SOURCE: Buysse DJ, et al. JAMA 2017;318:1973-1974.

Everyone likely experiences transient sleeplessness sometimes. However, when sustained for at least three nights/week for at least three months (in the absence of factors that predictably would preclude normal sleep, such as excessive stimulants, illicit drugs, load ambient noise, prominent ambient light, restless legs syndrome), the condition merits the diagnosis of insomnia. The potential consequences of insomnia are obvious even to those who experience an occasional transient sleep disruption: daytime fatigue and difficulty concentrating.

The American College of Physicians recommends cognitive behavioral therapy as preferred initial treatment for insomnia. When insomnia is a major component of depression, there is some advocacy for inclusion of soporific agents (e.g., zolpidem, zaleplon, eszopiclone) as “bridging” sleep agents during the initial titration of antidepressants, with discontinuation once antidepressants have established efficacy (assuming depression-related insomnia is resolving appropriately). Despite the entrenched habits of clinicians and patients for chronic use of sleep agents, evidence supporting this practice is weak. Clinical trials on which currently available sleep agents have been approved generally are short-term. The absence of long-term safety data is a cause for concern. It is suggested that when using soporific agents, short-acting agents are preferred (e.g., temazepam, zolpidem). If possible, intermittent use (three to four nights/week) also is preferred, with intention to taper and discontinue medications after three to four weeks. Ultimately, if cognitive behavioral therapy is insufficient to remedy insomnia, sedative-hypnotic agents must be added sometimes. Consultation with a sleep expert for refractory cases, or for cases requiring more sustained use of medications, is fully appropriate.