Insomnia

November, 2022. In a recent article entitled “The Extraordinary Importance of Sleep,” Worley¹ reports on the “relationships between inadequate sleep and a wide range of disorders, including hypertension, obesity and type-2 diabetes, impaired immune functioning, cardiovascular disease and arrhythmias, mood disorders, neurodegeneration and dementia, and even loneliness.” She quotes David F. Dinges, PhD, Professor and Chief of the Division of Sleep and Chronobiology at the University of Pennsylvania Perelman School of Medicine, who said “We know … that sleep is critical for waking cognition—that is, for the ability to think clearly, to be vigilant and alert, and sustain attention. We also know that memories are consolidated during sleep, and that sleep serves a key role in emotional regulation.” In fact, in the last decade especially, there has been an explosion of scientific research studying the health benefits of sleep, the perils of sleep deprivation, and the importance of good sleep hygiene.

DSM-5 states that the “essential feature of insomnia disorder is dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep,”^2(p363) and that it causes significant distress or impairment in functioning. There must be adequate opportunity for sleep, and the difficulty must occur at least 3 nights per week for at least 3 months. So let’s think about this for a minute. Right away, my mind jumps to Ukraine and the impossibility for the troops to have “adequate opportunity for sleep.” In which case, they would not be diagnosed with insomnia disorder, but that doesn’t mean they aren’t sleep-deprived, on top of unimaginable and relentless stress, putting their brains and bodies at even greater risk, while dodging bullets and bombs. And that’s just one example; these days, the list of disaster zones is long.

But even in day-to-day life, far from danger, where there is indeed adequate opportunity to sleep, insomnia gets in the way all too often. What to do about it? Does social media have the answers? Websites promoting sleep products and strategies abound, but how to evaluate their credibility? Luckily, reputable institutions such as the NIH, the American Academy of Sleep Medicine, and advice from sleep experts in the world of academic medicine provide valuable, readily available guidance. In this issue of the Journal, Seow and colleagues provide a systematic review of guidelines that have been developed for the treatment of insomnia disorder. On the basis of their review, they reported that a good number of the clinical practice guidelines “recommended pharmacotherapy only if cognitive behavioral therapy for insomnia or other nonpharmacological interventions were unavailable, unsuccessful, or declined by patients.” In terms of the guidelines’ recommendations for medications for insomnia disorder, they found that “[o]ther than indications for initiating pharmacotherapy, there was little agreement on other considerations, such as the type, dose, and duration of medication, adverse effects for which clinicians should be alert, and treatment alternatives.” The prevalence of medication use for insomnia is well-known but far from risk-free, and this look at what the evidence shows, even though limited, is welcome.

Also in this issue, Preskorn reviews the pharmacokinetics of three new FDA-approved medications to treat insomnia. After summarizing a few basics about the normal sleep cycle, he provides important clinical guidance about the appropriate and safe use of these newer medications. As is the case for other medications for insomnia, these new compounds should be prescribed judiciously, in combination with nonpharmacological treatment approaches.