The ACP does not recommend specific pharmacotherapy, but rather that clinicians use a shared decision-making approach when determining whether to add pharmacotherapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBTI) alone was unsuccessful.
If still no improvement, introduce alternative therapies (eg, valerian, melatonin). If still no improvement, combine CBT with evidence-based pharmacology. Reevaluate, especially for occult comorbid disorders. If still no improvement, reconsider diagnosis. If no effect, consider adding additional nonpharmacologic modalities. Initiate treatment with cognitive behavioral therapy (CBT) with/without relaxation therapy. Optimize treatment for any comorbid disorders. However, they follow a general approach 1-5,8: The guidelines vary in their recommendations of specific pharmacologic treatments. Questionnaires, at-home sleep logs, and actigraphy can all be helpful tools for the assessment of insomnia in the absence of other apparent etiologies. For instance, insomnia may lead to anxiety about insomnia, which could further exacerbate sleep fragmentation. Many individuals may experience insomnia and comorbid disorder(s) concurrently. 
Other factors contributing to sleep disruption (eg, circadian rhythm sleep-wake disorders).Behavioral contributions (eg, excessive screen time, exercise, or fluids before bed poor sleep hygiene).Substance abuse/misuse (eg, alcohol, caffeine, drug and herbal stimulants).
Psychiatric disorders (eg, depression, anxiety, posttraumatic stress disorder). Medical conditions (eg, obstructive sleep apnea, pulmonary disease, heart failure, chronic pain, restless legs syndrome, hyperthyroidism). 1-5 The patient evaluation of comorbid conditions should exclude: Insomnia may be a condition in and of itself or a symptom of another underlying medical or behavioral condition. The diagnosis of insomnia is usually based on patient self-reporting. British Association for Psychopharmacology (2019) 5. Agency for Healthcare Research and Quality (AHRQ) (US Department of Health and Human Services) (2017) 3. American College of Physicians (ACP) (2016) 2. American Academy of Sleep Medicine (AASM) (2017) 1. Several groups have published guidelines for the management of insomnia, including: Insomnia can be treated with pharmacologic and nonpharmacologic approaches, individually or in combination. Guideline Recommendations for the Treatment of Insomnia 1-7 Older adults more often have difficulty maintaining sleep (wake time after sleep onset ), whereas younger adults report more difficulty falling asleep (sleep onset latency ). This article will discuss chronic insomnia primarily.Ĭhronic insomnia is associated with numerous adverse effects (AEs) on a person’s well-being, including fatigue, poor cognitive function, mood disturbance, and distress or interference with personal functioning. Insomnia can occur over either a short period of time (acute) or a longer period (chronic). Insomnia is pervasive in the United States and other Western societies. 1-5 It impairs daytime well-being and subjective abilities and functioning. Insomnia is a condition of unsatisfactory sleep in terms of sleep onset, sleep maintenance, or early waking. This article will review the available pharmacotherapeutic options for treating insomnia. However, several other agents are in later stages of development. To date, only suvorexant and lemborexant have been approved for the treatment of insomnia. More recently, orexin inhibitors have been introduced that may have fewer adverse effects, including the development of dependence. 
Benzodiazepines and nonbenzodiazepine GABA-A receptor agonists are the traditional medications used to treat insomnia. When cognitive behavioral therapy is not enough, medications can help patients overcome the barriers and learned behaviors that prevent a good night’s sleep.
Cognitive behavioral therapy is the core treatment for insomnia. Up to 10% of the US adult population will experience chronic insomnia, with women and elderly individuals at particularly high risk.
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