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Chiu HY, Lee HC, Liu JW, Hua SJ, Chen PY, Tsai PS, Tu YK. Comparative efficacy and safety of hypnotics for insomnia in older adults: a systematic review and network meta-analysis. Sleep 2021; 44:6010169. [PMID: 33249496 DOI: 10.1093/sleep/zsaa260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES To compare the efficacy and safety of various hypnotics for identifying the best treatments for insomnia in older adults. METHODS We searched the EMBASE, PubMed, ClinicalTrials.gov, and ProQuest Dissertations and Theses A&I databases from the inception to September 12, 2020. Only randomized controlled trials comparing hypnotics with either another hypnotic or placebo for insomnia treatment in elderly people were included. Sleep outcomes, including total sleep time, sleep onset latency, wake after sleep onset, sleep efficiency, were derived from polysomnography, valid questionnaires, or sleep diaries. RESULTS We identified 24 articles with 5917 older adults. Eszopiclone and low-dose doxepin were ranked the optimal therapy for prolonging objective and subjective total sleep time (26.69 and 28.19 min), respectively, compared to placebo. Zaleplon was the most effective therapy in reducing objective and subjective sleep onset latency (-21.63 and -15.86 min) compared with control. Temazepam was the best treatment for objective and subjective wake after sleep onset (-25.29 and -22.25 min) compared with control. Low-dose doxepin appeared to be the effective treatment for increasing objective sleep efficiency (6.08%) Triazolam showed the higher risk of overall adverse events (odds ratio, 1.96, 95% confidence interval 1.03-3.74) when compared to zaleplon. CONCLUSIONS Considering study quality and the potential adverse effects of benzodiazepines and nonbenzodiazepines, low-dose doxepin seems to be the optimal pharmacotherapy for the improvements in total sleep time and sleep efficiency. Future RCTs investigating the treatment effects of hypnotics, particularly low-dose doxepin, on insomnia in older adults are warranted. PROSPERO Registration number: CRD42016046301.
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Affiliation(s)
- Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsin-Chien Lee
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, Taipei Medical University Hospital, Taipei, Taiwan
| | - Jen-Wei Liu
- Department of Pharmacy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan.,School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Shi-Jun Hua
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.,Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan
| | - Pin-Yuan Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Shan Tsai
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kang Tu
- Department of Public Health, Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
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Park KM, Kim TH, Kim WJ, An SK, Namkoong K, Lee E. Cognitive Behavioral Therapy for Insomnia Reduces Hypnotic Prescriptions. Psychiatry Investig 2018; 15:499-504. [PMID: 29695151 PMCID: PMC5976005 DOI: 10.30773/pi.2017.11.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/20/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE This study determined whether cognitive behavioral therapy for insomnia (CBT-i) decreased the need for sleep medications and produced better treatment outcomes than pharmacotherapy alone. METHODS We reviewed data from patients with insomnia in the outpatient clinic of a general hospital between 2009 and 2015. We compared 41 patients who received five sessions of CBT-i with 100 age- and sex-matched patients who received pharmacotherapy only. We evaluated the change in prescription for sleep (i.e., antidepressants, hypnotics, and others) between the first and last visits using repeated measures analysis of variance (ANOVA). Clinical global impressions and completion status at the last visit were assessed using the chisquare test. RESULTS We found a significant decrease in the prescription rate and the dosage of hypnotics among patients who received CBT-i when compared with control patients. There was no significant change in the dosage of antidepressants between the two groups. Achievement of case closure was better in the CBT-i group at the trend level. Clinical global impression at the last visit was not significantly different. CONCLUSION These results show that CBT-i reduces the need for hypnotics among insomnia patients. Our results indicate that CBT-i offers additional benefits beyond improving sleep characteristics and thus provides another reason for recommending CBT-i as a first-line treatment for insomnia.
