Doxepin for insomnia: A systematic review of randomized placebo-controlled trials

Sleep Disturbance and Perimenopause: A Narrative Review

Background/Objectives: Perimenopause, impacting 80-90% of women, encompasses a range of vasomotor, urogenital, cognitive, and psychiatric symptoms associated with the fluctuation and gradual reduction of gonadal hormones. Moreover, the onset or worsening of sleep disturbances is prevalent during the menopausal transition. This narrative review seeks to elucidate the pathogenetic processes behind sleep disturbances during perimenopause and the main therapeutic options. Methods: The electronic databases PubMed, Scopus, Google Scholar, Web of Science, and Embase were queried for publications up to May 2024. Longitudinal, observational, case-control, and cross-sectional studies, as well as reviews and meta-analyses, were included in the review in order to explore the prevalence of sleep disorders during perimenopause, the pathogenetic mechanisms underlying the association between menopausal transition and sleep disorders, and the available non-pharmacological and pharmacological treatment options. Results: Sleep disturbances are common among perimenopausal women and include insomnia, sleep-related breathing disorders, and movement disorders. Fluctuations in estrogen and progesterone affect sleep quality, while vasomotor symptoms can disrupt sleep. Circadian changes, decreased melatonin production, and physiological changes associated with aging and mood disorders further exacerbate sleep disturbances. Conclusions: Managing sleep disorders in perimenopause requires an individualized approach, considering the multifactorial nature of these disturbances and providing background knowledge about the relationship between reproductive hormonal changes and sleep. Non-pharmacological treatments should be considered the first-line therapy; hormone therapy or non-hormonal pharmacological treatments can be considered according to the patients' specific needs and risk factors. However, there is still a lack of standards on the appropriate management and treatment of sleep disorders in perimenopause.

Rice bran as a potent ingredient: unveiling its potential for value-added applications

Rice bran production significantly contributes to global environmental deterioration, yet its potential remains underutilized. This review discusses the nutritional composition, bioactive compounds, health benefits, limitations, and potential application of rice bran in both food and non-food sectors. While minor variations exist between pigmented and non-pigmented rice bran, the former is abundant in phytochemicals, which offer therapeutic benefits. The primary limitations hindering rice bran's food application include rancidity, toxic heavy metals, and antinutrients. Effective stabilization is crucial to extend rice bran's shelf life. Despite these challenges, rice bran holds significant potential for value-added products. Hence, its rich composition and diverse applications underscore its importance as a valuable resource for sustainable production practices.

A selective photoinduced radical O-alkenylation of phenols and naphthols with terminal alkynes

The visible light-promoted O-alkenylation of phenols and naphthols with terminal alkynes is achieved using 2,4,6-tris(4-fluorophenyl)pyrylium tetrafluoroborate (T(p-F)PPT) as a photocatalyst at room temperature without the need of any external ligand or additive. Apart from its excellent functional group tolerance, the protocol described herein represents an appealing alternative strategy to classical transition-metal catalysed hydroarylation reactions. Mechanistic investigations revealed that the reaction involves a radical pathway. The utility of the hydroarylated products for the synthesis of fused benzofurans via a one-pot annulation was also demonstrated. Herein, we report the first intermolecular radical hydroarylation of alkynes.

Insomnia-related rodent models in drug discovery

Despite the widespread prevalence and important medical impact of insomnia, effective agents with few side effects are lacking in clinics. This is most likely due to relatively poor understanding of the etiology and pathophysiology of insomnia, and the lack of appropriate animal models for screening new compounds. As the main homeostatic, circadian, and neurochemical modulations of sleep remain essentially similar between humans and rodents, rodent models are often used to elucidate the mechanisms of insomnia and to develop novel therapeutic targets. In this article, we focus on several rodent models of insomnia induced by stress, diseases, drugs, disruption of the circadian clock, and other means such as genetic manipulation of specific neuronal activity, respectively, which could be used to screen for novel hypnotics. Moreover, important advantages and constraints of some animal models are discussed. Finally, this review highlights that the rodent models of insomnia may play a crucial role in novel drug development to optimize the management of insomnia.

Comparative short-term safety and efficacy of hypnotics: A quantitative risk-benefit analysis

Several professional societies have provided recommendations for prescribing medications for insomnia. None has provided an integrative analysis that concurrently quantifies safety and efficacy (e.g., risk-benefit ratios). This represents an important gap for informing clinician decision-making. Accordingly, the aim of the present review is to provide such an analysis for five classes of sleep-promoting medications. Adverse event data values were extracted from the most recent FDA-approved package inserts and converted to an integer before being placebo-adjusted and standardized as a rate per 1000 (AEr). Efficacy data, pre-to-post self-reported data for active and placebo conditions were acquired from pivotal trials identified in "white papers" and systematic reviews/meta-analyses. Weighted effect sizes were calculated for subjective sleep latency, wake time after sleep onset and total sleep time, and then were averaged by medication class for each sleep continuity variable. Overall efficacy was represented by a single variable, SWT (sleep latency + wake time after sleep onset + total sleep time). Risk-benefit was represented using a simple ratio value. For safety, it was found that melatonin receptor agonists had the lowest adverse event rate (AEr = 43.1), and non-benzodiazepine benzodiazepine receptor agonists had the highest rate (AEr = 255.0). For efficacy, it was found that the pre-to-post placebo adjusted effect sizes were largest for benzodiazepines (effect size = 1.94) and smallest for melatonin receptor agonists (effect size = 0.109). For risk-benefit, histamine antagonist had the most favourable profile (risk-benefit = 69.5), while melatonin receptor agonist had the least favourable profile (risk-benefit = 395.7). Overall, the combined metric for risk-benefit suggests that treatment with a histamine antagonist is optimal and potentially represents the best first-line therapy for the medical management of insomnia.

