Pharmacological Management of Insomnia

Although many clinicians may be inclined to first give patients medications to treat chronic insomnia, the National Institutes of health has advocated for the use of nonpharmacological interventions as first line treatments for insomnia. This recommendation is based on evidence that non-pharmacological interventions are equally as effective as hypnotic medications and have longer lasting treatment effects, while also equipping patients with skill sets to help cope with future bouts of insomnia. The two most important models of insomnia are Spielman’s 3-p model and Bootzin’s operant conditioning model. The 3-p model by Spielman and colleagues views chronic insomnia through a diathesis-stress based lens and argues that constitutional diatheses are aggravated by acute stressors, resulting in the initial episode of insomnia, which is then maintained by compensatory behaviors such as spending excess time in bed. On the other hand, Bootzin’s model posits that insomnia is a problem of operant learning, and the failure of the bedroom to serve as a discriminate cue for sleep onset. Thus, the intervention formulated by Spielman, Sleep Restriction Therapy, relies on restricting time in bed to achieve its aim, while Bootzin’s intervention, stimulus control therapy, removes people from the bedroom if they are not falling asleep or sleepy. These two techniques have been combined with relaxation techniques, cognitive therapy, and sleep hygiene to create a multicomponent intervention called Cognitive Behavioral Therapy for Insomnia. A separate, emerging technique, known as Intensive Sleep Retraining also views insomnia through the operant model, and attempts to re-associate the bed with sleep by giving patients a great number of learning trials in rapid succession.