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Affiliation(s)
- Kyung Mee Park
- Institute of Behavioral Science in Medicine and Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Ho Kim
- Institute of Behavioral Science in Medicine and Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jung Kim
- Department of Psychiatry, Seonam University College of Medicine, Myongji Hospital, Goyang, Republic of Korea
| | - Suk Kyoon An
- Institute of Behavioral Science in Medicine and Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kee Namkoong
- Institute of Behavioral Science in Medicine and Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Lee
- Institute of Behavioral Science in Medicine and Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
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Barygin OI, Nagaeva EI, Tikhonov DB, Belinskaya DA, Vanchakova NP, Shestakova NN. Inhibition of the NMDA and AMPA receptor channels by antidepressants and antipsychotics. Brain Res 2017; 1660:58-66. [PMID: 28167075 DOI: 10.1016/j.brainres.2017.01.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 12/22/2022]
Abstract
It is known that some antidepressants and antipsychotics directly inhibit NMDA-type ionotropic glutamate receptors. In this study we systematically studied action of seven drugs (Fluoxetine, Citalopram, Desipramine, Amitriptyline, Atomoxetine, Chlorpromazine, and Clozapine) on NMDA receptors and Ca2+-permeable and -impermeable AMPA receptors in rat brain neurons by whole-cell patch-clamp technique. Except for weak effect of fluoxetine, all drugs were virtually inactive against Ca2+-impermeable AMPA receptors. Fluoxetine and desipramine significantly inhibited Ca2+-permeable AMPA receptors (IC50=43±7 and 105±12µM, respectively). Desipramine, atomoxetine and chlorpromazine inhibited NMDA receptors in clinically relevant low micromolar concentrations, while citalopram had only weak effect. All tested medicines have been clustered into two groups by their action on NMDA receptors: desipramine, amitriptyline, chlorpromazine, and atomoxetine display voltage- and magnesium-dependent open channel blocking mechanism. Action of fluoxetine and clozapine was found to be voltage- and magnesium-independent. All voltage-dependent compounds could be trapped in closed NMDA receptor channels. Possible contribution of NMDA receptor inhibition by certain antidepressants and antipsychotics to their analgesic effects in neuropathic pain is discussed.
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Affiliation(s)
- Oleg I Barygin
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia.
| | - Elina I Nagaeva
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Denis B Tikhonov
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Darya A Belinskaya
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Nina P Vanchakova
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Natalia N Shestakova
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
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4
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Nefs G, Donga E, van Someren E, Bot M, Speight J, Pouwer F. Subjective sleep impairment in adults with type 1 or type 2 diabetes: Results from Diabetes MILES--The Netherlands. Diabetes Res Clin Pract 2015; 109:466-75. [PMID: 26264411 DOI: 10.1016/j.diabres.2015.07.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/12/2015] [Accepted: 07/24/2015] [Indexed: 10/23/2022]
Abstract
AIMS Despite growing recognition of the impact of sleep on diabetes, a clear profile of people with diabetes regarding subjective sleep impairment has yet to be established. This study examines: (1) subjective sleep characteristics in adults with type 1 and type 2 diabetes; (2) the relationship of poor subjective sleep quality with glycaemic control, self-care and daytime functioning; (3) possible risk markers for poor sleep quality. METHODS In a cross-sectional study, Dutch adults with type 1 (n=267) or type 2 diabetes (n=361) completed an online survey, including the Pittsburgh Sleep Quality Index (PSQI), socio-demographic, clinical, self-care and psychological measures. RESULTS Poor sleep quality (PSQI-score >5) was reported by 31% of adults with type 1 and 42% of adults with type 2 diabetes. Participants with good and poor sleep quality did not differ in self-reported HbA1c or the frequency of meeting lifestyle recommendations. Poor sleep quality was related to a higher self-care burden and higher levels of daytime sleepiness, fatigue, depressive and anxiety symptoms, and diabetes-specific distress. In multivariable logistic regression analyses examining risk markers, poor sleep quality was associated with depressive symptoms in adults with type 1 (OR=1.39, 95% CI 1.25-1.54) and type 2 diabetes (OR=1.31, 1.16-1.47), and with being female in those with type 2 diabetes (OR=2.72, 1.42-5.20). CONCLUSIONS Poor subjective sleep quality is prevalent both in adults with type 1 and type 2 diabetes, and is related to poor daytime functioning and higher self-care burden. The temporal relation with depression and merits of therapy should be explored.
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Affiliation(s)
- Giesje Nefs
- Center of Research on Psychology in Somatic diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, Tilburg, 5000 LE, The Netherlands.
