Insomnia in ambulatory care: A clinical review.

This clinical review focuses on the causes, assessment, and evidence-based treatment options for insomnia in ambulatory care outpatients. It emphasizes the importance of screening for coexisting conditions such as obstructive sleep apnea, restless legs syndrome, narcolepsy, psychiatric disorders, and substance use disorders, as well as documenting the type and duration of insomnia. Cognitive behavioral therapy for insomnia (CBT-I), including digital delivery, is recommended as the first-line treatment, with pharmacological options such as prescription hypnotics (benzodiazepine receptor–active agents, Z-hypnotics, dual orexin receptor antagonists) and off-label medications (e.g., trazodone, mirtazapine) reserved for short-term or specific cases. Nonprescription treatments like antihistamines and melatonin have limited efficacy and are recommended only for select populations. Treatment decisions should consider patient age, comorbidities, and insomnia type, with pharmacotherapy used at the lowest effective dose and shortest duration to minimize risks such as next-day impairment, dependence, and adverse effects.