Abundance of Insomnia Therapies in the Pipeline

“I treat a lot of patients with medication, but I always spend some time on behavioral approaches as well,” the psychiatrist stressed.

His first-line pharmacotherapy, used in combination with behavioral measures, is a short-acting benzodiazepine receptor agonist. If the patient still wakes up too early, he'll switch to one with a longer half-life.

His second-line therapy is low-dose trazodone, doxepin, or amitriptyline. Third-line therapy, reserved for desperate cases, is gabapentin or tiagabine.

One of the few situations where he doesn't use a benzodiazepine receptor agonist as first-line therapy is in patients with a history of substance abuse. “Although there are very few true benzodiazepine addicts out there, I just don't feel that lucky. So if I know that a person has a history of, say, alcohol abuse, I'll start with something else,” he said.

Dr. Buysse said he prefers to treat insomnia with comorbid depression or anxiety with separate medications–usually a benzodiazepine receptor agonist and a selective serotonin reuptake inhibitor–because the disorders often don't follow the same time course.

Dr. Buysse is a consultant to Sepracor Inc., sponsor of the satellite session, as well as to numerous other pharmaceutical companies.