In some studies, low-dose Trazodone in conjunction with another full-dose antidepressant have moderate efficacy in improving sleep quality and/or duration.Trazodone should not be used as a treatment for sleep onset or sleep maintenance insomnia.Low dose Doxepin is a suggested treatment for sleep maintenance insomnia.Tricyclic antidepressants (TCAs) have been used in lower doses to treat insomnia in patients with comorbid depressive disorders but are dangerous when overdosed.Eg Amitriptyline, Dothiepin, Doxepin, Mirtazapine, Trazodone.Suvorexant was suggested for treatment of sleep maintenance insomnia.Daridorexant and Lemborexant were recently approved for the treatment of insomnia in adults that have difficulties with sleep onset and/or sleep maintenance.Eg Daridorexant, Lemborexant, Suvorexant.Has not been associated with hypnotic side effects, withdrawal or rebound insomnia.May be beneficial to patients with delayed sleep phase syndrome and in a subgroup of patients with low melatonin level.

Limited clinical data on use for chronic insomnia.Clinical trials data have shown that prolonged-release Melatonin improves sleep onset latency and quality in patients >55 years old.Decreases sleep latency when compared to placebo and generally increases sleep duration without changing normal sleep patterns.Does not alter normal sleep patterns and is usually not associated with rebound insomnia.Suggested for treatment of sleep onset and sleep maintenance insomnia.Effective for patients with difficulty in falling asleep but not in patients with difficulty in maintaining sleep.Suggested for treatment of sleep onset insomnia.Effective for sleep onset and maintenance insomnia.Longest half-life among non-benzodiazepine hypnotics: 5-7 hours.Improve sleep duration and sleep quality.Decrease sleep latency and number of awakenings.Diazepam is generally not used in the treatment of insomnia due to its long duration of effect and possibility of accumulating active metabolites.Temazepam is suggested as treatment for sleep onset and sleep maintenance insomnia.Intermediate-acting: Estazolam, Temazepam.Suggested as treatment for sleep onset insomnia.Has been associated with rebound anxiety and is therefore not first line for insomnia.Tolerance to hypnotic effects develops on repeated administration.Long-term use increases chances of habituation and withdrawal symptoms.Decrease anxiety impair memory prevent seizure occurrence.Reduce time to sleep onset prolong stage 2 sleep prolong total sleep time may slightly reduce rapid eye movement sleep.Proven effective for short-term insomnia treatment.May be used as adjunctive therapy with behavioral therapy.Most commonly prescribed agents for treatment of insomnia.Regular follow-up is recommended to ensure effectiveness, monitor for side effects, dependence (both psychological and physiological), and assess continuing need for medication.Can be offered if cognitive behavioral therapy is not sufficiently effective or not available or when patient is not motivated.Individualized drug regimen may be short-term or long-term but intermittent.Prescribe the lowest effective dose and do not exceed the maximum recommended dose.Considered as adjunctive therapy to non-pharmacological therapy.ISI may be used to monitor the effect of treatment interventions.When patient forms a clear association between the bed and sleeping.Satisfaction with sleep and reduction in sleep-related distress.Sleep onset latency (time to fall asleep following bedtime).The following may be measured using a sleep log and specific questionnaires to determine treatment outcomes: Improve insomnia-related daytime dysfunction.Insomnia due to nocturia, pain or shortness of breath will most likely not improve without treatment of the medical disorder.Other sleep disorders such as obstructive sleep apnea and restless leg syndrome may present with insomnia but will most likely not improve without treatment of the specific disorder.Concomitant treatment of insomnia and psychiatric disorders is recommended to accelerate recovery and increase the likelihood of sustained response.Choice of agent should be based on type of insomnia and presence of comorbidities.If there are comorbidities, clinical judgment should decide whether the insomnia or the comorbid condition is treated first or they can be treated at the same time.

Maintenance insomnia treatment