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Brandt J, Bressi J, Lê ML, Neal D, Cadogan C, Witt-Doerring J, Witt-Doerring M, Wright S. Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review. EClinicalMedicine 2024; 70:102507. [PMID: 38516102 PMCID: PMC10955669 DOI: 10.1016/j.eclinm.2024.102507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/03/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
Background Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion. Methods A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing. Findings 113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents. Interpretation Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering. Funding The authors received no funding for this work.
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Affiliation(s)
- Jaden Brandt
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
| | - Jolene Bressi
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Wegman's School of Pharmacy, St. John Fisher University, Rochester, NY, USA
| | - Mê-Linh Lê
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
- Neil John Maclean Health Sciences Library, University of Manitoba, MB, Canada
| | - Dejanee Neal
- Wegman's School of Pharmacy, St. John Fisher University, Rochester, NY, USA
| | - Cathal Cadogan
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Josef Witt-Doerring
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Witt-Doerring Psychiatry, Heber City, UT, USA
| | - Marissa Witt-Doerring
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Witt-Doerring Psychiatry, Heber City, UT, USA
| | - Steven Wright
- Alliance for Benzodiazepine Best Practices, Portland, OR, USA
- Wright Medical Consulting, Ashland, OR, USA
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Vinkers CH, Kupka RW, Penninx BW, Ruhé HG, van Gaalen JM, van Haaren PCF, Schellekens AFA, Jauhar S, Ramos-Quiroga JA, Vieta E, Tiihonen J, Veldman SE, Veling W, Vis R, de Wit LE, Luykx JJ. Discontinuation of psychotropic medication: a synthesis of evidence across medication classes. Mol Psychiatry 2024:10.1038/s41380-024-02445-4. [PMID: 38503923 DOI: 10.1038/s41380-024-02445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 03/21/2024]
Abstract
Pharmacotherapy is an effective treatment modality across psychiatric disorders. Nevertheless, many patients discontinue their medication at some point. Evidence-based guidance for patients, clinicians, and policymakers on rational discontinuation strategies is vital to enable the best, personalized treatment for any given patient. Nonetheless, there is a scarcity of guidelines on discontinuation strategies. In this perspective, we therefore summarize and critically appraise the evidence on discontinuation of six major psychotropic medication classes: antidepressants, antipsychotics, benzodiazepines, mood stabilizers, opioids, and stimulants. For each medication class, a wide range of topics pertaining to each of the following questions are discussed: (1) Who can discontinue (e.g., what are risk factors for relapse?); (2) When to discontinue (e.g., after 1 year or several years of antidepressant use?); and (3) How to discontinue (e.g., what's the efficacy of dose reduction compared to full cessation and interventions to mitigate relapse risk?). We thus highlight how comparing the evidence across medication classes can identify knowledge gaps, which may pave the way for more integrated research on discontinuation.
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Affiliation(s)
- Christiaan H Vinkers
- Department of Psychiatry and Anatomy & Neurosciences, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands.
- Amsterdam Public Health, Mental Health Program and Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, The Netherlands.
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands.
