Nonpharmacologic strategies in the management of insomnia.

Psychiatrists are quite familiar with insomnia. It has been estimated that 35% to 40% of patients with insomnia have one or more comorbid psychiatric diagnoses, with affective disorders, anxiety disorders, and substance abuse the most prevalent [1,2]. Psychiatric research has explored the interaction between sleep and mental disorders, especially depression, including the alterations in sleep associated with subtypes of depression [3,4], the use of rapid-eye-movement sleep deprivation and total sleep deprivation as treatments for depression [5,6], brain imaging in sleep and depression [7–9], the lack of nocturnal suppression of cortisol in depression [10,11], the delta sleep deficit in depression and schizophrenia [12], and the delineation of insomnia as a risk factor for future depression [2,13]. Although primary insomnia has long been a diagnostic entity in versions of the Diagnostic and Statistical Manual of Psychiatric Disorders since 1987 [14], within psychiatric settings insomnia typically is seen as a relatively nonspecific symptom of numerous disorders—it serves as a diagnostic criterion for many of these. Treatment often focuses on the psychiatric disturbance, with the expectation that ancillary sleep problems would be alleviated. When sleep is targeted directly, it is usually with medications, including antidepressants and sleeping pills. Short-term use of hypnotics has been shown to be safe and effective, whereas the use of antidepressants has received scant systematic investigation. Longterm use of hypnotics is controversial because of the potential risk of rebound