July, 2006. One of life's essentials is sleep, yet how often it eludes us. While some people are good sleepers for life, others take their troubles to bed with them and can't turn them off. Stress makes it worse, and there is no shortage of stress in today's world. Paradoxically, as the overall health of the nation improves and the average lifespan increases, the gremlin of insomnia increases as well, since restful and restorative sleep is in shorter and shorter supply as we age. Insomnia thus plays a leading part among the cast of characters that bedevil us, and the cost to the nation in terms of lost productivity, secondary health problems, money spent on potions and remedies, and the problem of addiction to sleeping pills is enormous. While insomnia challenges the ability to "shut down for the night" for many of us, insomnia also plays a prominent role in psychopathology-accompanying anxiety disorders, mania, depression, dementia, and many other conditions.
We are pleased to feature in this issue of the Journal the winner of this year's Resident Paper Award, "Searching for New Options for Treating Insomnia," by Alfredo Bellon. As Bellon points out, 30%-40% of the adult population reportedly suffer from insomnia. The search for "natural" ways to re-set our biological clocks and to re-establish health-promoting patterns of sleep is a growth industry, and one focus of interest is the role of the naturally occurring hormone melatonin in promoting or regulating sleep. Bellon presents a thorough review of published studies of melatonin as a potential sleep aid, as well as studies of ramelteon, a melatonin receptor agonist recently approved by the Food and Drug Administration for the long-term treatment of insomnia. Since only a few scientifically rigorous studies of the use of these agents for sleep disorders have been published to date, no clear conclusions can be reached. Bellon advises us that, while melatonin and ramelteon appear promising as therapeutic agents in the treatment of insomnia, more research on these compounds is needed.
Also in this issue, Trivedi and colleagues explore another "natural remedy," the role of exercise as an augmentation strategy in the treatment of depression. Although this is a small pilot study that needs replication, the results suggest that exercise has a clear additive benefit for patients who only partially respond to antidepressant treatment.
Two other studies presented in this issue of the Journal focus on conditions characterized, perhaps in common with insomnia, by engines running too hot-aggression in youth with pediatric bipolar disorder, and psychotic agitation in patients presenting in emergency treatment settings. In the former, MacMillan et al. report that divalproex shows more favorable benefits than oxcarbazepine in the treatment of aggression in bipolar youth. In the latter, Currier et al. report disappointing results in the use of oral quetiapine to reduce psychotic agitation in the emergency setting; they recommend renewed efforts to identify an effective and rapidly acting oral agent for such patients.
John Oldham, MD