Handbook of Psychology

Treatments 329

National Institute of Mental Health survey of psychothera-
peutic drug use indicate that only 15% of those reporting
serious insomnia had used either a prescribed or over-the-
counter sleep aid within the previous year (Mellinger et al.,
1985). The average insomnia duration before seeking profes-
sional treatment often exceeds 10 years. When individuals
with persistent insomnia are asked about the types of meth-
ods they have used to cope with insomnia, the majority report
passive strategies such as reading, listening to the radio or
watching TV, trying to relax or, simply doing nothing.
The “rst line of active treatment usually involves self-
help remedies such as alcohol, over-the-counter products
(Sominex, Unisom, Nytol), or herbal/dietary supplements
such as melatonin or valerian. When all of these strate-
gies have failed, some individuals may seek professional
help. As for other health conditions (e.g., pain), most individ-
uals with insomnia typically seek treatment, not from a psy-
chologist, but from a primary care physician, and treatment
usually involves drug therapy. Nearly 50% of patients con-
sulting for insomnia in medical practice are prescribed a
hypnotic medication and the majority of those continue
using their medications almost daily for more than one year
(Hohagen et al., 1993; Ohayon & Caulet, 1996).

Help-Seeking Determinants

There is little information about the natural history of insom-
nia and related help-seeking determinants. Nonetheless, sev-
eral factors, other than socioeconomic ones, may regulate
health-seeking behaviors in the context of insomnia. Patients
seeking treatment for insomnia in primary care medicine
often present more co-existing medical and psychological
problems than untreated individuals or those attempting to
treat their sleep dif“culties on their own. Likewise, those who
seek treatment in sleep disorder clinics display more emo-
tional distress than those who do not seek treatment, although
the severity of sleep disturbances is comparable for these two
groups (Stepanski et al., 1989). The speed of onset of insom-
nia may also in”uence help-seeking behaviors. Acute insom-
nia is often associated with a major stressful life event (e.g.,
death of a loved one, medical illness, separation) and is more
likely to be brought to the attention of a physician and to re-
ceive clinical attention. Conversely, when insomnia evolves
gradually and is tolerated for prolonged periods of time, it is
less likely to be brought to clinical attention and, perhaps,
less likely to be taken seriously. Another important determi-
nant is the degree of acceptability of sleep medications.
Many insomniacs may not consult their physicians for sleep
because they are concerned that they may not be taken seri-
ously or that a sleeping pill prescription will be the only

recommended treatment. Survey data show that very few

individuals with chronic insomnia ( 10%) seek treatment

speci“cally for this condition (Mellinger et al., 1985);

however, many more mention it in the context of a visit for

another medical condition, and even more report sleep prob-

lems when speci“cally asked about their sleep patterns.

Barriers to Treatment

There are several barriers to insomnia treatment, partic-

ularly to psychological therapies. Among these are the lack

of recognition of insomnia by health care practitioners,

inadequate dissemination of knowledge about validated in-

terventions, and the costs and limited availability of these

treatments (National Institutes of Health, 1996). Although

nondrug interventions for insomnia are generally well ac-

cepted by patients (Morin, Gaulier, Barry, & Kowatch, 1992)

and physicians, speci“c behavioral interventions, other than

general sleep hygiene recommendations (e.g., reduce caf-

feine, increased exercise) are not well known and are infre-

quently used in clinical practice (Rothenberg, 1992). For

these reasons, drug therapy remains the mainstream of in-

somnia treatments.

Benefits and Limitations of Sleep Medications

Several classes of medications are used for treating insomnia,

including benzodiazepines, nonbenzodiazepine hypnotics, an-

tidepressants, and antihistamines. The most frequently pre-

scribed hypnotics include benzodiazepines (e.g., ”urazepam,

temazepam, lorazepam, triazolam, nitrazepam) and newer

agents (e.g., zolpidem, zopiclone, zelaplon) with more selec-

tive/speci“c hypnotic actions. Some antidepressants (e.g., tra-

zodone, amitriptyline, doxepin) are also prescribed for sleep

problems because of their sedative properties, but this practice

is controversial and not supported by empirical evidence.

Most over-the-counter medicines advertised as sleep aids

(e.g., Sominex, Nytol, Sleep-Eze, Unisom) contain a sedative

antihistamine such as diphenhydramine. Although these

agents produce drowsiness, there is limited evidence that

they are ef“cacious in the treatment of insomnia (Monti &

Monti, 2000). Melatonin, a naturally occurring hormone pro-

duced by the pineal gland at night, is increasingly used as a

sleep aid. Although it may be useful for some forms of circa-

dian sleep disturbances associated with shift-work and jet-

lag, the bene“ts of melatonin for insomnia are equivocal and

the adverse effects associated with long-term usage are un-

known (Mendelson, 1997). Valerian, which is extracted from

a plant of the same name, produces a mild hypnotic effect but

additional studies are needed to evaluate its therapeutic