Hey marshlakemom, how are you doing?
Hypnotics and benzodiazepines (bzds) are the mainstays of short-term treatment of primary insomnia. Basic principles for rational treatment of insomnia are to use the lowest effective dose, use intermittent dosing (2-3 nights per wk), use for short term (2-3 wk at a time), discontinue after slow taper if the patient has been taking it regularly, and use agents with short and/or intermediate half-life to minimize daytime sedation.
Primary insomnia (sleep state misperception) is sleeplessness that is not attributable to a medical, psychiatric, or environmental cause. Bad sleep habits such as those naturally acquired during periods of stress are occasionally reinforced and, therefore, are not resolved and become persistent.
Primary insomnia is diagnosed in approximately 15% of patients with insomnia who are referred to sleep disorder centers following exclusion of other predisposing conditions. However, true incidence is not known. Primary insomnia is estimated to occur in 25% of all patients with chronic insomnia.
The active agent in many of these over-the-counter medications are generally safe but have anticholinergic adverse effects such as dry mouth, blurred vision, urinary retention, and confusion in older patients, which can be potentially more serious in patients with dental caries, glaucoma, prostatic enlargement, and dementia (or delirium), respectively. They are also minimally effective in inducing sleep and may reduce sleep quality and thereby should not be used on a routine basis.
Use of a variety of herbal preparations (eg, herbal tea) and so-called nutritional substances should not be used, also, because of the lack of evidence in their support. A recent study showed that melatonin did not produce any sleep benefit in patients with primary insomnia.
The primary indication is for short-term management of insomnia, either as the sole treatment modality or as adjunctive therapy until the underlying problem is controlled. An occasional hypnotic (flurazepam (dalmane), quazepam (doral), or estazolam (prosom) can be used for sleep state misperception when the patient becomes extremely worried about perceived lack of sleep for several nights.
For excellent patient education resources, visit emedicine's sleep disorders center and mental health and behavior center. Also, see emedicine's patient education articles primary insomnia, insomnia, disorders that disrupt sleep (parasomnias), and understanding insomnia medications.
Best wishes,
