The popularity of antidepressants in the treatment of insomnia is not supported 
by a large amount of convincing data, but rather by opinions and beliefs of the 
prescribing physicians on the advantages of these agents compared with drugs 
acting on the benzodiazepine receptor or other drugs used for the treatment of 
insomnia. The existing data do not allow for clear-cut, evidence-based 
recommendations concerning the use of antidepressants in insomnia. Our 
conclusions result from a few short-term studies on single agents, clinical 
experience and inferences from knowledge on the effect of antidepressants in 
other indications. At present, prescribing antidepressants for short-term 
treatment of insomnia can be useful if there is some amount of concomitant 
depressive symptomology or a history of depression, raising the impression that 
the present insomnia may be a prodromal sign for a new depressive episode. In 
all other cases, benzodiazepine receptor agonists, especially the 
nonbenzodiazepines among them (the so-called 'z drugs') should be the drugs of 
choice. For long-term treatment, antidepressants are among the pharmacological 
options, in addition to other groups of psychotropics. Off-label use of 
antidepressants may be considered for chronic insomnia if there is a concomitant 
depressive symptomalogy (which is not so pronounced that an antidepressant 
treatment with adequate higher doses would be required) and if there is no 
specific indication for one of the other groups of psychotropics (e.g. 
dementia-related nocturnal agitation, in which case an antipsychotic would be 
preferred, or circadian problems, in which case melatonin or a melatonin agonist 
would be favoured). If antidepressants are used to treat insomnia, sedating ones 
should be preferred over activating agents such as serotonin reuptake 
inhibitors. In general, drugs lacking strong cholinergic activity should be 
preferred. Drugs blocking serotonin 5-HT2A or 5-HT2C receptors should be 
preferred over those whose sedative property is caused by histamine receptor 
blockade only. The dose should be as low as possible (e.g. as an initial dose: 
doxepin 25 mg, mirtazapine 15 mg, trazodone 50 mg, trimipramine 25 mg). 
Regarding the lack of substantial data allowing for evidence-based 
recommendations, we are facing a clear need for well designed, long-term, 
comparative studies to further define the role of antidepressants versus other 
agents in the management of insomnia.