The cardiovascular safety of tricyclic antidepressants in overdose and in clinical use

Tricyclic antidepressants (TCAs) remain widely prescribed for depression and many other conditions. There may be important differences between individual TCA in regard to their overdose toxicity and their cardiac toxicity in clinical use. We conducted a systematic review to compare the toxicity of individual TCA in overdose and the risk of serious adverse cardiac events occurring with therapeutic doses. We used the fatal toxicity index (FTI) and case fatality ratio as markers of fatality in overdose, and hazard ratios or odds ratios for the risk of cardiovascular adverse events during normal clinical use. In all, 30 reports of mortality in overdose and 14 observational studies assessing the risk of cardiovascular adverse events in clinical use were included. FTI values were of the same order of magnitude (101-102) for all TCAs except lofepramine. Desipramine appears to be somewhat more likely than other TCAs to lead to death in overdose. Amitriptyline, clomipramine, dothiepin/dosulepin, doxepin, trimipramine and imipramine showed broadly similar toxicity and were usually reported to be less toxic than desipramine. Data on nortriptyline were contradictory. Lofepramine had the lowest risk of death in overdose. The rank order of overdose toxicity was broadly consistent between different FTI definitions and between markers used. With respect to the risk of cardiovascular events at clinically relevant exposure, amitriptyline, nortriptyline and lofepramine were associated with a greater risk of in-use cardiotoxicity. All measures of overdose toxicity were subject to external influences and confounding. The continued use of TCAs in depression and other conditions should be minimized when considering their undoubted toxicity in overdose and possible toxicity in normal clinical use.

Doxepin is more effective than zolpidem in improving executive function in patients with insomnia disorder

BACKGROUND : Insomnia disorder is associated with an impairment in cognitive performance. Doxepin and zolpidem have been found to be effective in improving sleep. In this study, we aimed to compare the effects of doxepin and zolpidem on sleep structure and executive function in patients with insomnia disorder.

METHODS

Patients with primary insomnia were randomly assigned to receive doxepin 6 mg/day orally or zolpidem 5-10 mg/day orally. Polysomnography (PSG) and the Pittsburgh Sleep Quality Index (PSQI) were used at baseline and after the 8-week treatment to compare clinical efficacy in the two groups. Safety was assessed using the Treatment Emergent Symptom Scale (TESS). Executive function was evaluated using the Wisconsin sorting card test (WSCT).

RESULTS

Of 120 patients enrolled in the study, 60 participants were assigned to each group. A total of 109 participants (53 in the doxepin group and 56 in the zolpidem group) completed the study. After treatment, the wake after sleep onset (WASO) and total sleep time (TST) values in the doxepin group were 80.3 ± 21.4 min and 378.9 ± 21.9 min, respectively, which were significantly better than those in the zolpidem group (132.9 ± 26.5 min and 333.2 ± 24.2 min, respectively; (P < 0.05)). The sleep onset latency (SOL) value in the zolpidem group (20.3 ± 4.7 min) was significantly better than that in the doxepin group (28.2 ± 5.6 min; P < 0.05). The sleep efficiency (SE) in the doxepin group was 77.8 ± 4.2%, which was significantly better than that in the zolpidem group (68.6 ± 5.0%; P < 0.05). The PSQI score of the doxepin group was 6.1 ± 1.1, which was significantly lower than that in the zolpidem group (7.9 ± 1.9; P < 0.05). The treatment adverse events in the doxepin group was 23.3%, which was significantly higher than that in the zolpidem group (13.3%; P < 0.05). The WSCT showed a significant improvement in persistent errors (PE), random errors (RE), and categories in the two groups after 8-week treatment, and the improvement in RE and the categories was more obvious in the doxepin group (P < 0.05).

CONCLUSIONS

Both doxepin and zolpidem were found to be effective in improving sleep quality, but the effects exhibited different patterns. Doxepin improved executive function more effectively than zolpidem in patients with insomnia disorder.

Insomnia in Postmenopausal Women: How to Approach and Treat It?

Insomnia is one of the major complaints of menopausal women with advancing age and may be complexly related to a variety of causes. However, there is still a lack of standards on the general approach and treatment for insomnia in menopausal women. The aim of this review is to summarize recent pathogenic theories of sleep disturbance in the menopausal period and discuss the approach and management of insomnia in postmenopausal women. Sleep disturbances in menopausal women may be associated with physical and psychiatric factors and other comorbid diseases. Careful history taking and multidisciplinary physical and psychosocial evaluation are necessary and, in particular, comorbidities related to sleep disorders, such as obstructive sleep apnea, must be taken into consideration. A unique aspect of insomnia in postmenopausal women is that menopausal symptoms due to hormonal decline can be closely related to sleep disturbances. Therefore, menopausal hormone therapy (MHT) should be considered as the treatment of choice among pharmacological treatments following cognitive behavioral therapy, which is suggested as the first-line treatment in the general population insomnia treatment guidelines. Additionally, melatonin and 5HT-based drugs, which have fewer side effects, along with MHT should be preferentially recommended in menopausal women.