| | - Ralph W Kupka
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Brenda W Penninx
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Henricus G Ruhé
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
| | - Jakob M van Gaalen
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul C F van Haaren
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - Sameer Jauhar
- Centre for Affective Disorders, Psychological Medicine, IoPPN, King's College, London, UK
| | - Josep A Ramos-Quiroga
- Department of Mental Health, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain
- Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
- Biomedical Network Research Centre on Mental Health (CIBERSAM), Barcelona, Catalonia, Spain
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, 11364, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Stijn E Veldman
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Novadic-Kentron Addiction Care, Vught, The Netherlands
| | - Wim Veling
- Department of Psychiatry, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Roeland Vis
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Laura E de Wit
- Department of Psychiatry, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Jurjen J Luykx
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
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Espie CA, Henry AL. Disseminating cognitive behavioural therapy (CBT) for insomnia at scale: capitalising on the potential of digital CBT to deliver clinical guideline care. J Sleep Res 2023; 32:e14025. [PMID: 37642008 DOI: 10.1111/jsr.14025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023]
Abstract
Cognitive behavioural therapy (CBT) is the recommended first-line treatment for insomnia. However, guideline care is very seldom available and most patients receive no treatment, or less effective second-line pharmacotherapy or sleep hygiene, neither of which are evidence-based for chronic insomnia. The primary challenge for CBT has been supply. There are not enough therapists to meet the enormous demand. We must accelerate clinician training, but this approach can never be sufficient, even with abbreviated, efficient therapies. Fortunately, however, the treatment landscape has also changed dramatically. Fully-automated digital CBT (dCBT) has emerged as a safe, effective, and scalable treatment delivery format. dCBT is software only, so it can be disseminated as readily and widely as sleep medication. Moreover, dCBT can be integrated into services. Just as medications can be delivered through health professionals and health systems, approved dCBT programmes can be the same. However, an ecosystem of psychologically-based care should not necessitate a medical prescription model. Our proposed stepped care framework, comprises both population health and clinical health service initiatives, enabling universal access to guideline care for insomnia. The diverse ways in which CBT may be delivered (in-person, face-to-face, using telehealth, group therapy, digitally) can operate congruently and efficiently to optimise treatment for people at all levels of complexity and need. With safe and clinically effective dCBT products now set to become established as treatments, clearly differentiated from wellness apps, there is potential to rapidly transform insomnia services and, for the first time, to deliver clinical guideline care at international scale.
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Affiliation(s)
- Colin A Espie
- Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Big Health Ltd., London, UK
- Big Health Inc., San Francisco, CA, USA
| | - Alasdair L Henry
- Big Health Ltd., London, UK
- Big Health Inc., San Francisco, CA, USA
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Aoki Y, Takaesu Y, Inada K, Yamada H, Murao T, Kikuchi T, Takeshima M, Tani M, Mishima K, Otsubo T. Development and acceptability of a decision aid for anxiety disorder considering discontinuation of benzodiazepine anxiolytic. Front Psychiatry 2023; 14:1083568. [PMID: 37252154 PMCID: PMC10213963 DOI: 10.3389/fpsyt.2023.1083568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Aim We aimed to develop a decision aid (DA) for individuals with anxiety disorders who consider tapering benzodiazepine (BZD) anxiolytics, and if tapering, tapering BZD anxiolytics with or without cognitive behavioral therapy (CBT) for anxiety. We also assessed its acceptability among stakeholders. Methods First, we conducted a literature review regarding anxiety disorders to determine treatment options. We cited the results of the systematic review and meta-analysis, which we conducted previously, to describe the related outcomes of two options: tapering BZD anxiolytics with CBT and tapering BZD anxiolytics without CBT. Second, we developed a DA prototype in accordance with the International Patient Decision Aid Standards. We carried out a mixed methods survey to assess the acceptability among stakeholders including those with anxiety disorders and healthcare providers. Results Our DA provided information such as explanation of anxiety disorders, options of tapering or not tapering BZD anxiolytics (if tapering, the options of tapering BZD anxiolytics with or without CBT) for anxiety disorder, benefits and risks of each option, and a worksheet for value clarification. For patients (n = 21), the DA appeared to be acceptable language (86%), adequate information (81%), and well-balanced presentation (86%). The developed DA was also acceptable for healthcare providers (n = 10). Conclusion We successfully created a DA for individuals with anxiety disorders who consider tapering BZD anxiolytics, which was acceptable for both patients and healthcare providers. Our DA was designed to assist patients and healthcare providers to involve decision-making about whether to taper BZD anxiolytics or not.
