There are a several therapies available for the treatment of primary insomnia, most notably cognitive-behavioral therapy (CBT) and pharmacologic treatment. The benzodiazepines are a group of chemically related compounds represented by medications such as triazolam, temazepam, and lorazepam. Non-benzodiazepines, such as zaleplon, zolpidem extended-release (ER), eszopiclone and zopiclone, act via a mechanism similar to the benzodiazepines but have a different chemical structure. Also available is the melatonin receptor agonist, ramelteon, as well as several antihistamines such as diphenhydramine, doxylamine, hydroxyzine.

Medications, such as the antidepressants trazodone, mirtazapine, doxepin, and amitriptyline as well as the antipsychotics, quetiapine, olanzapine, and risperidone, have been used off-label for the treatment of insomnia. Patients often turn to alcohol, over-the-counter agents, and melatonin for relief of their sleep problems (Slide 1).

Given these treatment options, there are several questions faced in clinical practice concerning when to treat patients for insomnia, what treatments should be used, and how long treatment should continue. CBT is typically continued for a fixed length of time. Generally, the greater the functional impairment a person experiences, the more there is to be gained from treatment. The decision about whether to treat and which treatments should be used, should consider the risks and expected benefits of all treatment options. CBT for insomnia has relatively minimal risks, with the only downsides being cost, access, and convenience. CBT should always be a therapeutic option.

Valerian is a medicinal agent deriving from the plant Valeriana officinalis L. We reviewed the available literature on the use of valerian preparations in the treatment of neuropsychiatric disorders. Preclinical studies suggest that valerian has sedative and muscle-relaxant effects. Few clinical trials with valerian have been carried out in conditions other than insomnia. The insomnia studies have methodologic shortcomings but suggest that some preparations lead to significant subjective improvement in sleep complaints with remarkably few side effects. Furthermore, some evidence indicates that valerian preparations may have a mechanism of action and clinical characteristics that differ from the benzodiazepine-related sedative/hypnotics, making them more suitable for long-term use. If this safety profile and the plant's sedative/hypnotic efficacy are confirmed in double-blind, placebo-controlled trials with carefully and consistently prepared valerian compounds, then those compounds would fill an important and presently unfilled niche in the treatment of insomnia.

Insomnia is a disorder characterized by chronic sleep disturbance associated with daytime disability or distress, such as memory impairment and fatigue, that occurs despite adequate opportunity for sleep. Insomnia may present as difficulty falling/staying asleep or as sleep that is nonrestorative. Studies show a strong correlation between insomnia and impaired quality of life. Pain conditions and depression are commonly associated with insomnia, either as secondary or comorbid conditions. In addition, a greater incidence of anxiety, alcohol and drug dependence, and cardiovascular disease is found in people with insomnia. Data indicate insomnia results from over-engaged arousal systems. Insomnia patients experience increased metabolic rate, body temperature, and heart rate, and elevated levels of norepinephrine and catecholamines. Pharmacologic options for the treatment of insomnia include benzodiazepine hypnotics, a selective melatonin receptor agonist, and sedating antidepressants. However, insomnia may be best treated with cognitive-behavioral therapy and instruction in good sleep hygiene, either alone or in concert with pharmacologic agents. Studies on the effects of insomnia treatment use variable methodologies or do not publish negative results, and there are currently no studies of treatment focusing on morbidity. Further research is necessary to better understand the effects of insomnia therapies on medical and psychiatric disorders.

In this Clinical Information Supplement, Thomas Roth, PhD, describes the nature of insomnia and its pathophysiology. Next, Andrew D. Krystal, MD, MS, reviews morbidities associated with insomnia. Finally, Joseph A. Lieberman III, MD, MPH, provides an overview of therapeutics utilized in patients with insomnia, including behavioral therapies and pharmacologic options.