Special Considerations for Treatment of Insomnia

The treatment of insomnia since antiquity to the 1960s has included substances and medications such as alcohol, laudanum, bromides, chloral hydrate, paraldehyde, urethane, and barbiturates. Benzodiazepines have been used to treat insomnia, but problems such as dependence, daytime drowsiness, and prevention of the transition from N2 to N3 sleep have resulted in providers prescribing this class of medications less frequently to their patients. Similarly, antidepressants with sedating properties such as trazodone are commonly prescribed to insomnia sufferers, despite considerable adverse effects such as tolerance, constipation, orthostatic hypotension, blurred vision, and priapism. Atypical antipsychotics such as olanzapine and quetiapine are also prescribed to patients with insomnia and also are associated with adverse effects that are not minor, such as dizziness, anticholinergic effects, and weight gain. Newer treatment options, which will be the focus of this chapter, include medications acting on the a-1 subunit of the benzodiazepine receptor complex and a novel MT1/MT2 receptor agonist, have rapidly become the first-line therapy for patients with insomnia, in conjunction with behavioral therapy.