| | - Esther Donga
- Department of Internal Medicine, St. Elisabeth Hospital, PO Box 90151, Tilburg, 5000 LC, The Netherlands
| | - Eus van Someren
- Department of Sleep and Cognition, Netherlands Institute for Neuroscience, Meibergdreef 47, Amsterdam, 1105 BA, The Netherlands; Departments of Integrative Neurophysiology and Medical Psychology, Center for Neurogenomics and Cognitive Research (CNCR), Neuroscience Campus Amsterdam, VU University and Medical Center, De Boelelaan 1085, Amsterdam, 1081 HV, the Netherlands
| | - Mariska Bot
- Center of Research on Psychology in Somatic diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, Tilburg, 5000 LE, The Netherlands; Department of Psychiatry, VU University Medical Center and EMGO Institute for Health and Care Research, A.J. Ernststraat 1187, Amsterdam, 1081 HL, The Netherlands
| | - Jane Speight
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia, Vic, 570 Elizabeth Street, Melbourne, Victoria, 3000, Australia; Centre for Mental Health and Wellbeing Research, School of Psychology, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia; AHP Research, 16 Walden Way, Hornchurch, UK
| | - François Pouwer
- Center of Research on Psychology in Somatic diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, Tilburg, 5000 LE, The Netherlands
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Doxepin for insomnia: A systematic review of randomized placebo-controlled trials. Sleep Med Rev 2015; 19:75-83. [DOI: 10.1016/j.smrv.2014.06.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 05/15/2014] [Accepted: 06/04/2014] [Indexed: 11/23/2022]
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Rafihi-Ferreira RE, Soares MRZ. Insônia em pacientes com câncer de mama. ESTUDOS DE PSICOLOGIA (CAMPINAS) 2012. [DOI: 10.1590/s0103-166x2012000400014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A insônia é uma queixa frequente em pacientes com câncer de mama, e suas consequências podem causar impacto na qualidade de vida e no curso da doença. O objetivo deste estudo foi revisar a literatura especializada sobre a relação entre insônia e câncer de mama, abordando definição, prevalência, fatores etiológicos e as consequências da insônia no contexto da neoplasia mamária, bem como os tratamentos para insônia nessa população. A busca da literatura ocorreu nos bancos de dados Scopus, Web of Science e SciELO, utilizando as palavras chaves: insomnia, sleep, breast cancer, treatment, cognitive-behavioral therapy. Os estudos revisados demonstraram que a etiologia da insônia envolve fatores de predisposição, precipitação e perpetuação. Evidencia-se a importância da melhora na qualidade de sono em pacientes oncológicos, além de se indicar a combinação de terapia farmacológica e cognitivocomportamental no tratamento dos problemas de sono.
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Effects of moderate aerobic exercise training on chronic primary insomnia. Sleep Med 2011; 12:1018-27. [DOI: 10.1016/j.sleep.2011.02.007] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 01/27/2011] [Accepted: 02/09/2011] [Indexed: 11/21/2022]
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Kim H, Rose K. Sleep disturbances in family caregivers: an overview of the state of the science. Arch Psychiatr Nurs 2011; 25:456-68. [PMID: 22114799 DOI: 10.1016/j.apnu.2011.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 02/19/2011] [Indexed: 10/18/2022]
Abstract
Sleep disturbance is a prevalent and complex issue within the family caregiver population that affects the overall health of the caregivers themselves and their care recipients. However, there is limited evidence to support the efficacy of current practice and a lack of consensus regarding the optimal treatment protocol. This article will provide an overview of sleep research in family caregivers. It explores current trends in sleep research and identifies relevant conceptual and methodological issues, suggesting implications for further research and highlighting the need to improve sleep quality in the caregiver population.
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Affiliation(s)
- Heejung Kim
- University of Virginia, University of Virginia, School of Nursing, Charlottesville, VA 22908-0782, USA.
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11
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Affiliation(s)
- M S Reddy
- Asha Hospital, Hyderabad, Andhra Pradesh, India. E-mail:
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Abstract
The aim of this research was to determine the quality of sleep, reasons for sleep disturbances, and nonpharmacological strategies versus sleep disturbances of cancer patients' family caregivers. A descriptive, cross-sectional study design was used. Ninety family caregivers were included. Data were collected using the Pittsburgh Sleep Quality Index (PSQI), demographic data form, and open-ended questions about reasons for sleep disturbances and nonpharmacological strategies used by family caregivers. Descriptive statistics, Kruskal-Wallis variance analysis, and Bonferoni-corrected Mann-Whitney U test were performed using SPSS program. The PSQI score of 72.22% of the caregivers was above 5, which indicated poor sleep quality. The most commonly determined reasons for sleep disturbances were "emotional distress because of the patient's illness" (83.33%), "financial problems" (36.66%), and "inadequate support system" (34.44%); 76.92% of caregivers used at least 1 nonpharmacological strategy, which included mostly "lifestyle practices" (54.28%) and "behavioral practices" (25.71%). The total PSQI scores of caregivers having an illness were significantly higher than those of caregivers having no illness (Z = 3.230; P = .001). Total PSQI scores did not differ by sex, age, education, marital status, or duration of caregiving (P > .05). This study implies that caregivers are in need of support by healthcare professionals to provide a positive environment during the care process.