Insomnia and related mental health conditions: Essential neurobiological underpinnings towards reduced polypharmacy utilization rates

Insomnia represents a significant public health burden, with a 10% prevalence in the general population. Reduced sleep affects social and working functioning, productivity, and patient's quality of life, leading to a total of $100 billion per year in direct and indirect healthcare costs. Primary insomnia is unrelated to any other mental or medical illness; secondary insomnia co-occurs with other underlying medical, iatrogenic, or mental conditions. Epidemiological studies found a 40-50% comorbidity prevalence between insomnia and psychiatric disorders, suggesting a high relevance of mental health in insomniacs. Sleep disturbances also worsen the outcomes of several psychiatric disorders, leading to more severe psychopathology and incomplete remission, plausibly contributing to treatment-resistant conditions. Insomnia and psychiatric disorder coexistence can lead to polypharmacy, namely, the concurrent use of two or more medications in the same patient, regardless of their purpose or rationale. Polypharmacy increases the risk of using unnecessary drugs, the likelihood of drug interactions and adverse events, and reduces the patient's compliance due to regimen complexity. The workup of insomnia must consider the patient's sleep habits and inquire about any medical and mental concurrent conditions that must be handled to allow insomnia to be remitted adequately. Monotherapy or limited polypharmacy should be preferred, especially in case of multiple comorbidities, promoting multipurpose molecules with sedative properties and with bedtime administration. Also, non-pharmacological interventions for insomnia, such as sleep hygiene, relaxation training and Cognitive Behavioral Therapy may be useful in secondary insomnia to confront behaviors and thoughts contributing to insomnia and help optimizing the pharmacotherapy. However, insomnia therapy should always be patient-tailored, considering drug indications, contraindications, and pharmacokinetics, besides insomnia phenotype, clinical picture, patient preferences, and side effect profile.

Sleep and Circadian Disturbances in Children With Neurodevelopmental Disorders

Sleep problems are highly prevalent in those with neurodevelopmental disorders (NDDs). We propose this is secondary to multiple factors that directly and indirectly negatively impact sleep and circadian processes in those with NDDs, which in turn, further perturbs development, resulting in a "developmental and sleep/circadian-related encephalopathy." In this review, we discuss select NDDs with known or suspected sleep and circadian phenotypes. We also highlight important considerations when evaluating and treating sleep and circadian disorders in these populations.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

Insomnia

OBJECTIVE

This article provides an overview of the current definitions, diagnostic tools, and overall management of insomnia.

LATEST DEVELOPMENTS

The treatment of insomnia has shifted over time, with a growing emphasis on nonpharmacologic therapies as a first-line intervention and the leveraging of technology to aid in the dissemination of these therapies. With this evolution, the definition of insomnia has changed to reflect a common treatment pathway. As pharmacologic treatment options have increased, so has concern about the dangerous short-term and long-term adverse effects of these treatment options.

ESSENTIAL POINTS

Insomnia is a common disorder, frequently overlapping with other neurologic and psychiatric disorders, which can cause significant distress and disruption to patients' lives. Nonpharmacologic therapies are highly effective and are now considered first-line treatments. Although efficacy is variable, numerous pharmacologic interventions are available, and many options come with considerable concern about adverse effects, particularly in populations over 65 years old.

Should Trazodone Be First-Line Therapy for Insomnia? A Clinical Suitability Appraisal

Trazodone is one of the most commonly used prescription medications for insomnia; however, some recent clinical guidelines do not recommend its use for treating insomnia. This clinical appraisal critically reviews the scientific literature on trazodone as a first-line treatment for insomnia, with the focus statement "Trazodone should never be used as a first-line medication for insomnia." In addition, field surveys were sent to practicing physicians, psychiatrists, and sleep specialists to assess general support for this statement. Subsequently, a meeting with a seven-member panel of key opinion leaders was held to discuss published evidence in support and against the statement. This paper reports on the evidence review, the panel discussion, and the panel's and healthcare professionals' ratings of the statement's acceptability. While the majority of field survey responders disagreed with the statement, the majority of panel members agreed with the statement based on the limited published evidence supporting trazodone as a first-line agent as they understood the term "first-line agent".

Inhibition of Microglial Activation by Amitriptyline and Doxepin in Interferon-β Pre-Treated Astrocyte–Microglia Co-Culture Model of Inflammation

Depression may occur in patients with multiple sclerosis, especially during interferon-β (IFN-β) treatment, and therapy with antidepressants may be necessary. Interactions of IFN-β with antidepressants concerning glia-mediated inflammation have not yet been studied. Primary rat co-cultures of astrocytes containing 5% (M5, consistent with “physiological” conditions) or 30% (M30, consistent with “pathological, inflammatory” conditions) of microglia were incubated with 10 ng/mL amitriptyline or doxepin for 2 h, or with 2000 U/mL IFN-β for 22 h. To investigate the effects of antidepressants on IFN-β treatment, amitriptyline or doxepin was added to IFN-β pre-treated co-cultures. An MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay was performed to measure the glial cell viability, immunocytochemistry was performed to evaluate the microglial activation state, and ELISA was performed to measure pro-inflammatory TNF-α and IL-6 cytokine concentrations. Incubation of inflammatory astrocyte–microglia co-cultures with amitriptyline, doxepin or IFN-β alone, or co-incubation of IFN-β pre-treated co-cultures with both antidepressants, significantly reduced the extent of inflammation, with the inhibition of microglial activation. TNF-α and IL-6 levels were not affected. Accordingly, the two antidepressants did not interfere with the anti-inflammatory effect of IFN-β on astrocytes and microglia. Furthermore, no cytotoxic effects on glial cells were observed. This is the first in vitro study offering novel perspectives in IFN-β treatment and accompanying depression regarding glia.

