Future directions in the management of insomnia

Research on insomnia has provided a number of important new insights, but f undamental deficits in our understanding remain. In considering priorities for future research, 3 areas warrant immediate attention. Fil-st, a causal relationship between insomnia and the adverse outcomes seen in insomnia pat ients needs to be established. Second, currently available symptomatic ther apies need to be optimized. Recent data suggest that some benzodiazepine re ceptor agonists produce their hypnotic effect without side effects that wer e presumed to be inherent to sedation. Understanding the neuropharmacology underlying this differential effect would allow substantial improvements in the risk-benefit ratio for these drugs. Finally, the mechanisms of insomni a need to be better understood. Several lines of evidence suggest that phys iologic arousal is important to the clinical presentation of primary insomn ia. It remains unclear, however, whether this activation is primary or seco ndary to the insomnia itself. If physiologic hyperarousal causes primary in somnia, it would provide new approaches to the management of this disorder.