When to Initiate Pharmacologic Therapy for Insomnia


Focusing on the pharmacologic setting of insomnia, experts consider when it is best to initiate therapy.


Michael J. Thorpy, MD:Let’s talk about prescription medications now. The clinician is often faced after he’s tried some behavioral techniques, or even at the time when he’s actually initially trying behavioral techniques, he’s considering should this patient be treated with a medication for insomnia. What do you think, Nate, is the most important thing in making that decision as to which patient should get a sleeping pill, a hypnotic, or which patient should not?

Nathaniel Fletcher Watson, MD: Well, if they are meeting the diagnostic criteria for chronic insomnia and they didn’t derive benefit or didn’t have access to cognitive behavioral therapy for insomnia [CBTI], and this is affecting, not only their nighttime sleep but their daytime functioning then I think you’re in a situation where it’s time to turn to medications. For some reason, it’s just really interesting in our society. There seems to be a negative association with medications for insomnia and when I talk to hesitant patients, I’d say, “Well, if you had hypertension, you wouldn’t be hesitant to take a medication to lower your blood pressure. You have insomnia, why are you hesitant to take a medication for that?” And I think there’s some pejorative association with falls, maybe daytime residual adverse effects with some of these treatments that we use. There’s been some cross-sectional studies associating treatment with dementing illness, although from my perspective that story has not been told. Nothing definitive there. And it may well, in fact, be in the sleep difficulty. That’s the problem. Not the treatment for it. Thus, I think oftentimes, we have a patient there in front of us, they have an insomnia complaint and you’re at the point where it’s time to begin to consider medical treatment and they’re hesitant I think for a lot of those reasons. The other thing I would say is we talked a lot about comorbidities. We definitely want to treat the comorbidities and see what happens to the insomnia. That would be how I would treat it. Some people would treat both at the same time but sometimes, if I find a comorbidity, let’s say it is obstructive sleep apnea, then insomnia is a common symptom of obstructive sleep apnea. I may well treat the sleep apnea first and see what happens to the insomnia before moving on to medical treatment. But nonetheless, I think there’s lots of effective medications with many different mechanisms of action that we have at our disposal that can really help people with this problem.

Michael J. Thorpy, MD:Yes. Erinn, for many patients who have insomnia, by the time they come to the decision, I really want to get a sleeping pill to help me, or I feel I need one, I mean, the insomnia has been going on for quite a number of weeks. And by the time they get an appointment that makes standard another couple of weeks to see their doctor. By the time they come into the doctor and say, “Look, I really don’t think I need a sleeping pill,” their insomnia has been going on for quite some time. But what about the people that have really severe acute insomnia lasting a few days? I mean, is there some benefit in those patients getting a sleeping pill? I mean, typically, they’re not going to be able to get a prescription very quickly within a couple of days. But what about the acute versus the more chronic patient from the point of view of medication?

Erinn E. Beagin, MD: I think there’s a benefit of treating that acute insomnia and trying to hit it and get it under control sooner than later. Especially if it’s a stressor that we can identify that’s going to be short-lived. I find that those patients, if I do get them sooner, I might even be able to prevent them from becoming a chronic insomniac because I’m alleviating their fear of not sleeping. They’re actually the ones that I’m probably more apt to say, “OK, let’s do something now and get ahead of it” before they get into all those other cognitive thoughts of the not sleeping, what’s going to happen, things of that nature. Thus, I think that they are a unique population, too. I personally do think that they’re the ones to give some type of medication to use for a couple of nights maybe to get them back on to a more regular sleep cycle and break that, of course, while addressing there are other stressors that are going on.

Transcript edited for clarity.

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