Odevixibat: A Review of a Bioactive Compound for the Treatment of Pruritus Approved by the FDA

Odevixibat is synthesized through chemical modification of Benzothiazepine's structure. It is a tiny chemical that inhibits the ileal bile acid transporter and is used to treat a variety of cholestatic illnesses, including progressive familial intrahepatic cholestasis (PFIC). For cholestatic pruritus and liver disease development, bile acid transporter inhibition is a unique treatment strategy. Odevixibat reduces enteric bile acid reuptake. Oral odevixibat was also studied in children with cholestatic liver disease. Odevixibat received its first approval in the European Union (EU) in July 2021 for the treatment of PFIC in patients aged 6 months, followed by approval in the USA in August 2021 for the treatment of pruritus in PFIC patients aged 3 months. Bile acids in the distal ileum can be reabsorbed by the ileal sodium/bile acid cotransporter, a transport glycoprotein. Odevixibat is a sodium/bile acid co-transporter reversible inhibitor. An average 3 mg once-daily dose of odevixibat for a week resulted in a 56% reduction in the area under the curve of bile acid. A daily dose of 1.5 mg resulted in a 43% decrease in the area under the curve for bile acid. Odevixibat is also being evaluated in many countries for the treatment of other cholestatic illnesses, including Alagille syndrome and biliary atresia. This article reviews the updated information on odevixibat with respect to its clinical pharmacology, mechanism of action, pharmacokinetics, pharmacodynamics, metabolism, drug-drug interactions, pre-clinical studies, and clinical trials.

The Relationship Between 5-Hydroxytryptamine and Its Metabolite Changes With Post-stroke Depression

Post-stroke depression (PSD) is the most common and serious sequelae of stroke. Approximately 33% of stroke survivors were affected by PSD. However, many issues (e.g., incidence, diagnostic marker, and risk factor) related to PSD remained unclear. The "monoamine hypothesis" is a significant hypothesis for depression, which suggests that three monoamines play a key role in depression. Therefore, most current antidepressants are developed to modulate the monoamines on PSD treatment, and these antidepressants have good effects on patients with PSD. However, the potential mechanisms of three monoamines in PSD are still unclear. Previously, we proposed "three primary emotions," which suggested a new model of basic emotions based on the three monoamines. It may provide a new way for PSD treatment. In addition, recent studies have found that monoamine-related emotional intervention also showed potential effects in the treatment and prevention of PSD. This study discusses these issues and attempts to provide a prospect for future research on PSD.

Histamine and histamine receptors: Roles in major depressive disorder

Although the incidence of major depressive disorder (MDD) is high and its social impact is great, we still know very little about the pathophysiology of depression. The monoamine hypothesis of depression suggests that 5-HT, NE, and DA synergistically affect mood, which is the basis of current drug therapy for depression. However, histamine as a monoamine transmitter is rarely studied. Our review is the first time to illustrate the effect of histaminergic system on depression in order to find the way for the development of new antidepressant drugs. The brain neurotransmitter histamine is involved in MDD, and the brain histaminergic system operates through four receptors. Histamine and its receptors can also regulate the immune response to improve symptoms of depression. In addition, H3R can interact with other depression-related transmitters (including 5-HT, DA, GLU, and MCH); thus, histamine may participate in the occurrence of depression through other neural circuits. Notably, in rodent studies, several H3R and H1R antagonists were found to be safe and effective in alleviating depression-like behavior. To highlight the complex functions of histamine in depression, and reveals that histamine receptors can be used as new targets for antidepressant therapy.

Sleep Problems in Chronic Inflammatory Diseases: Prevalence, Treatment, and New Perspectives: A Narrative Review

Epidemiological studies have shown that individuals with sleep problems are at a greater risk of developing immune and chronic inflammatory diseases. As sleep disorders and low sleep quality in the general population are frequent ailments, it seems important to recognize them as serious public health problems. The exact relation between immunity and sleep remains elusive; however, it might be suspected that it is shaped by others stress and alterations of the circadian rhythm (commonly caused by for example shift work). As studies show, drugs used in the therapy of chronic inflammatory diseases, such as steroids or monoclonal antibodies, also influence sleep in more complex ways than those resulting from attenuation of the disease symptoms. Interestingly, the relation between sleep and immunity appears to be bidirectional; that is, sleep may influence the course of immune diseases, such as inflammatory bowel disease. Thus, proper diagnosis and treatment of sleep disorders are vital to the patient's immune status and, in effect, health. This review examines the epidemiology of sleep disorders and immune diseases, the associations between them, and their current treatment and novel perspectives in therapy.

Doxepin prevents the Expression and Development of Paclitaxel-Induced Neuropathic Pain

BACKGROUND

Peripheral neurotoxicity is a common side effect of many anticancer chemotherapy drugs, including paclitaxel. Peripheral neurotoxicity may present as changes in sensory function and mild paresthesia that, in turn, can lead to alleviation of the prescribed dose of the medication. The aim of this study was to evaluate the effectiveness of acute and chronic doxepin administration on development and expression of neuropathic pain during the treatment of cancer with paclitaxel.

MATERIALS AND METHODS

Neuropathic pain was induced in mice by paclitaxel (2 mg/kg, intraperitoneally [i.p.,] once daily from day 1 to day 5) that caused mechanical and cold allodynia. Doxepin was administrated every day from day 6 to 10 (10 and 15 mg/kg i.p.). Mechanical and cold allodynia was evaluated on day 11 of the experiment in both the test and the control group.

RESULTS

Daily administration of doxepin (2.5, 5, and 10 mg/kg i.p.) from day 1 to 5 significantly inhibited the development of cold and mechanical allodynia. As well doxepin administration (5 and 10 mg/kg i.p.) from the 6th day, to 10th day significantly inhibited cold and mechanical allodynia expression. To address the concerns associated with the effectiveness of chemotherapy agents on the tumor, we evaluated paclitaxel cytotoxicity effect in combination with doxepin. Our observations indicate that doxepin even at high concentrations (1 and 10 μg/ml) does not interfere with the cytotoxic effect of paclitaxel (0.05 μg/ml).

