Treating insomnia

“By the way, doctor, I don't sleep at night. Can you give me something for that?” or “You can take away any of my other pills, but I have to have something for sleep!” are sentiments heard daily in any general medical environment. Patients with persistent complaints of insomnia—often elderly, frail, with multiple morbidities, multiple medications, already on or previously on a hypnotic medication—become problematic. Once past invoking sleep hygiene guidelines; looking for primary causes of insomnia; discussing medication risks such as falls, impaired cognition, driving crashes, and dependence; or discontinuing sedatives (and grumbling to the nurses for promoting them and to the house staff and referring doctors for prescribing them), what is the doctor to do? Why is this one of the least satisfying symptoms to treat and to educate medical professionals about?

Perhaps because the definition of “normal sleep” remains elusive, as do the determinants of normal sleep, the correlation of psychopathology (which many doctors have neither time nor training to …