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Abstract
Doxepin binds with high specificity and affinity to the histamine H(1) receptor compared with other receptors. Therefore, at low doses, doxepin selectively antagonises H(1) receptors, which is believed to promote the initiation and maintenance of sleep. In three large, well designed, phase III trials in adult or elderly patients with chronic primary insomnia, oral, low-dose doxepin 3 or 6 mg once daily improved wake time after sleep onset, total sleep time and sleep efficiency to a significantly greater extent than placebo. Significant between-group differences in polysomnographic sleep recordings that favoured low-dose doxepin were evident after a single administration of the drug. Other efficacy measures, including patient-reported sleep quality, also favoured low-dose doxepin over placebo. Symptom control was maintained for up to 12 weeks of low-dose doxepin administration and there was no evidence of physical dependence or worsening insomnia after doxepin withdrawal. Oral, low-dose doxepin 6 mg was also significantly more effective than placebo in a large, well designed trial modelling transient insomnia in healthy adults, according to polysomnographic recordings (e.g. in latency to persistent sleep). Oral, low-dose doxepin was generally well tolerated in clinical trials.
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Affiliation(s)
- Juliane Weber
- Adis, a Wolters Kluwer Business, Auckland, New Zealand
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Abstract
A sleep history should be taken routinely in patients with epilepsy. Treatment of sleep disorders and improvement in sleep hygiene may improve seizure control, daytime cognitive functioning, and quality of life. Patients with recurrent sleepiness interfering with daily activities or an Epworth Sleepiness Scale score more than 10 should be considered for additional evaluation by a sleep specialist. Treatment options for insomnia include improvements in sleep hygiene, cognitive behavior therapies, and sedative or hypnotic drugs. Alterations in the timing or type of antiepileptic drugs (AEDs) may be helpful (for example, using sedating medications before bedtime and avoiding evening use of drugs that may exacerbate insomnia ). Improvements in sleep hygiene alone are less effective than cognitive behavioral therapy or pharmacologic therapy. Cognitive behavioral therapy is more efficacious and its effects longer lasting than pharmacologic treatments. Sedative and hypnotic drugs may exacerbate AED cognitive adverse effects during the day and should be used only after other therapies have failed. Excessive daytime sleepiness (EDS) in patients with epilepsy may be secondary to AEDs, nocturnal seizures, or a concomitant sleep disorder such as sleep apnea or restless leg syndrome. Sedating AEDs should be minimized during the day, and activating AEDs should be used as appropriate. Video electroencephalogram polysomnography should be performed when EDS interferes with daily activities and the etiology of sleepiness is unclear. AEDs that are associated with weight gain should be avoided in patients with sleep apnea. AEDs that may promote weight loss should be considered for obese patients with sleep apnea. Continuous positive airway pressure is the treatment of choice for sleep apnea.
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Affiliation(s)
- Susan T Herman
- Hospital of the University of Pennsylvania, Department of Neurology, 3400 Spruce Street, Philadelphia, PA 10104, USA.
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Becker PM, Sattar M. Treatment of sleep dysfunction and psychiatric disorders. Curr Treat Options Neurol 2009; 11:349-57. [DOI: 10.1007/s11940-009-0039-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Fibromyalgia is a prevalent disorder that is characterized by widespread pain along with numerous other symptoms, including fatigue, poor sleep, mood disorders, and stiffness. Previous guidelines for the management of fibromyalgia recommended an approach that integrates pharmacologic and nonpharmacologic therapies selected according to the symptoms experienced by individual patients. However, they offered no recommendations for a system of patient assessment that would provide a basis for individualized treatment selection. We present a simple, rapid and easily remembered system for symptom quantitation and pharmacologic management of fibromyalgia that combines visual analogue scale symptom scores from a modified form of the disease-neutral Fibromyalgia Impact Questionnaire, with a review of medications that can be used to treat the individual symptoms. This symptom-based approach is amenable to caring for patients with fibromyalgia in a busy clinical practice.