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Affiliation(s)
- Yumi Aoki
- Department of Psychiatric and Mental Health Nursing, Graduate School of Nursing, St. Luke’s International University, Tokyo, Japan
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Ken Inada
- Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Hiroki Yamada
- Department of Psychiatry, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | | | - Toshiaki Kikuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Masayuki Tani
- Department of Psychiatry, Oouchi Hospital, Tokyo, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Tempei Otsubo
- Department of Psychiatry, Tokyo Women’s Medical University Adachi Medical Center, Tokyo, Japan
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Takaesu Y, Sakurai H, Aoki Y, Takeshima M, Ie K, Matsui K, Utsumi T, Shimura A, Okajima I, Kotorii N, Yamashita H, Suzuki M, Kuriyama K, Shimizu E, Mishima K, Watanabe K, Inada K. Treatment strategy for insomnia disorder: Japanese expert consensus. Front Psychiatry 2023; 14:1168100. [PMID: 37229388 PMCID: PMC10203548 DOI: 10.3389/fpsyt.2023.1168100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Purpose There is a lack of evidence regarding answers for clinical questions about treating insomnia disorder. This study aimed to answer the following clinical questions: (1) how to use each hypnotic and non-pharmacological treatment differently depending on clinical situations and (2) how to reduce or stop benzodiazepine hypnotics using alternative pharmacological and non-pharmacological treatments. Methods Experts were asked to evaluate treatment choices based on 10 clinical questions about insomnia disorder using a nine-point Likert scale (1 = "disagree" to 9 = "agree"). The responses of 196 experts were collected, and the answers were categorized into first-, second-, and third-line recommendations. Results The primary pharmacological treatment, lemborexant (7.3 ± 2.0), was categorized as a first-line recommendation for sleep initiation insomnia, and lemborexant (7.3 ± 1.8) and suvorexant (6.8 ± 1.8) were categorized as the first-line recommendations for sleep maintenance insomnia. Regarding non-pharmacological treatments for primary treatment, sleep hygiene education was categorized as the first-line recommendation for both sleep initiation (8.4 ± 1.1) and maintenance insomnia (8.1 ± 1.5), while multicomponent cognitive behavioral therapy for insomnia was categorized as the second-line treatment for both sleep initiation (5.6 ± 2.3) and maintenance insomnia (5.7 ± 2.4). When reducing or discontinuing benzodiazepine hypnotics by switching to other medications, lemborexant (7.5 ± 1.8) and suvorexant (6.9 ± 1.9) were categorized as first-line recommendations. Conclusion Expert consensus indicates that orexin receptor antagonists and sleep hygiene education are recommended as first-line treatments in most clinical situations to treat insomnia disorder.
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Affiliation(s)
- Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Hitoshi Sakurai
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Yumi Aoki
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
- Psychiatric and Mental Health Nursing, St. Luke’s International University, Tokyo, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Kenya Ie
- Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
- Division of General Internal Medicine, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
| | - Kentaro Matsui
- Department of Clinical Laboratory, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Tomohiro Utsumi
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japan
| | - Akiyoshi Shimura
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Isa Okajima
- Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, Tokyo, Japan
| | - Nozomu Kotorii
- Kotorii Isahaya Hospital, Nagasaki, Japan
- Department of Psychiatry, School of Medicine, Kurume University, Fukuoka, Japan
| | | | - Masahiro Suzuki
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Kenichi Kuriyama
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Eiji Shimizu
- Research Center for Child Mental Development, Chiba University, Chiba, Japan
- Department of Cognitive Behavioral Physiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, School of Medicine, Kitasato University, Tokyo, Japan
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Watson NF, Benca RM, Krystal AD, McCall WV, Neubauer DN. Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia. J Clin Med 2023; 12:jcm12072493. [PMID: 37048577 PMCID: PMC10095217 DOI: 10.3390/jcm12072493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
Determining the most effective insomnia medication for patients may require therapeutic trials of different medications. In addition, medication side effects, interactions with co-administered medications, and declining therapeutic efficacy can necessitate switching between different insomnia medications or deprescribing altogether. Currently, little guidance exists regarding the safest and most effective way to transition from one medication to another. Thus, we developed evidence-based guidelines to inform clinicians regarding best practices when deprescribing or transitioning between insomnia medications. Five U.S.-based sleep experts reviewed the literature involving insomnia medication deprescribing, tapering, and switching and rated the quality of evidence. They used this evidence to generate recommendations through discussion and consensus. When switching or discontinuing insomnia medications, we recommend benzodiazepine hypnotic drugs be tapered while additional CBT-I is provided. For Z-drugs zolpidem and eszopiclone (and not zaleplon), especially when prescribed at supratherapeutic doses, tapering is recommended with a 1–2-day delay in administration of the next insomnia therapy when applicable. There is no need to taper DORAs, doxepin, and ramelteon. Lastly, off-label antidepressants and antipsychotics used to treat insomnia should be gradually reduced when discontinuing. In general, offering individuals a rationale for deprescribing or switching and involving them in the decision-making process can facilitate the change and enhance treatment success.
