2. Duration of Therapy

In adults, insomnia is classified based on symptom duration. Periods of sleep difficulty lasting from one to three nights are classified as situational insomnia, periods lasting less than three months are classified as short-term insomnia, while chronic or long-term insomnia represents sleep difficulties exceeding three months occurring at least three nights per week^25-27.

Acute, situational insomnia is due to minor situational, familial, and/or occupational stress and is managed primarily by teaching patients to re-establish normal sleep-wake patterns.26 Short-term insomnia is precipitated by events such as divorce, job loss, health concerns, or prescription medications and may be managed by behavioral techniques, lifestyle changes, and, if necessary, short-term pharmacologic therapy²⁷.

Long-term insomnia may be associated with medical or psychiatric illness (e.g., mood and anxiety disorders, asthma, chronic pain, and gastroesophageal reflux) as well as a variety of prescribed medications, although approximately 40% of patients may develop chronic insomnia due to psychophysiological characteristics^27-28. Chronic insomnia with a psychophysiological component is characterized by a marked over concern about the inability to fall asleep²⁹ . A definitive diagnosis of the specific cause for long-term insomnia is necessary before a treatment plan can be delineated^{27, 30}. Sedative/hypnotics are generally reserved for use in those patients with insomnia in whom secondary causes of insomnia have been evaluated and managed or in whom sleep hygiene practices have failed.30 Chronic insomnia without underlying medical or psychiatric disease can be managed most effectively with a benzodiazepine or nonbenzodiazepine hypnotic used concurrently for a finite period with daily behavioral therapy³¹. Ideally, sedative/hypnotics are not routinely recommended for the management of chronic insomnia^{25, 29}. However, in certain circumstances (e.g., severe, refractory insomnia, chronic comorbid illnesses), benzodiazepine and nonbenzodiazepine hypnotics may be administered in conjunction with non-pharmacologic behavioral therapy in the lowest effective dose several times per week for extended durations²⁹. Hypnotics should typically be dosed intermittently once every two to three nights to avoid tolerance and dependence²⁹ . Recently, though, eszopiclone and ramelteon have been approved for use in the long-term management of sleep onset and/or sleep maintenance insomnia, while zolpidem extended-release has been approved for use in managing insomnia for up to 24 weeks to treatment duration^{10,11,14,18,19}.

Suvorexant, lemborexant, and daridorexant, the most recently approved medications for insomnia, are prescribed to help patients with sleep onset and sleep maintenance. These drugs may be prescribed on a nightly basis if patients can remain in bed for at least 7 hours before the scheduled waking time^20-22.

Zolpidem immediate-release prescribed quantities should not exceed four to five weeks supply¹³. Barbiturates are indicated for short-term treatment of insomnia, as these agents appear to lose effectiveness in sleep induction and maintenance after 2 weeks^{8, 9}.

Sedative/hypnotic treatment regimens lasting longer than four months in adult patients will be reviewed.

In pediatric patients, sedative/hypnotics are primarily used to alleviate anxiety and/or pain associated with painful or nonpainful but threatening procedures.