Wake up to insomnia: future approaches to the management of insomnia

Insomnia is rife. Acutely, almost every individual has experienced a poor night's sleep, and many short-term remedies for insomnia are tried, including over-the-counter sleep aids and alcohol. Chronic insomnia is the most common sleep disorder, affecting nearly 40 million Americans and accounting for nearly one-third of adults. The annual cost associated with this disorder in the US is estimated at over $15 billion 1 and over $100 billion for indirect costs, such as costs of self-medication, health care-related costs due to exacerbations of comorbid conditions, and costs of reduced productivity. 2 Degradations of sleep quantity and sleep quality in insomnia have been associated with deleterious long-term effects, including cardiovascular, endocrine, psychological, and immune system complications. Despite these facts, chronic insomnia is not always perceived as a treatable and important medical condition. Symptoms are not always proffered by patients, and diagnoses can be ignored by physicians, partly because insomnia is so common that it is considered somewhat normal, particularly in elderly individuals. These days, recognized treatments for insomnia include pharmacological therapies and the more recently accepted behavioral therapies, including stimulus control, relaxation, and cognitive and behavioral therapy. Research to evaluate and formulate treatments for insomnia is often beset by the problem that insomnia is usually of multifactorial etiology among individuals. Thus, complex and important questions remain, eg, which types of insomnia can be cured, which therapy is best in each situation and in each patient, and why do so many untreated or suboptimally treated individuals with insomnia exist? There is also a clear need to examine the long-term effects of treatment on diverse cultures, ages, and races and in those with comorbid disorders, using randomized clinical trials of sufficient duration. In the first full year of publication, the Nature and Science of Sleep (NSS) has published a set of articles that begins to examine the advantages and limitations of a number of relatively novel pharmacological and behavioral therapies for insomnia. These papers ought to help clinicians appraise new therapies, better manage insomnia, and identify important gaps in our knowledge and promising future approaches. A number of papers in NSS review new pharmacological strategies for insomnia therapy, including the use of nonbenzodiazepine gamma-aminobutyric acid receptor agonists such as zolpidem, zaleplon, and eszopiclone (Z-drugs), which potentially have reduced adverse effects with improved safety and tolerance compared with older benzodiazepines;