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Stege G, Vos PJ, van den Elshout FJ, Richard Dekhuijzen P, van de Ven MJ, Heijdra YF. Sleep, hypnotics and chronic obstructive pulmonary disease. Respir Med 2008; 102:801-14. [DOI: 10.1016/j.rmed.2007.12.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 12/11/2007] [Accepted: 12/19/2007] [Indexed: 10/22/2022]
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Passos GS, Tufik S, Santana MGD, Poyares D, Mello MTD. Tratamento não farmacológico para a insônia crônica. REVISTA BRASILEIRA DE PSIQUIATRIA 2007; 29:279-82. [PMID: 17713700 DOI: 10.1590/s1516-44462006005000045] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Accepted: 03/07/2007] [Indexed: 11/21/2022]
Abstract
O objetivo deste artigo é descrever, resumidamente, quais são as terapias não farmacológicas e também a atualização do uso destas para o tratamento da insônia crônica. Além da insônia ser o mais prevalente distúrbio do sono, ela está diretamente associada aos transtornos psiquiátricos. Embora o tratamento farmacológico seja o mais comumente utilizado, as terapias não farmacológicas vêm sendo amplamente estudadas, em particular as relacionadas às mudanças de comportamento. Entre estas estão a cognitiva; a higiene do sono; a do controle de estímulos; a de restrição do sono; a do relaxamento muscular; a da intenção paradoxal e, mais recentemente, a prática regular de exercícios físicos. Inicialmente, o principal objetivo dos estudos realizados com as intervenções comportamentais foi o de melhorar a qualidade do sono dos pacientes. No entanto, alguns estudos recentes têm sido desenvolvidos com o objetivo de avaliar o efeito de tais terapias auxiliando à redução da dose e da freqüência de uso de medicamentos utilizados, bem como à melhora da qualidade de vida dos pacientes. Como a insônia é um problema crônico, os tratamentos de longo prazo têm sido alvos de estudos e de uso comum entre os clínicos.
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Becker PM. Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Psychiatr Clin North Am 2006; 29:855-70; abstract vii. [PMID: 17118272 DOI: 10.1016/j.psc.2006.08.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
When patients report problems sleeping, a psychiatrist must determine their significance based on frequency, duration, and daytime impairment. Because up to 50% of adults report sleep problems in any year, it is necessary to define when insomnia becomes long-standing, severe, and a complication to daytime function. Psychiatrists must determine if a sleep disturbance reduces mood, motor performance, or cognitive function. If insomnia syndrome is present, major depression, dysthymia, and anxiety disorders commonly are comorbid. To assist in evaluating insomnia, psychiatrists are urged to use the 6 Ps + M of insomnia model to conceptualize the characteristics of the insomnia and coordinate therapeutic intervention.
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Affiliation(s)
- Philip M Becker
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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Abstract
Patients with neurologic disorders commonly experience sleep dysfunction and psychiatric disorders. The most common sleep dysfunction is insomnia, which is a primary symptom in 30% to 90% of psychiatric disorders. Insomnia and fatigue are prominent symptoms of anxiety disorders and major depression, including patients who are treated but have residual symptoms. Anxiety and depressive disorders account for 40% to 50% of all cases of chronic insomnia. It is also recognized that primary insomnia and other primary sleep disorders produce symptoms that are similar to those reported by patients with psychiatric disorders. A clinician must judge whether sleep deprivation causes mood disturbance or whether depressive or anxiety disorder represents the primary reason for sleep dysfunction. When insomnia is comorbid with mild to moderate depression, therapy should begin with bedtime dosing of sedating antidepressants such as mirtazapine, nefazodone, or tricyclic antidepressants, which are preferred because of their sedative effects, although side effects may limit their usefulness. Intervention for chronic insomnia is similar in nonpsychiatric and psychiatric patients. Behavioral therapies, particularly cognitive behavioral therapy, and lifestyle changes show significant long-term efficacy as treatments for chronic insomnia. Sedative hypnotic agents are the most studied agents to treat insomnia, particularly those that are active through the benzodiazepine receptor-GABA complex, such as benzodiazepines, eszopiclone, zaleplon, and zolpidem. The new melatonin-receptor agonist ramelteon has not yet been studied in psychiatric patients. Prescription of adjunctive trazodone 50 to 150 mg is a common clinical practice to treat comorbid insomnia during antidepressant therapy, but published data are surprisingly limited when considered against the frequent usage of trazodone. Although there has been insufficient research on the use of atypical antipsychotic agents in severe insomnia, psychiatrists use quetiapine, olanzapine, or other agents to lessen agitation that disrupts sleep onset or maintenance. When insomnia or hypersomnia continues even as mood, anxiety, or thought disorders improve with standard therapy, the physician should consider the potential presence of underlying sleep disorders.
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Affiliation(s)
- Philip M Becker
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 5477 Glen Lakes Drive, #100, Dallas, TX 75234, USA.
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Insomnia Medications. J Nurse Pract 2006. [DOI: 10.1016/j.nurpra.2006.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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