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Abstract
Cognitive behavioral therapy for insomnia (CBT-I) is the universally recommended treatment of choice for insomnia disorder based on its safety and posttreatment durability of benefit. However, CBT-I does not help all patients achieve remission. The second most evidence-based treatment, hypnotic pharmacotherapy (PCT), does not resolve perpetuating factors of insomnia, resulting in potential waning of benefit and dependence. This article presents a rationale that supports consideration of hypnotic augmentation of CBT-I (COMB), along with a review of select randomized controlled trials relevant to clinical decision-making.
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Tanielian M, Antoun J, Sidani M, Halabi A, Hoballah M, Hawatian K, Assaf G. Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older adults with insomnia. BMC PRIMARY CARE 2022; 23:98. [PMID: 35501700 PMCID: PMC9063057 DOI: 10.1186/s12875-022-01707-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 04/19/2022] [Indexed: 01/01/2023]
Abstract
Introduction This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia. Methods Patients aged 50–75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone. Results A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use. Conclusion Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual sedation. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics.
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Gozda K, Leung J, Baum L, Singer A, Konrad G, McMillan DE, Falk J, Kosowan L, Leong C. Insights into patient characteristics and documentation of the use of sedative-hypnotic/anxiolytics in primary care: a retrospective chart review study. BMC PRIMARY CARE 2022; 23:111. [PMID: 35538427 PMCID: PMC9087974 DOI: 10.1186/s12875-022-01724-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/25/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Despite the known safety risks of long-term use of sedative-hypnotic/anxiolytic medications, there has been limited guidance for the safe and effective use of their chronic use in a primary care clinic setting. Understanding the characteristics of patients who receive sedative-hypnotic/anxiolytic medication and the clinical documentation process in primary care is the first step towards understanding the nature of the problem and will help inform future strategies for clinical research and practice.
Objectives
Characterize patients who received a sedative-hypnotic/anxiolytic prescription in primary care, and (2) gain an understanding of the clinical documentation of sedative-hypnotic/anxiolytic indication and monitoring in electronic medical records (EMR).
Methods
A random selection of patients who received a prescription for a benzodiazepine or Z-drug hypnotic between January 2014 and August 2016 from four primary care clinics in Winnipeg were included. Data was collected retrospectively using the EMR (Accuro®). Patient variables recorded included sex, age, comorbidities, medications, smoking status, and alcohol status. Treatment variables included drug type, indication, pattern of use, dose, adverse events, psychosocial intervention, tapering attempts, social support, life stressor, and monitoring parameters for sedative-hypnotic use. Demographic and clinical characteristics were described using descriptive statistics.
Results
Records from a sample of 200 primary care patients prescribed sedative-hypnotic/anxiolytics were analyzed (mean age 55.8 years old, 61.5% ≥ 65 years old, 61.0% female). Long-term chronic use (≥ 1 year) of a sedative-hypnotic/anxiolytic agent was observed in 29.5% of the sample. Zopiclone (30.7%) and lorazepam (28.7%) were the most common agents prescribed. Only 9.5% of patients had documentation of a past tapering attempt of their sedative-hypnotic/anxiolytic. The most common indications for sedative-hypnotic/anxiolytic use recorded were anxiety (33.0%) and sleep (18.0%), but indication was undetermined for 57.0% of patients. Depression (33.5%) and falls (18.5%) were reported by patients after the initiation of these agents.
Conclusions
A higher proportion of females and users 65 years and older received a prescription for a sedative-hypnotic/anxiolytic, consistent with previous studies on sedative-hypnotic use. We found inconsistencies in the documentation surrounding sedative-hypnotic/anxiolytic use. The indication for their use was unclear in a large number of patients. These findings will help us understand the state of the problem in primary care and inform future strategies for clinical research.