CONCLUSIONS

These results indicate that doxepin, when administered during chemotherapy, can prevent the development and expression of paclitaxel-induced neuropathic pain.

Changes in histaminergic system in neuropsychiatric disorders and the potential treatment consequences

In contrast to that of other monoamine neurotransmitters, the association of the histaminergic system with neuropsychiatric disorders is not well documented. In the last two decades, several clinical studies involved in the development of drugs targeting the histaminergic system have been reported. These include the H3R-antagonist/inverse agonist, pitolisant, used for the treatment of excessive sleepiness in narcolepsy, and the H1R antagonist, doxepin, used to alleviate symptoms of insomnia. The current review summarizes reports from animal models, including genetic and neuroimaging studies, as well as human brain samples and cerebrospinal fluid measurements from clinical trials, on the possible role of the histaminergic system in neuropsychiatric disorders. These studies will potentially pave the way for novel histamine-related therapeutic strategies.

Sleep Disorders and Mood, Anxiety, and Post-Traumatic Stress Disorders: Overview of Clinical Treatments in the Context of Sleep Disturbances

Sleep disruptions are frequently reported by persons with mood, anxiety, and post-traumatic stress disorders, and co-occur with psychiatric disorders. There is evidence that sleep disorders can predict the likelihood of developing a future psychiatric disorder and exacerbate existing symptoms. Understanding the inter-relationships between sleep and psychiatric disorders is important. The primary goals of this article are to describe the interactions between psychiatric and sleep disorders in the context of sleep disturbances, underscore the bidirectional effects of mental health treatments on sleep disorder outcomes, and provide general recommendations to optimize treatment in the context of sleep disturbances.

The effect of melatonin on sleep quality and insomnia in patients with cancer: a systematic review study

BACKGROUND

Considering the importance of sleep in the treatment success and quality of life in patients with cancer, it is necessary to seek effective solutions to improve their sleep quality. In this regard, a comprehensive review of the effect of melatonin on sleep can be very useful to provide an evidence-based clinical guide. Therefore, the aim of the present systematic review was to investigate effect of melatonin on sleep quality and insomnia in patients with cancer.

METHODS

The present systematic review was conducted in 2021. To find evidence related to the study objective, Iranian databases (SID, Magiran) and international databases (Google scholar, Web of Science, ProQuest, Medline via PubMed, Scopus) were searched using specified keywords (Melatonin, Sleep, insomnia, Cancer, Neoplasms, Carcinomas, Tumor, Carcinomatosis, Carcinomatoses, Sarcomas) from the beginning of the establishment of the mentioned databases until 31st December of 2020. After primary and secondary screening, and selection of studies according to inclusion and exclusion criteria, information obtained from studies were extracted in a checklist with items such as author (year), study design, sample size, age, melatonin dose, duration of intervention, results, and conclusion.

RESULTS

From 295 articles found, finally six relevant studies entered the review process. The intervention used in the studies included oral melatonin administration. The minimum and maximum dose of melatonin was 3 mg and 20 mg, respectively, which was taken by patients for 10 days and to four months, usually every night before bedtime in studies. The results of the review showed that melatonin had a significant effect on sleep quality and insomnia in four studies. However, two studies showed no significant improvement on sleep quality after the intervention and melatonin administration, although melatonin had significant effect on increasing sleep efficiency in the short term.

CONCLUSIONS

The present review study showed that melatonin may be effective in improving sleep quality and insomnia in patients with cancer. It is suggested to carry out further extensive and detailed studies to achieve the most effective and safest method of melatonin administration in terms of dose and duration of use in order to improve sleep quality among patients with cancer.

Longitudinal Evaluation of the Effect of Tricyclic Antidepressants and Neuroleptics on the Course of Huntington's Disease-Data from a Real World Cohort

Background: Reducing the progress of neurodegeneration is a key goal in Huntington´s disease (HD). A previously performed systematic screening for medications with neuroprotective features identified tricyclic antidepressants and neuroleptics as neuroprotective and mitochondrioprotective agents. Here, we analyzed the characteristics of disease manifestation, progression and potential beneficial effects in HD patients treated with afore-mentioned medications compared to un- and otherwise treated motor-manifest patients in a large real-world cohort over two years. Methods: We analyzed cross-sectional data of the largest cohort worldwide of motor-manifest HD patients using the ENROLL-HD database, including demographic, moleculargenetic, clinical-motoric, cognitive and functional data. Longitudinal data of up to two years were obtained to analyze potential effects on disease progression between groups with different medications used. Data were analyzed using repeated ANOVA-analyses while controlling for the co-variates age and CAG-repeat length. Results: We identified n = 7397 motor-manifest HD patients using no or different medication (HD-ctrl) and subgroups treated with clomipramine (n = 56), clozapine (n = 66), chlorpromazine (n = 17), doxepine (n = 34) and desi-, imi- or trimipramine (n = 19). Demographic parameters, disease onset and CAP-score did not differ. Total motor scores (TMS) at baseline were higher in patients treated with clozapine (p < 0.001), chlorpromazine and clomipramine (p < 0.05) compared to HD-ctrl with higher sub scores for bradykinesia (all p < 0.01) and dystonia in clozapine treated patients (p < 0.001). Functional and cognitive capacities were worse in medication groups in comparison to HD-ctrl at baseline (p < 0.001). Repeated measures analysis of variance documented no differences regarding motoric, functional and cognitive disease progressions between groups. Conclusions: We identified group differences, potentially caused by side effects or potential selection bias in terms of bradykinetic motoric symptoms, more dystonia and lower functional and cognitive performance in some treatment groups at baseline, which were not entirely explained because of underlying fundamental characteristics. Disease progression regarding clinical, functional and cognitive outcomes over two years was not affected by any of the treatment groups compared to HD-ctrl. Our data do not support our hypothesis of a potential neuroprotective effect of these drugs on disease progression.

