Pharmacological Treatments for Insomnia

Purpose of Review: We reviewed existing guidelines from the American Academy of Sleep Medicine (AASM) and recent literature from PubMed to detail the basic physiology of the sleep-wake system and discuss all current FDA approved sedative-hypnotics and common non-FDA approved medications for insomnia. Recent Findings: A 2022 review with network meta-analysis found eszopiclone and lemborexant to be relatively more effective than other options for long-term treatment, and doxepin and zaleplon showed favorable tolerability. A large cohort study published in 2022 found significant safety issues in using low-dose quetiapine for insomnia. A 2021 article highlights the lack of evidence on the topic of treatment-resistant insomnia. Summary: Chronic insomnia is a common sleep disorder associated with significant morbidity and healthcare costs. While cognitive behavior therapy for insomnia is the recommended first-line treatment, due to limited availability, expense, and other limitations, sedative-hypnotic medications are still commonly utilized treatment options. We detail their mechanisms of action, efficacy, and discuss common side effects and dosages for select medications. We also discuss their usage in specialized populations such as in children, the elderly, pregnant patients, and their use in the context of common medical and psychiatric conditions. Finally, we evaluate the data examining the risks and benefits of their long-term use and briefly discuss treatment resistance to hypnotics in chronic insomnia disorder.