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Takeshima M, Aoki Y, Ie K, Katsumoto E, Tsuru E, Tsuboi T, Inada K, Kise M, Watanabe K, Mishima K, Takaesu Y. Attitudes and Difficulties Associated with Benzodiazepine Discontinuation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15990. [PMID: 36498061 PMCID: PMC9741206 DOI: 10.3390/ijerph192315990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
Long-term use of benzodiazepine receptor agonists (BZDs) may depend on clinicians' BZD discontinuation strategies. We aimed to explore differences in strategies and difficulties with BZD discontinuation between psychiatrists and non-psychiatrists and to identify factors related to difficulties with BZD discontinuation. Japanese physicians affiliated with the Japan Primary Care Association, All Japan Hospital Association, and Japanese Association of Neuro-Psychiatric Clinics were surveyed on the following items: age group, specialty (psychiatric or otherwise), preferred time to start BZD reduction after improvement in symptoms, methods used to discontinue, difficulties regarding BZD discontinuation, and reasons for the difficulties. We obtained 962 responses from physicians (390 from non-psychiatrists and 572 from psychiatrists), of which 94.0% reported difficulty discontinuing BZDs. Non-psychiatrists had more difficulty with BZD discontinuation strategies, while psychiatrists had more difficulty with symptom recurrence/relapse and withdrawal symptoms. Psychiatrists used more candidate strategies in BZD reduction than non-psychiatrists but initiated BZD discontinuation after symptom improvement. Logistic regression analysis showed that psychosocial therapy was associated with less difficulty in BZD discontinuation (odds ratio, 0.438; 95% confidence interval, 0.204-0.942; p = 0.035). Educating physicians about psychosocial therapy may alleviate physicians' difficulty in discontinuing BZDs and reduce long-term BZD prescriptions.
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Affiliation(s)
- Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City 010-8543, Japan
| | - Yumi Aoki
- Psychiatric and Mental Health Nursing, St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan
- Department of Neuropsychiatry, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
| | - Kenya Ie
- Department of General Internal Medicine, St. Marianna University School of Medicine, 1-30-37 Shukugawara, Kawasaki 214-8525, Japan
| | - Eiichi Katsumoto
- Katsumoto Mental Clinic, 10-13 Horikoshicho, Tennoji-ku, Osaka City 543-0056, Japan
| | - Eichi Tsuru
- Department of Neurosurgery, Munakata Suikokai General Hospital, 5-7-1 Himakino, Fukutsu-shi 811-3298, Japan
| | - Takashi Tsuboi
- Department of Neuropsychiatry, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
| | - Ken Inada
- Department of Psychiatry, School of Medicine, Kitasato University, Kitazato, Sagamihara shi 252-0329, Japan
| | - Morito Kise
- Centre for Family Medicine Development, Japanese Health and Welfare Co-Operative Federation, 3-25-1 Hyakunincho, Shinjuku-ku, Tokyo 169-0073, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita City 010-8543, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, 207 Aza-Uehara, Nishihara-cho, Nakagami-gun, Nishihara 903-0215, Japan
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11
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Gibson CJ, Li Y, Jasuja GK, Keyhani S, Byers AL. Long-term Psychoactive Medications, Polypharmacy, and Risk of Suicide and Unintended Overdose Death Among Midlife and Older Women Veterans. J Gen Intern Med 2022; 37:770-777. [PMID: 36042093 PMCID: PMC9481785 DOI: 10.1007/s11606-022-07592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rates of suicide and unintended overdose death are high among midlife and older women, yet there is paucity of data identifying women at greatest risk. Psychoactive medications, commonly prescribed and co-prescribed in this population, may serve as salient indicators of risk for these outcomes. OBJECTIVE To determine whether long-term psychoactive medications and psychoactive polypharmacy predict risk of suicide and unintended overdose death among midlife and older women Veterans above and beyond other recognized factors. DESIGN Longitudinal cohort study PARTICIPANTS: Women Veterans aged ≥ 50 with at least one Veterans Health Administration (VHA) clinical encounter in FY2012-2013. MAIN MEASURES Long-term psychoactive medications (opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics, prescribed for ≥ 90/180 days) and psychoactive polypharmacy (overlapping for ≥ 1 day) from VHA pharmacy records; suicide and unintended overdose death through December 31, 2018. KEY RESULTS In this national sample of 154,558 midlife and older women Veterans (mean age 63.4, SD 9.3 years), 130 died by suicide and 175 died from unintentional overdose over an average of 5.6 years. In fully adjusted models, long-term opioids (hazard ratio (HR) 2.01, 95% CI 1.21-3.35) and benzodiazepines (HR 2.99, 95% CI 1.82-4.91) were associated with death by suicide; opioids (HR 3.62, 95% CI 2.46-5.34), benzodiazepines (HR 2.77, 95% CI 1.73-4.42), sedative-hypnotics (HR 1.87, 95% CI 1.06-3.29), antidepressants (HR 1.47, 95% CI 1.03-2.12), antipsychotics (HR 1.81, 95% CI 1.02-3.22), and antiepileptics (HR 2.17, 95% CI 1.48-3.19) were associated with unintended overdose death. Women who were co-prescribed ≥ 3 psychoactive medications had over 2-fold increased risk of suicide (HR 2.83, 95% CI 1.65-4.84) and unintended overdose death (HR 2.60, 95% CI 1.72-3.94). CONCLUSIONS Long-term psychoactive medications and psychoactive medication polypharmacy were important indicators of risk for death by suicide and death by unintended overdose among midlife and older women Veterans, even after accounting for psychiatric and substance use disorders.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA.
