Pharmacologic management of insomnia: past, present, and future

An Update on Assessment, Therapeutic Management, and Patents on Insomnia

Insomnia is an ordinary situation related to noticeable disability in function and quality of life, mental and actual sickness, and mishappenings. It represents more than 5.5 million appointments to family doctors every year. Nonetheless, the ratio of insomniacs who are treated keeps on being low, demonstrating the requirement for proceeding with advancement and dispersal of effective treatments. Accordingly, it becomes significant to provide a compelling treatment for clinical practice. It indicates a need for the determination of various critical viewpoints for the evaluation of insomnia along with various accessible alternatives for treatment. These alternatives incorporate both nonpharmacological therapy, specifically cognitive behavioural therapy for insomnia, and a number of pharmacological treatments like orexin antagonists, "z-drugs," benzodiazepines, selective histamine H1 antagonists, nonselective antihistamines, melatonin receptor agonists, antipsychotics, antidepressants, and anticonvulsants. Besides in individuals whose insomnia is due to restless leg syndrome, depression/mood disorder, or/and circadian disturbance, there is insignificant proof favouring the effectiveness of different prescriptions for the treatment of insomnia though they are widely used. Other pharmacological agents producing sedation should be prescribed with care for insomnia therapy because of greater risk of next-day sleepiness along with known adverse effects and toxicities. This review is also aimed at providing an update on various patents on dosage forms containing drugs for insomnia therapy.

Speed and trajectory of changes of insomnia symptoms during acute treatment with cognitive-behavioral therapy, singly and combined with medication

OBJECTIVES

To examine the speed and trajectory of changes in sleep/wake parameters during short-term treatment of insomnia with cognitive-behavioral therapy (CBT) alone versus CBT combined with medication; and to explore the relationship between early treatment response and post-treatment recovery status.

METHODS

Participants were 160 adults with insomnia (mean age, 50.3 years; 97 women, 63 men) who underwent a six-week course of CBT, singly or combined with 10 mg zolpidem nightly. The main dependent variables were sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and sleep quality, derived from sleep diaries completed daily by patients throughout the course of treatment.

RESULTS

Participants treated with CBT plus medication exhibited faster sleep improvements as evidenced by the first week of treatment compared to those receiving CBT alone. Optimal sleep improvement was reached on average after only one week for the combined treatment compared to two to three weeks for CBT alone. Early treatment response did not reliably predict post-treatment recovery status.

CONCLUSIONS

Adding medication to CBT produces faster sleep improvement than CBT alone. However, the magnitude of early treatment response is not predictive of final response after the six-week therapy. Additional research is needed to examine mechanisms involved in this early treatment augmentation effect and its impact on long-term outcome.

Methods for the analysis of nonbenzodiazepine hypnotic drugs in biological matrices

Zopiclone, zolpidem and zaleplon (Z-drugs) are nonbenzodiazepine hypnotic drugs that are used for the treatment of insomnia. These drugs were developed with the intent to overcome some disadvantages of benzodiazepines, such as dependence and next day sedation. In general, the nonbenzodiazepine hypnotic drugs are administered in oral doses daily and are widely biotransformed in the body. A large number of analytical methods based on chromatographic and electrophoretic techniques for the quantification of Z-drugs and their metabolites in biological matrices have been reported. In this review, the bioanalytical methods for Z-drugs were reviewed with the focus placed on sample preparation procedures and the separation techniques used. Furthermore, as these drugs are also reported as drugs of abuse or in drug-facilitated crime, screening methods that simultaneously cover these drugs and also other drugs of abuse were included in this review.

Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in primary care, although it is often underrecognized and undertreated. GAD is chronic, disabling, and associated with other health problems. Treatment response is often unsatisfactory, but the clinical evidence base for new treatments has expanded substantially in the past decade and suggests a growing range of options for reducing the burden of GAD. The objective of this article was to review current literature on GAD and its management to provide an overview of the clinical importance of GAD in primary care and available treatments.

DATA SOURCES

Recent studies (ie, over the past decade) on the epidemiology and treatment of GAD were identified by searching Medline using the term generalized anxiety disorder only and in combination with the terms epidemiology and treatment and for each drug class (benzodiazepines, azapirones, antidepressants, antihistamines, alpha-2-delta ligands, and antipsychotics) and for named drugs (buspirone, venlafaxine, duloxetine, fluoxetine, escitalopram, olanzapine, paroxetine, pregabalin, quetiapine, and risperidone in addition to psychological therapies and cognitive-behavioral therapy. The literature search was conducted in August 2008 for the period 1987-2009.

STUDY SELECTION

Studies were included if judged to be relevant to a review of the epidemiology and management of GAD. Articles were excluded if they were not written in English or were published more than 10 years before the literature search was conducted. A few older studies were included for which more recent research evidence was not available. Recent national and international guidelines for the management of GAD were also reviewed.

