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Disturbed sleep is a common problem particularly among depressed patients. Diagnostic and treatment considerations are reviewed for two of the more common insomnia problems, psychophysiological insomnia and insomnia associated with depression. Studies of the actual sleep patterns of patients with these disorders reveal reliable differences that are important to understand for optimized treatment outcome. As the differentiation of sleep disorders becomes more precise and the pharmacologic armamentarium becomes greater, emphasis needs to be placed on both understanding the etiology of the sleep complaint and selecting a drug that is best matched to correct the underlying problem.

The effects of trazodone on sleep were compared with those of placebo and the sedating tricyclic antidepressant trimipramine in a double-blind crossover study in six healthy young men. Only trazodone significantly increased deep sleep without otherwise altering the normal architecture of sleep. The alpha-adrenergic receptor-blocking property of trazodone and a relative lack of noradrenergic reuptake blocking and the lack of anticholinergic effects are hypothesized to be responsible for the effects on sleep.

The use of tricyclic antidepressants as opposed to hypnotics in treating insomnia is reviewed. Available data indicate that TCAs alleviate sleep disturbances related to depression (often before antidepressant effects are seen) and, in selected cases, may prove effective in disturbed sleep related to sleep apnea, fibrositis, and sleep related bruxism, as well as in adults with childhood onset insomnia or a history of hyperkinesis. However, TCAs share many of the problems reported for hypnotics, as well as having some potentially serious side effects not present with benzodiazepines. The need for determination of the etiology of sleep disorders, and specific pharmacotherapy directed toward identified causes rather than the symptom of insomnia, is stressed.