Prescription Drugs Used in Insomnia

Several prescription drugs are available that, at least temporarily, improve sleep duration and continuity objectively and subjectively, with acceptable side effects. Although new medication classes (eg, DORAs) are becoming available, the ideal sleeping pill still does not exist. Will such a drug ever overthrow CBT-I as the first-line therapy for chronic insomnia? CBT-I targets many sleep mechanisms. Sleep restriction affects homeostatic sleep pressure, keeping strict bed and rise times, targets circadian timing and relaxation training reduces cognitive arousal. It is unlikely that a single drug will be able to modulate all these mechanisms simultaneously. However, pharmacologic treatment will remain important for patients in whom CBT-I is not effective or not available. However, even then, the use of medication should always be part of a broader treatment plan in which dysfunctional sleep habits are challenged, substance use is optimized, and comorbid conditions are addressed. In insomnia, the subjective aspects of the sleep complaint are paramount in the diagnostic criteria. Epidemiologic studies increasingly point to a link between insomnia and somatic morbidity and mortality, but until now, only in the subgroup of objectively poor sleepers.(96-99) Although pharmacologic treatment might offer some benefits to this subgroup of insomnia patients, to date, there is no evidence that hypnotics can ameliorate their health risks. It is hoped that further unraveling of the neurobiology and genetics of sleep regulation and the pathophysiology of insomnia will help the development of drugs that not only improve subjective sleep complaints but also objective health outcomes.