- University of California, San Francisco, San Francisco, USA.
| | - Yixia Li
- NCIRE-The Veterans Health Research Institute, San Francisco, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, USA
- Boston University School of Medicine, Boston, USA
| | - Salomeh Keyhani
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA
- University of California, San Francisco, San Francisco, USA
| | - Amy L Byers
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA
- University of California, San Francisco, San Francisco, USA
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12
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Takeshima M, Enomoto M, Ogasawara M, Kudo M, Itoh Y, Yoshizawa K, Fujiwara D, Takaesu Y, Mishima K. Changes in psychotropic polypharmacy and high-potency prescription following policy change: Findings from a large scale Japanese claims database. Psychiatry Clin Neurosci 2022; 76:475-477. [PMID: 35655425 PMCID: PMC9546399 DOI: 10.1111/pcn.13432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Minori Enomoto
- Department of Medical Technology, School of Health Sciences, Tokyo University of Technology, Tokyo, Japan
| | - Masaya Ogasawara
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Mizuki Kudo
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Yu Itoh
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Kazuhisa Yoshizawa
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Dai Fujiwara
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
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13
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Comparative efficacy and acceptability of psychotherapies, pharmacotherapies, and their combination for the treatment of adult insomnia: A systematic review and network meta-analysis. Sleep Med Rev 2022; 65:101687. [PMID: 36027795 DOI: 10.1016/j.smrv.2022.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/08/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022]
Abstract
This study aims to explore the comparative efficacy and acceptability of psychotherapies, pharmacotherapies, and their combinations for insomnia. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and ClinicalTrials.gov were searched for randomized clinical trials (RCTs) examining the comparative efficacy in which a psychotherapy and a pharmacotherapy for insomnia were directly compared with each other, or in which a combination of psychotherapy and pharmacotherapy was compared with either alone. The analysis included data from 23 RCTs. In 18 of 23 studies, cognitive behavior therapy for insomnia (CBT-I) was the psychotherapy. At post-treatment, CBT-I showed higher subjective sleep efficiency (SE), and lower subjective wake time after sleep onset (WASO) and insomnia severity index (ISI) score. Compared with CBT-I plus pharmacotherapy, pharmacotherapy showed lower subjective SE, and higher subjective sleep latency (SL), PSG measured SL, subjective WASO, and ISI score. Overall, the findings derived from post-treatment data suggested that CBT-I is more beneficial in treating insomnia compared with pharmacotherapy. CBT-I combined with pharmacotherapy is beneficial in improving some sleep parameters (i.e., subjective SE, SL, WASO, and PSG measured SL) compared with pharmacotherapy alone. Daily clinical decisions should consider these findings on the relative efficacy of the principal approaches to insomnia treatment.
