Hypnotics should not be considered for the initial treatment of chronic insomnia. Con.

Analysis of the use of hypnotic medication versus CBT for insomnia using an established model for ethical medical decision making leads to the conclusion that hypnotics are not appropriate as the initial treatment in cases of chronic insomnia. Instead, CBT should be considered as the initial treatment for chronic insomnia. This decision is based on empirical data demonstrating that CBT is equally effective in the short-term treatment of insomnia and is superior to pharmacologic treatment in the long-term management of insomnia. Long-term management is a critically important concern, since 'chronic' insomnia requires a long-term solution. Using CBT as the initial treatment is also supported by empirical data showing that combining hypnotic use with CBT leads to worse outcomes compared with CBT alone. In addition to the efficacy data described above, patients have been shown to prefer nondrug therapy for insomnia when given the choice. QoL issues support the use of CBT because of the avoidance of side effects associated with use of hypnotic medication, such as residual sedation, psychomotor and cognitive impairment, and perhaps, most importantly, psychologic dependence. The greatest challenge to endorsement of use of CBT arises from contextual issues, such as the out-of-pocket cost to the patient and availability of the treatment. In some instances, these factors may be significant barriers to the use of CBT for insomnia. These barriers can be addressed with improved insurance reimbursement for CBT, in addition to training more providers.