GUEST EDITORIAL: Rational pharmacotherapy for insomnia: time for a new paradigm.

Abstract

Any interesting debate must have two sides well-defended by facts, realities, and even emotion. The debate over the pharmacological treatment of insomnia is no exception. Milton Kramer has argued that long-term treatment of insomnia with benzodiazepine receptor agonist (BzRA) hypnotics is more effective than often acknowledged, less toxic than often feared, and greatly appreciated by many insomnia sufferers (1). Daniel Kripke, in a previous article as well as in his response to Kramer, cites convincing data that long-term use of BzRA drugs has minimal therapeutic effects at the cost of significant adverse effects (2, 3). The debate is framed in quasi-religious terms: should we avoid the “pharmacologic Calvinism” that denies effective treatment to those with insomnia? Or should we rather fear the “hypnotic Bacchanalianism” that promotes an ineffective and potentially dangerous “treatment”, albeit one that feels good? Is there a middle ground for the well-intentioned clinician and researcher? I believe the answer is yes. In fact, even Kramer and Kripke agree on several key points regarding the type of information that will help us gain a better perspective on this debate. Between the paths of Calvin and Bacchus, I would like to propose a new paradigm that I will call “rational pharmacotherapy for insomnia”.