Paul P. Doghramji
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A variety of methods have been used to treat insomnia over the years. Alcohol, opium, and
herbs were replaced by barbiturates early in the 20th century. In the 1960s, barbiturates were replaced
with a safer class of medication, the benzodiazepines. Later, the selective benzodiazepine receptor
agonists (BZRAs), agents that work through the benzodiazepine receptor but are not chemically
benzodiazepines, were developed. These medications have proved to be safer, less toxic, and just
as effective without the heightened risk of dependence compared with their predecessors. Several
over-the-counter medications, including antihistamines, herbal supplements, valerian, melatonin, and L-tryptophan, are popular sleep aids, but little evidence supports their use for insomnia. Despite the
lack of U.S. Food and Drug Administration (FDA) approval for insomnia, the risk of adverse events,
and limited efficacy, antidepressants remain popular treatments for sleep disorders. Recent FDA approvals
of 2 longer acting selective BZRAs have been unique in their lack of limitation to short-term
usage as well as their indication for sleep maintenance. In late 2005, the melatonin receptor agonist
ramelteon was approved for sleep initiation and is likewise not restricted to short-term use. New compounds
under development include indiplon, another selective BZRA, and gaboxadol, a selective
extrasynaptic γ-aminobutyric acid-A agonist. Additional melatonin receptor agonists and medications
that work through the serotonin system are under development. Physician education is an important
component to ensuring that patients receive safe and adequate treatment for their insomnia.
J Clin Psychiatry 2006;67(suppl 13):5-8
© Copyright 2006 Physicians Postgraduate Press, Inc.