The Science and Art of Prescribing for Insomnia

The medical management of insomnia involves medications which either enhance the sleep-promoting mechanisms or inhibit the wakefulness-promoting mechanisms of the brain. A wide range of neurotransmitters are involved in sleep-wake regulation. There are therefore, in theory, multiple pathways by which we can enhance a patient’s sleep. In practice, the licenced hypnotics focus on only a few of these pathways, but a clear understanding of the pharmacology of these drugs reveals a number of subtleties and allows for targeted and effective prescribing. Studies of the use of hypnotics in psychiatric patients are relatively limited, and one needs to utilize clinical acumen and a good understanding of the mechanisms of action of the drugs in addition to the research data.