Pharmacological Management of Insomnia

Insomnia is a highly prevalent condition associated with significant morbidity, reduction in quality of life, and increase in healthcare costs, and is a risk factor for multiple physical and mental disorders. The primary treatment modality is cognitive behavioral therapy for insomnia (CBT-I) but this is associated with difficulties with access and higher cost as well as poor response in some patients. Therefore, pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States. Older medications for insomnia are limited by their side effect burden and narrow therapeutic window. Newer hypnotics, on the other hand, have been shown to have a better safety profile and longer term efficacy. While some studies have shown that long-term hypnotic use is associated with adverse outcomes, the current evidence is equivocal. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations. This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles. This review also provides guidance on long-term management of hypnotics and the use of these medications in the elderly, those with medical comorbidities, and other special populations.

Korean Clinical Practice Guideline for the Diagnosis and Treatment of Insomnia in Adults

OBJECTIVE

We aim to present a clinical guideline for the diagnosis and treatment of insomnia in adults by reviewing and integrating existing clinical guidelines. The purpose of this guideline is to assist clinicians who perform evidence-based insomnia treatment.

METHODS

We selected literature that may be appropriate for use in guideline development from evidence-based practice guidelines that have been issued by an academic or governmental institution within the last five years. The core question of this guideline was made in sentence form including Patient/Problem, Intervention, Comparison, Outcome (PICO) elements. After searching PubMed, EMBASE, and medical guideline issuing agencies, three guidelines were judged to be the most appropriately reviewed, up-to-date, and from trusted sources.

RESULTS

The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to evaluate the quality of the three clinical guidelines. The final outcome of the guideline development process is a total of 15 recommendations that report the strength of the recommendation, the quality of evidence, a summary of content, and considerations in applying the recommendation.

CONCLUSION

It is vital for clinical guidelines for insomnia to be developed and continually updated in order to provide more accurate evidence-based treatments to patients.

Repurposing Doxepin to Ameliorate Steatosis and Hyperglycemia by Activating FAM3A Signaling Pathway

Mitochondrial protein FAM3A suppresses hepatic gluconeogenesis and lipogenesis. This study aimed to screen drug(s) that activates FAM3A expression and evaluate its effect(s) on hyperglycemia and steatosis. Drug-repurposing methodology predicted that antidepressive drug doxepin was among the drugs that potentially activated FAM3A expression. Doxepin was further validated to stimulate the translocation of transcription factor HNF4α from the cytoplasm into the nucleus, where it promoted FAM3A transcription to enhance ATP synthesis, suppress gluconeogenesis, and reduce lipid deposition in hepatocytes. HNF4α antagonism or FAM3A deficiency blunted doxepin-induced suppression on gluconeogenesis and lipid deposition in hepatocytes. Doxepin administration attenuated hyperglycemia, steatosis, and obesity in obese diabetic mice with upregulated FAM3A expression in liver and brown adipose tissues (BAT). Notably, doxepin failed to correct dysregulated glucose and lipid metabolism in FAM3A-deficient mice fed on high-fat diet. Doxepin's effects on ATP production, Akt activation, gluconeogenesis, and lipogenesis repression were also blunted in FAM3A-deficient mouse livers. In conclusion, FAM3A is a therapeutic target for diabetes and steatosis. Antidepressive drug doxepin activates FAM3A signaling pathways in liver and BAT to improve hyperglycemia and steatosis of obese diabetic mice. Doxepin might be preferentially recommended as an antidepressive drug in potential treatment of patients with diabetes complicated with depression.

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions.

METHODS

In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

Doxepin in children and adolescents with symptoms of insomnia: a single-center experience

STUDY OBJECTIVES

Pediatric insomnia is a widespread problem and especially difficult to manage in children with neurodevelopmental disorders. There are currently no US Food and Drug Administration-approved medications to use once first-line therapy fails. The objective of this study was to evaluate the efficacy and tolerability of doxepin in pediatric patients.

METHODS

This is a retrospective single-center chart review of children and adolescents (2-17 years of age) whose sleep failed to improve with behavioral intervention and melatonin who were then trialed on doxepin. Treatment was initiated at a median starting dose of 2 mg and slowly escalated to a median maintenance dose of 10 mg. Improvement in sleep was recorded using a 4-point Likert scale reported by parents on follow-up visits.

RESULTS

A total of 29 patients were included in the analysis. Mean follow-up duration was 6.5 ± 3.5 months. Of 29 patients, 4 (13.8%) patients discontinued doxepin because of lack of efficacy or side effects. Eight (27.6%) patients showed significant improvement of their insomnia, 8 (27.6%) showed moderate improvement, 10 (34.5%) showed mild improvement, and 3 (10.3%) showed minimal to no improvement on treatment with doxepin (P < .05) Only 2 patients (6.9%) experienced adverse effects in the form of behavioral side effects (aggression) and enuresis.

CONCLUSIONS

Results of our studies suggest that low-dose doxepin is both effective and well tolerated in pediatric patients with insomnia.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Insomnia in patients with schizophrenia: current understanding and treatment options

In patients with schizophrenia, insomnia is a common yet often overlooked comorbidity. With sleep disturbances inextricably linked to increased severity of schizophrenia and worsening clinical outcomes, insomnia is an important therapeutic target within this patient population. Thus, through a review of the current literature, this paper reiterates the important etiological link between these two conditions, while evaluating the safety, efficacy, and limitations of current therapeutic options for the treatment of comorbid insomnia in schizophrenia. Despite the continued use of benzodiazepine receptor agonists (BZRAs) for insomnia, the use of other therapies such as Cognitive Behavioral Therapy for Insomnia (CBT-I) and suvorexant warrants increased consideration. More large-scale clinical trials are needed to assess the efficacy of such therapeutic options in the schizophrenia patient population.

