Sleep initiation and maintenance disorders

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In medicine, sleep initiation and maintenance disorders, including insomnia, are "disorders characterized by impairment of the ability to initiate or maintain sleep. This may occur as a primary disorder or in association with another medical or psychiatric condition."[1][2]


There are many underlying associations[3][4] including psychiatric disorders[5][4].


While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a polysomnogram is often needed for the differential diagnosis.


Randomized controlled trial of treatment options for insomnia.[6]
Treatment Outcome at 6 months
Responders Remitters
6 weeks of CBT 55% 40%
6 months of CBT 63% 44%
6 months of CBT
6 weeks of zolpidem
81% 68%
6 months of CBT
6 months of zolpidem
65% 42%
Adapted from Table 4 of Morin et al.[6]

Treatment options for geriatric patients have been reviewed.[7]

Non-drug treatment

No-drug treatments such as light therapy, exercise, and sleep-hygiene modification have been reviewed.[8]

A combination of education, sleep hygiene, exercise, and light therapy helped patients with Alzheimer's disease in the NITE-AD randomized controlled trial.[9]

Indirect evidence suggests a warm bath may help.[10]

Exercise, perhaps by raising body temperature, may help.[10]


Pharmacological interventions for sleepiness and sleep disturbances caused by shift work has been reviewed by the Cochrane Collaboration.[11]

GABA agonists

These medications are agonists of the gamma aminobutyric acid.

Nonselective BZ1 and BZ2 agonists
For more information, see: Benzodiazepine.

BZ1 selective agonists

These medications include zopiclone, eszopiclone, zolpidem, and zaleplon. Overall, the benefit of these medications is small.[12]

In treating persistent insomnia in adults, 6 weeks of zolpidem 10 mg nightly along with weekly sessions of cognitive behavioral therapy followed by 6 months of monthly sessions and no medications yielded the most remission of insomnia in a randomized controlled trial.[6]

In geriatrics, the benefits of zolpidem for insomnia to not clearly exceed the drug toxicity.[13][14]

The benefit of eszopiclone may not be strong.[15]

Melatonin agonists

These may increase sleep by less than 30 minutes.[11]

Ramelteon is one available agonist. Its magnitude of benefit may be small among outpatients.[15]

Tasimelteon can help transient insomnia due to shift changes related to employment.[16]


  1. Anonymous (2023), Sleep initiation and maintenance disorders (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Silber MH (2005). "Clinical practice. Chronic insomnia.". N Engl J Med 353 (8): 803-10. DOI:10.1056/NEJMcp043762. PMID 16120860. Research Blogging.
  3. Arroll B, Fernando A, Falloon K, Goodyear-Smith F, Samaranayake C, Warman G (2012). "Prevalence of causes of insomnia in primary care: a cross-sectional study.". Br J Gen Pract 62 (595): e99-103. DOI:10.3399/bjgp12X625157. PMID 22520782. PMC PMC3268500. Research Blogging.
  4. 4.0 4.1 Maggi S, Langlois JA, Minicuci N, Grigoletto F, Pavan M, Foley DJ et al. (1998). "Sleep complaints in community-dwelling older persons: prevalence, associated factors, and reported causes.". J Am Geriatr Soc 46 (2): 161-8. PMID 9475443[e]
  5. Ford DE, Kamerow DB (1989). "Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?". JAMA 262 (11): 1479-84. PMID 2769898[e]
  6. 6.0 6.1 6.2 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.". JAMA 301 (19): 2005-15. DOI:10.1001/jama.2009.682. PMID 19454639. Research Blogging. Cite error: Invalid <ref> tag; name "pmid19454639" defined multiple times with different content
  7. Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al. (2009). "Evidence-based recommendations for the assessment and management of sleep disorders in older persons.". J Am Geriatr Soc 57 (5): 761-89. PMID 19484833. PMC PMC2748127.
  8. Shub D, Darvishi R, Kunik ME (2009). "Non-pharmacologic treatment of insomnia in persons with dementia.". Geriatrics 64 (2): 22-6. PMID 19256583.
  9. McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L (2005). "Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial.". J Am Geriatr Soc 53 (5): 793-802. DOI:10.1111/j.1532-5415.2005.53252.x. PMID 15877554. Research Blogging.
  10. 10.0 10.1 Horne JA, Moore VJ (1985). "Sleep EEG effects of exercise with and without additional body cooling.". Electroencephalogr Clin Neurophysiol 60 (1): 33-8. PMID 2578352.
  11. 11.0 11.1 Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen M, Isotalo LK et al. (2014). "Pharmacological interventions for sleepiness and sleep disturbances caused by shift work.". Cochrane Database Syst Rev 8: CD009776. DOI:10.1002/14651858.CD009776.pub2. PMID 25113164. Research Blogging.
  12. Huedo-Medina, T. B.; I. Kirsch, J. Middlemass, M. Klonizakis, A. N. Siriwardena (2012-12-17). "Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration". BMJ 345 (dec17 6): e8343-e8343. DOI:10.1136/bmj.e8343. ISSN 1756-1833. Retrieved on 2012-12-19. Research Blogging.
  13. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE (2005). "Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.". BMJ 331 (7526): 1169. DOI:10.1136/bmj.38623.768588.47. PMID 16284208. PMC PMC1285093. Research Blogging. Review in: ACP J Club. 2006 Jul-Aug;145(1):14 Review in: Evid Based Med. 2006 Aug;11(4):110 Review in: Evid Based Nurs. 2006 Jul;9(3):87
  14. Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ (1997 Dec 24-31). "Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy.". JAMA 278 (24): 2170-7. PMID 9417012.
  15. 15.0 15.1 Schwartz LM, Woloshin S (2009). "Lost in transmission--FDA drug information that never reaches clinicians.". N Engl J Med 361 (18): 1717-20. DOI:10.1056/NEJMp0907708. PMID 19846841. Research Blogging.
  16. Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al. (2009). "Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials.". Lancet 373 (9662): 482-91. DOI:10.1016/S0140-6736(08)61812-7. PMID 19054552. Research Blogging.