This patient with chronic insomnia should undergo counseling regarding sleep hygiene. Insomnia is defined as the inability to initiate or maintain adequate sleep and is a common disorder. It can lead to daytime somnolence, work absenteeism, motor vehicle accidents, poor general health, functional impairment, and impaired quality of life. The initial management of insomnia focuses on implementing good sleep hygiene, which refers to the optimization of the environmental and behavioral factors associated with sleep. Patients should be advised to establish a regular relaxing bedtime routine; associate the bed and bedroom with sleep; avoid increasingly common disruptors of sleep such as cell phone, television, or computer use in the bedroom; adhere to a stable bed time and arising time; and keep the room quiet and dark.

Alcohol disrupts continuous sleep; however, this patient's modest alcohol use is unlikely to be contributing to his chronic and progressive insomnia.

Antidepressant therapy may improve sleep difficulties in the depressed patient. In addition, some antidepressants, including trazodone, doxepin, and mirtazapine, have sedative side effects, which can be used to advantage in a depressed patient with significant insomnia. Doxepin, in doses lower than needed for an antidepressant effect, is the only antidepressant agent approved for the treatment of insomnia. This patient does not manifest other symptoms of depression, and treating insomnia in the absence of depression with antidepressant agents other than doxepin is not indicated.

Zolpidem is a short-acting nonbenzodiazapine that is used in the treatment of insomnia. Because of potential adverse effects, the use of pharmacologic agents such as zolpidem should be considered only after attempts at behavioral therapy and other nonpharmacologic interventions have failed.