Genetic lesioning of histamine neurons increases sleep-wake fragmentation and reveals their contribution to modafinil-induced wakefulness

Acute chemogenetic inhibition of histamine (HA) neurons in adult mice induced nonrapid eye movement (NREM) sleep with an increased delta power. By contrast, selective genetic lesioning of HA neurons with caspase in adult mice exhibited a normal sleep-wake cycle overall, except at the diurnal start of the lights-off period, when they remained sleepier. The amount of time spent in NREM sleep and in the wake state in mice with lesioned HA neurons was unchanged over 24 hr, but the sleep-wake cycle was more fragmented. Both the delayed increase in wakefulness at the start of the night and the sleep-wake fragmentation are similar phenotypes to histidine decarboxylase knockout mice, which cannot synthesize HA. Chronic loss of HA neurons did not affect sleep homeostasis after sleep deprivation. However, the chronic loss of HA neurons or chemogenetic inhibition of HA neurons did notably reduce the ability of the wake-promoting compound modafinil to sustain wakefulness. Thus, part of modafinil's wake-promoting actions arise through the HA system.

Inhibitory Effect of Tricyclic Antidepressant Doxepin on Voltage-Dependent K+ Channels in Rabbit Coronary Arterial Smooth Muscle Cells

Doxepin, tricyclic antidepressant, is widely used for the treatment of depressive disorders. Our present study determined the inhibitory effect of doxepin on voltage-dependent K⁺ (Kv) channels in freshly isolated rabbit coronary arterial smooth muscle cells using a whole-cell patch clamp technique. Vascular Kv currents were inhibited by doxepin in a concentration-dependent manner, with a half-maximal inhibitory concentration (IC₅₀) value of 6.52 ± 1.35 μM and a Hill coefficient of 0.72 ± 0.03. Doxepin did not change the steady-state activation curve or inactivation curve, suggesting that doxepin does not alter the gating properties of Kv channels. Application of train pulses (1 or 2 Hz) slightly reduced the amplitude of Kv currents. However, the inhibition of Kv channels by train pulses were not changed in the presence of doxepin. Pretreatment with Kv1.5 inhibitor, DPO-1, effectively reduced the doxepin-induced inhibition of the Kv current. However, pretreatment with Kv2.1 inhibitor (guangxitoxin) or Kv7 inhibitor (linopirdine) did not change the inhibitory effect of doxepin on Kv currents. Inhibition of Kv channels by doxepin caused vasoconstriction and membrane depolarization. Therefore, our present study suggests that doxepin inhibits Kv channels in a concentration-dependent, but not use-, and state-dependent manners, irrespective of its own function.

Histamine and Delirium: Current Opinion

Delirium is a very common, but refractory clinical state, notably present in intensive care and in the growing aging community. It is characterized by fluctuating disturbances in a number of key behavioral features, namely cognition, mood, attention, arousal, and self-awareness. Histamine is arguably the most pleotropic neurotransmitter in the human brain, and this review provides a rationale, and proposes that this neuroactive amine plays a role in modulating the characteristic features of delirium. While centrally permeable H1 and H2 histamine receptor antagonists have pro-delirium potential, we propose that centrally permeable H3 histamine receptor antagonists may provide an exciting new strategy to combat delirium. The Histamine H4 receptor may also have an indirect inflammatory neuroglial role which requires further exploration.

Drug treatment strategies for insomnia in patients with post-traumatic stress disorder

INTRODUCTION

Insomnia is among the most reported sleep disturbances in patients with post-traumatic stress disorder (PTSD). The pervasiveness of this disorder among trauma-inflicted civilians and military personnel has been associated with reduced quality of life, impaired psychosocial functioning including cognitive impairments, negative mood swings, cardiovascular complications, and increased utilization of medical services.

AREAS COVERED

This review describes the current state of science with respect to the impact of the most dispensed pharmacological interventions for posttraumatic insomnia. At the present, there are no established treatment algorithms for PTSD-related insomnia. Pharmacotherapy offers an alternative treatment modality for patients with PTSD who fail or decline cognitive behavioral therapy (CBT). Selection of a hypnotic/sedative agent should be based on the patient's history, precipitating and perpetuating factors of insomnia, side effect profile, and potential medication-related interactions. Antipsychotics and benzodiazepines appear ineffective or are associated with significant harm in treating PTSD-related insomnia.

EXPERT OPINION

In the absence of randomized controlled trials, prescription patterns have been guided by anecdotal reports and expert opinion. Due to the complexity and multifactorial etiology of insomnia in PTSD, clinical investigations should examine available pharmacologic agents in comparative trials or in combination with CBT or complementary therapies to assess both short-term and long-term sleep outcomes in this population.

Effectiveness and safety of warm needle acupuncture on insomnia: Protocol for a systematic review and meta-analysis

BACKGROUND

Warm needle acupuncture (WNA) combines acupuncture and moxibustion, which is an integral part of the acupuncture therapy. Insomnia is a common sleep disorder, which affects sub-healthy people and patients with chronic disease. The clinical practice indicates that WNA has a therapeutic effect on insomnia. Here we will provide a protocol to explore the effectiveness and safety of WNA for insomnia.