DATA EXTRACTION/SYNTHESIS

Most currently available interventions have similar overall efficacy, and treatment choices should reflect the situation of individual patients. Important unmet needs exist for treatments (1) that work rapidly, with (2) broad spectrum benefits, (3) that can improve rates of remission and well-being, (4) are devoid of risk for withdrawal symptoms, and (5) have few if any adverse interactions with other drugs. Additional needs include (6) safer drugs for the elderly, (7) safe and effective drugs for children with GAD, (8) further evaluation of psychotherapy, and (9) understanding the appropriate circumstances for, and optimal choices of, drug combination.

CONCLUSION

While the development of novel treatments evolves, current management approaches can focus on improving identification and defining optimal use of available therapies for GAD.

Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial

CONTEXT

Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome.

OBJECTIVES

To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome.

DESIGN, SETTING, AND PATIENTS

Prospective, randomized controlled trial involving 2-stage therapy for 160 adults with persistent insomnia treated at a university hospital sleep center in Canada between January 2002 and April 2005.

INTERVENTIONS

Participants received CBT alone or CBT plus 10 mg/d (taken at bedtime) of zolpidem for an initial 6-week therapy, followed by extended 6-month therapy. Patients initially treated with CBT attended monthly maintenance CBT for 6 months or received no additional treatment and those initially treated with combined therapy (CBT plus 10 mg/d of zolpidem) continued with CBT plus intermittent use of zolpidem or CBT only.

MAIN OUTCOME MEASURES

Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary outcomes); treatment response and remission rates derived from the Insomnia Severity Index (secondary outcomes).

RESULTS

Cognitive behavioral therapy used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P<.001); a larger increase of sleep time was obtained with the combined approach (P = .04). Both CBT alone and CBT plus zolpidem produced similar rates of treatment responders (60% [45/75] vs 61% [45/74], respectively; P = .84) and treatment remissions (39% [29/75] vs 44% [33/74], respectively; P = .52) with the 6-week acute treatment, but combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P = .05). The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the 6-month follow-up compared with patients who continued to take zolpidem during extended therapy (68% [20/30] vs 42% [12/29]; P = .04).

CONCLUSION

In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00042146.

Sleep disorders and medical conditions in women. Proceedings of the Women & Sleep Workshop, National Sleep Foundation, Washington, DC, March 5-6, 2007

Sleep disorders affect women differently than they affect men and may have different manifestations and prevalences. With regard to obstructive sleep apnea (OSA), variations in symptoms may cause misdiagnoses and delay of appropriate treatment. The prevalence of OSA appears to increase markedly after the time of menopause. Although OSA as defined by the numbers of apneas/hypopneas may be less severe in women, its consequences are similar and perhaps worse. Therapeutic issues related to gender should be factored into the management of OSA. The prevalence of insomnia is significantly greater in women than in men throughout most of the life span. The ratio of insomnia in women to men is approximately 1.4:1.0, but the difference is minimal before puberty and increases steadily with age. Although much of the higher prevalence of insomnia in women may be attributable to the hormonal or psychological changes associated with major life transitions, some of the gender differences may result from the higher prevalence of depression and pain in women. Insomnia's negative impact on quality of life is important to address in women, given the high relative prevalence of insomnia as well as the comorbid disorders in this population. Gender differences in etiology and symptom manifestation in narcolepsy remain understudied in humans. There is little available scientific information to evaluate the clinical significance and specific consequences of the diagnosis of narcolepsy in women. Restless legs syndrome (RLS) is characterized by an urge to move the legs or other limbs during periods of rest or inactivity and may affect as much as 10% of the population. This condition is more likely to afflict women than men, and its risk is increased by pregnancy. Although RLS is associated with impaired quality of life, highly effective treatment is available.

Sleep in hospitalized medical patients, part 2: behavioral and pharmacological management of sleep disturbances

BACKGROUND

As described in Part 1 of this article, multiple factors lead to disrupted sleep in hospitalized medical patients. Recognizing and addressing these factors can help clinicians more effectively manage patients' sleep complaints.

METHODS

A PubMed search was conducted by cross-referencing the terms "sleep deprivation," "insomnia," and "sleep"; "hospitalized," "acutely ill," and "critically ill"; and "medication," "drugs," "hypnotics," "benzodiazepines," and "sedatives." The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search.

RESULTS

Few articles addressed the topic of the assessment and management of sleep problems in hospitalized medical patients. In Part 2, we propose an evaluation and treatment algorithm that includes recommendations regarding the use of nonpharmacologic and pharmacologic therapies as clinicians consider relevant clinical data. The algorithm is accompanied by 5 tables that include pertinent and practical information to assist clinicians as they manage their inpatients' sleep complaints.

CONCLUSIONS

Assessment of a sleep complaint should include a review of factors that could exacerbate patients' sleep. The treatment could then focus on ameliorating these factors, and the judicious use of nonpharmacologic strategies and psychopharmacologic agents.