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May 11, 1984

Drugs and Insomnia: The Use of Medications to Promote Sleep

JAMA. 1984;251(18):2410-2414. doi:10.1001/jama.1984.03340420076032

The past decade has provided new developments and methodologies in sleep research, clinical practices, neuropharmacology, and psychiatric diagnoses. A taxonomy of sleep disorders has been advanced, and there are two newly marketed hypnotic drugs that are rapidly eliminated, as well as others under development. Use of a sleep-promoting medication is a decision that physicians and patients alike frequently encounter.

A recent national survey found that one third of the population reported some degree of insomnia, and half of this group—17% of the population—considered the insomnia serious. Half of the group with "serious insomnia" reported a high level of emotional distress. Only 10% of the subjects reporting "severe" insomnia received prescribed sleep-promoting medications; 5% used over-the-counter compounds. Surveys of primary care practice indicate that the bulk of hypnotic drug therapy is directed to women and the elderly with medical or mental disorders and only a very small proportion with a primary diagnosis of insomnia.

Since insomnia occurs in different diagnostic contexts and under a variety of circumstances, it is often difficult for the physician to know whether, when, and how to select and use hypnotics and other sleep-promoting medications. Yet, with the more extensive pharmacologic and clinical information now available, more effective day-to-day clinical decision making is possible.

As an aid to clinicians, the National Institute of Mental Health and Office of Medical Applications of Research of the National Institutes of Health convened a Consensus Development Conference on Nov 15 through 17, 1983, to address these questions and develop principles to facilitate diagnosis and treatment. After a day and a half of presentation of data by experts, a Consensus Panel consisting of psychiatrists, psychopharmacologists, biomedical researchers, epidemiologists, primary care physicians, and public representatives considered the evidence and agreed on answers to the following questions:

  1. Under what circumstances might a sleep-promoting medication be considered; in what types of sleep disturbances are sleep-promoting medications undesirable?

  2. What are the pharmacologic factors to be considered in the selection of sleep-promoting medications?

  3. What are the appropriate treatment strategies to be employed in using sleep-promoting medications on a short-term or long-term basis?

  4. What are the principal cautions and risks associated with prescribing these drugs; what special considerations should be applied in regard to medical status, age, concurrent drug use, or other factors?

  5. What research areas need further development?

Conclusions  Insomnia is a symptom or condition of heterogeneous origin. It signals the need for careful and systematic diagnostic inquiry. Primary medical, psychiatric, and other causes of insomnia should be identified and treated accordingly. Treatment of insomnia should start with the assessment and necessary correction of sleep hygiene and habits. Psychotherapy, behavioral approaches, and pharmacotherapy, alone or in combination, should be considered in the formulation of a comprehensive treatment plan. When pharmacotherapy is indicated, benzodiazepines are preferable. Patients should receive the smallest effective dose for the shortest clinically necessary period of time; this recommendation applies especially to the elderly. The choice of a specific drug should be based on its pharmacological properties in conjunction with the particular clinical situation and needs of the patient. Physicians should educate patients and monitor their conditions to evaluate and reduce the risks of dependence, side effects, and possible withdrawal difficulties. The treatment of insomnia will advance further with better understanding of the pathophysiologic features of sleep disorders, as well as with the improvement of sleep-promoting agents and techniques.