Treatments for Insomnia and Restless Legs Syndrome

Treating a chief complaint of inability to sleep is a core problem in psychiatric practice, together with treating other comorbid physical or mental disorders. The treatments for insomnia and restless legs syndrome (RLS) are well within the scope of psychiatric practice. Treatments for insomnia have been controversial over the past several decades, with practice patterns being driven partly by nonmedical influences operating in the setting of limited data. In recent years, the need to consider both cognitive-behavioral and pharmacological approaches together has become more apparent, with less insistence on strict either-or approaches. Clinical trial data clearly point to the efficacy of cognitive-behavioral approaches such as stimulus control, bed restriction, and related approaches. The literature on the short-term efficacy of benzodiazepine receptor agonists (BZRAs) as hypnotics has strengthened. There is a great amount of use of non-BZRAs as hypnotics, even though there are limited studies supporting their use. For RLS, the use of low-dose dopamine agonists has been substantially supported in Type 1 clinical trials. For iron-deficiency-induced RLS, iron replacement is strongly encouraged. Approaches such as using benzodiazepines are second-line treatments. Limited support for the use of gabapentin and carbamazepine is available, but the centuries-old approach of using opiates for the treatment of RLS remains a third-line approach.