61,62 When compared with the BZs and GABA A selective medications, ramelteon has the major advantage of an apparent lack of abuse potential. In fact, it is the only currently available FDA-approved hypnotic that is not classified as a controlled substance. Experience with treating insomnia associated with depression and other mood disorders is, to

date, quite limited and it would be premature to consider this promising medication a proven treatment for the sleep disturbances of patients taking antidepressants. Inhibitors,research,lifescience,medical Patients with insomnia often self -medicate with over-thecounter medications and remedies, with range from various antihistaminergic compounds (such as diphenhydramine) to “natural” agents such as melatonin and valerian root. The utility (or, Inhibitors,research,lifescience,medical more accurately, the lack of efficacy) of these nonprescription medications has been reviewed elsewhere in more detail63-65

Suffice it to say that if a patient warrants treatment for relief of a significant persistent sleep disturbance, there are a number of more promising interventions that can be utilized. Cognitive-behavioral management of insomnia The past decade has witnessed increased interest in non-pharmacologic approaches to management Inhibitors,research,lifescience,medical of insomnia, particularly those emphasizing cognitive and behavioral methods.65,66 Beyond explicit attention to sleep hygiene, cognitive behavior therapy (CBT) for insomnia utilizes stimulus control and arousal reduction techniques. There is evidence from studies of primary insomnia that comprehensive CBT results in short-term improvements that are – at the least – as effective as pharmacotherapy with sedative-hypnotics.67 The potentially greatest advantage

of CBT is evident over time, however, as effectiveness is more durable Inhibitors,research,lifescience,medical than pharmacotherapy and benefits persist after therapy is terminated.68 Thus, although CBT may be a more costly approach than Inhibitors,research,lifescience,medical pharmacotherapy in the short run, it becomes a cost-effective approach across 6 months or longer. Given the positive experience as a treatment of primary insomnia, there is a clear need for studies on the utility of CBT – in combination with antidepressant therapy- for patients with major depressive disorder.69 It is noteworthy that other models of CBT GSK1120212 ic50 directed more broadly at the overall depressive syndrome often fail to vigorously address insomnia. For example, in one large comparative study of patients with chronic forms of major depressive disorder, the antidepressant nefazodone had a substantial advantage Carnitine palmitoyltransferase II over the cognitive behavior analysis system of psychotherapy for relief of both objective and subjectively assessed depressive insomnia, even though the two therapies had comparable overall effects.70,71 Given the relatively inconsistent performance of various models of psychotherapy for treatment of more severe depressive states72 it would be prudent for therapists to consider adding a more specific CBT module to address insomnia.