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14
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Zhou H, Zhao Y, Peng W, Han W, Wang D, Wang Z, Ren X, Pan G, Lin Q, Wang X. Efficacy and safety of Wuling capsule for insomnia disorder: a systematic review and meta-analysis of randomized controlled trials. Sleep Med 2022; 93:1-14. [PMID: 35397258 DOI: 10.1016/j.sleep.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Wuling capsule has been used in treatment of insomnia disorder in China for decades, but the reported treatment efficacy of different studies was not consistent. This study intended to evaluate the efficacy and safety of Wuling capsule for insomnia disorder, so as to provide evidence for clinical application. METHODS Eight databases (MEDLINE, EMBASE, Ovid, Cochrane Library, Chinese National Knowledge Infrastructure, VIP information database, Chinese Biomedical Database and Wanfang) were searched from inception to September 14, 2021. Randomized controlled trials (RCTs) comparing Wuling capsule with controls in adults with insomnia disorder were eligible. The primary outcome was sleep quality assessed by Pittsburgh Sleep Quality Index (PSQI), and the secondary outcomes were severity of insomnia disorder measured by Sleep Dysfunction Rating Scale (SDRS) and adverse events. This study was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0. RESULTS Nineteen RCTs with a total of 1850 participants were included. In terms of sleep quality assessed by PSQI, Wuling capsule significantly lowered PSQI score (MD: -1.92, 95% CI: [-2.34, -1.50], P < 0.00001, I2 = 95%) compared to controls, and the effect of Wuling capsule was significantly better than control no matter when Wuling capsule as monotherapy (MD: -1.71, 95% CI: [-2.33, -1.09], P < 0.00001, I2 = 97%) or as adjunctive therapy (MD: -2.10, 95% CI: [-2.66, -1.55], P < 0.00001, I2 = 90%). Wuling capsule was more effective for the treatment duration lasted 8 weeks (MD: -2.57, 95% CI: [-3.52, -1.62], P < 0.00001, I2 = 93%) than 4 weeks (MD: -1.68, 95% CI: [-2.13, -1.22], P < 0.00001, I2 = 95%). In terms of severity of insomnia disorder measured by SDRS, Wuling capsule significantly reduced SDRS score (MD: -4.21, 95% CI: [-4.95, -3.46], P < 0.00001, I2 = 0%) compared to benzodiazepines. Wuling capsule significantly reduced adverse events compared to controls (RR: 0.47, 95% CI: [0.34, 0.65], P < 0.00001, I2 = 43%). CONCLUSION Wuling capsule can safely and effectively improve sleep quality in patients with insomnia disorder. However, these findings require careful recommendation due to the high heterogeneity and high risk of bias in the included trials. Clinical trials with higher quality designs are needed.
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Affiliation(s)
- Hufang Zhou
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China
| | - Ying Zhao
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China
| | - Wenhua Peng
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China
| | - Wenbo Han
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, 100029, China
| | - Dayang Wang
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China
| | - Zichen Wang
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China
| | - Xiaoxia Ren
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China
| | - Guozhong Pan
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China.
| | - Qian Lin
- Changping District Hospital of Integrated Traditional Chinese and Western Medicine, Beijing, 102200, China.
| | - Xian Wang
- Cardiovascular Diseases Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100007, China.
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15
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Baldwin DS. Clinical management of withdrawal from benzodiazepine anxiolytic and hypnotic medications. Addiction 2022; 117:1472-1482. [PMID: 34542216 DOI: 10.1111/add.15695] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/22/2021] [Indexed: 11/30/2022]
Abstract
Benzodiazepines continue to be prescribed widely in the management of patients with insomnia or anxiety disorders, despite the availability and acceptability of alternative pharmacological and psychological treatments. Many patients will experience adverse effects during treatment and considerable distress when the dosage is reduced and stopped. Management of benzodiazepine withdrawal includes measures to prevent the development of dependence, careful attention to underlying medical conditions, medication consolidation and gradual dosage reduction, accompanying psychological interventions, occasional prescription of concomitant medication, and relapse prevention with on-going support to address psychosocial stressors. There are needs for easier patient access to services with refined expertise and for further research to optimise strategies for preventing dependence and facilitating withdrawal.
