease, chronic pain, degenerative neurological disease, and some medications such as glucocorticoids and serotonin reuptake inhibitors. A general principle of management of insomnia related to mental or medical disorders is that the principal disorder must be fully treated as part of the insomnia treatment plan. If there is an offending medication, it must be discontinued if possible.