Situational stress (e.g., occupational, interpersonal, financial, academic, medical) Selected causes of acute insomnia (< 30 days) * The better safety profile of the newer-generation non-benzodiazepines (i.e., zolpidem, zaleplon, eszopiclone, and ramelteon) makes them better first-line choices for long-term treatment of chronic insomnia. Benzodiazepines are most useful for short-term treatment however, long-term use may lead to adverse effects and withdrawal phenomena. Opiates are valuable in pain-associated insomnia. Alcohol has the potential for abuse and should not be used as a sleep aid. Routine use of over-the-counter drugs containing antihistamines should be discouraged. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. There is good evidence supporting the effectiveness of cognitive behavior therapy. Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted.
Physicians may initiate treatment of insomnia at an initial visit for patients with a clear acute stressor such as grief, no further evaluation may be indicated.
The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for evaluation and treatment.
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