METHODS

We will search the randomized controlled trails (RCT) literatures of WNA for insomnia in 9 electronic databases, including 5 English databases [PubMed, Web of Science, EMBASE, the Cochrane Central Register of Controlled Trials (Cochrane Library), and WHO International Clinical Trials Registry Platform (TCTRP)] and 4 Chinese databases [Chinese National Knowledge Infrastructure (CNKI), Chinese VIP Information, Wanfang Database, and Chinese Biomedical Literature Database (CBM)]. Sleep quality value of the patient will be considered as the primary outcome and the secondary outcome will include biochemical, indicators total scores on the insomnia severity index, quality of life, adverse events caused by WNA, and changes of symptom in Traditional Chinese Medicine. The selection of the studies will be performed by EndnoteX7 software. All analyses will be conducted by using RevMan software V5.3.

RESULT

This study will provide a rational synthesis of current evidences for warm needle acupuncture on insomnia.

CONCLUSION

The conclusion of this study will provide evidence to judge the effectiveness and safety of WNA on insomnia.

REGISTRATION

PROS-PERO CRD42018112645.

Aloysia citriodora Palau (lemon verbena) for insomnia patients: A randomized, double-blind, placebo-controlled clinical trial of efficacy and safety

Aloysia citriodora (A. citriodora) has a long history of traditional use for sedation and treatment of insomnia in different societies. This study was carried out to assess the efficacy of A. citriodora in patients with insomnia. One hundred patients were randomly divided into two groups of A. citriodora (total essential oil 1.66 mg/10 ml and total amount of flavonoid in terms of quercetin 3.22 mg/10 ml of the syrup) and placebo. They were advised to use 10 cc of the syrups; an hour before the bedtime for a period of 4 weeks. Participants were assessed using Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) questionnaires at the baseline and then 2 and 4 weeks after the enrollment. Mean scores of global PSQI and its four components including sleep latency, habitual sleep efficiency, daytime dysfunction, and subjective sleep quality and also ISI score in the A. citriodora group improved significantly after 4 weeks of treatment when compared with the placebo group (p < 0.001, for all of them). Also, improvement of global score of PSQI and ISI was observed in the intervention group as compared with the placebo group, 2 weeks after the enrollment (p < 0.001). The results of this study showed that oral intake of A. citriodora can be suggested as a complementary treatment for patients with insomnia.

Effects of resistance exercise training and stretching on chronic insomnia

Objective:

The aim of this study was to assess the effects of resistance exercise and stretching on sleep, mood, and quality of life in chronic insomnia patients.

Methods:

Three 4-month treatments included: resistance exercise (n=10), stretching (n=10), and control (n=8). Sleep was evaluated with polysomnography, actigraphy, and questionnaires. Mood and quality of life were assessed with the Profile of Mood States (POMS) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), respectively.

Results:

There were no significant treatment differences between resistance exercise and stretching. However, compared with the control treatment, resistance exercise and stretching led to significantly greater improvements in Insomnia Severity Index scores (-10.5±2.3, -8.1±2.0 vs. 2.3±1.8, respectively), and actigraphic measures of sleep latency (-7.1±4.6, -5.2±1.9 vs. 2.2±2.1 min), wake after sleep onset (-9.3±2.8, -7.1±3.0 vs. 3.6±4.2 min), and sleep efficiency (4.4±1.8, 5.0±0.8 vs. -2.3±2%). Pittsburgh Sleep Quality Index (PSQI) global scores (-5.3±0.8, -3.9±1.5 vs. -0.1±0.8) and sleep duration (1.2±0.3, 1.6±0.6 vs. -0.1±0.2 h) also improved following both experimental treatments compared with control. PSQI-Sleep efficiency increased after resistance exercise compared with control (19.5±3.9 vs. 2.1±4.3%). No significant differences were observed in polysomnography or quality of life measures. Tension-anxiety was lower in the stretching group than the control group.

Conclusion:

Moderate-intensity resistance exercise and stretching led to similar improvements in objective and subjective sleep in patients with chronic insomnia.

Clinical trial registration:

NCT01571115

Insomnia in Adolescence

Adolescent insomnia is a common condition that negatively impacts a developing young adult's mental and physical health. While the treatment of adult insomnia has been standardized, the treatment of pediatric insomnia is very practitioner-dependent and few large-scale studies are available to determine a standard recommended practice. There is great hope that as the adolescent medicine and sleep medicine fields flourish, larger cohort analyses will be performed to determine the prevalence and precipitating factors of adolescent insomnia, allowing for standardized treatment recommendations and systematic efforts to make these recommendations available to all adolescents.

Addressing the Side Effects of Contemporary Antidepressant Drugs: A Comprehensive Review

Randomized trials have shown that selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have better safety profiles than classical tricyclic antidepressants (TCAs). However, an increasing number of studies, including meta-analyses, naturalistic studies, and longer-term studies suggested that SSRIs and SNRIs are no less safe than TCAs. We focused on comparing the common side effects of TCAs with those of newer generation antidepressants including SSRIs, SNRIs, mirtazapine, and bupropion. The main purpose was to investigate safety profile differences among drug classes rather than the individual antidepressants, so studies containing comparison data on drug groups were prioritized. In terms of safety after overdose, the common belief on newer generation antidepressants having fewer side effects than TCAs appears to be true. TCAs were also associated with higher drop-out rates, lower tolerability, and higher cardiac side-effects. However, evidence regarding side effects including dry mouth, gastrointestinal side effects, hepatotoxicity, seizure, and weight has been inconsistent, some studies demonstrated the superiority of SSRIs and SNRIs over TCAs, while others found the opposite. Some other side effects such as sexual dysfunction, bleeding, and hyponatremia were more prominent with either SSRIs or SNRIs.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α2δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H1 antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.