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Affiliation(s)
- David S Baldwin
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.,Mood and Anxiety Disorders Service, Southern Health NHS Foundation Trust, Southampton, UK
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16
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Aoki Y, Takaesu Y, Suzuki M, Okajima I, Takeshima M, Shimura A, Utsumi T, Kotorii N, Yamashita H, Kuriyama K, Watanabe N, Mishima K. Development and acceptability of a decision aid for chronic insomnia considering discontinuation of benzodiazepine hypnotics. Neuropsychopharmacol Rep 2021; 42:10-20. [PMID: 34807524 PMCID: PMC8919126 DOI: 10.1002/npr2.12219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 12/23/2022] Open
Abstract
Aim To describe the development and acceptability of a decision aid (DA) for chronic insomnia considering discontinuation of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA) hypnotics, and if discontinuing, tapering with or without cognitive behavioral therapy for insomnia (CBT‐I). Methods We reviewed relevant literature describing chronic insomnia to identify options. We used the results of the systematic review and meta‐analysis conducted previously to determine the related outcomes of two options: discontinuation of BZD/BZRA hypnotics by gradual tapering alone and discontinuation of BZD/BZRA hypnotics by gradual tapering with CBT‐I. We then developed a prototype of DA following the International Patient Decision Aid Standards. A mixed methods survey was conducted to assess the acceptability among patients and healthcare providers. Results The prototype consisted of a description of insomnia, options of continuing or discontinuing BZD/BRZA hypnotics (if discontinuing, the options of tapering hypnotics with or without CBT‐I), pros and cons of each option, and a value clarification exercise. Patients (n = 24) reported that the DA had acceptable language (79%), adequate information (71%), and well‐balanced presentation (91%). Healthcare providers (n = 20) also provided favorable feedback. Conclusion We developed a DA for chronic insomnia considering discontinuation of BZD/BRZA hypnotics, which was acceptable for stakeholders. The developed DA was designed to support patients and healthcare providers to make a decision about whether to discontinue BZD/BRZA hypnotics.
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Affiliation(s)
- Yumi Aoki
- Department Psychiatric and Mental Health Nursing, Graduate School of Nursing, St. Luke's International University, Tokyo, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.,Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Masahiro Suzuki
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Isa Okajima
- Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, Tokyo, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Akiyoshi Shimura
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Tomohiro Utsumi
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | - Kenichi Kuriyama
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
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17
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Liu CR, Liou YM, Jou JH. Ambient bright lighting in the morning improves sleep disturbances of older adults with dementia. Sleep Med 2021; 89:1-9. [PMID: 34844127 DOI: 10.1016/j.sleep.2021.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/27/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ambient light therapies are potentially effective in improving sleep disturbances and circadian rhythms. This study created a new lighting intervention model for elderly patients with dementia. It is hypothesized that exposure to bright ambient light in the morning is more effective than general lighting in improving sleep disturbances and circadian rhythms. METHODS A single-blind longitudinal-group experimental design was employed. The dementia participants came from the community and nursing homes. Those in the experimental group were exposed to ambient light at 2500 lux, and those in the comparison group were exposed to 114-307 lux. The corresponding sleep disturbances and circadian rhythms were determined using an accelerometer (XA-5). A longitudinal experimental design was adopted to observe the time to an effective response. RESULTS The covariates of benzodiazepine use and total activity during the day were analyzed using generalized estimating equations. The experimental group showed significant sleep efficiency improvement, with mean increases of 41.9% (P < 0.001) and 31.7% (P = 0.002), sleep time increases of 141 min (P = 0.001) and 135 min (P = 0.008), awakening time decreases of 116 min (P = 0.001) and 108 min (P = 0.002), and sleep onset advancements of 60-84 min/sleep offset delays of 57-79 min upon the fifth and ninth week, respectively. A 4-week bright ambient light intervention was the most effective. CONCLUSIONS This study found that bright ambient light in the morning is beneficial for improving sleep disturbances and was driven by stabilizing circadian rhythms.
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Affiliation(s)
- Chuen-Ru Liu
- School of Nursing, National Yang Ming Chiao Tung University, (School of Nursing, National Yang-Ming University), Psychiatric Nurse of City Hospital, Songde Branch, Taiwan
| | - Yiing Mei Liou
- Institute of Community Health Care, School of Nursing, National Yang Ming Chiao Tung University (School of Nursing, National Yang-Ming University), President of Lambda Beta-at-Large Chapter, The Honor Society of Nursing, Sigma Theta Tau International, Taiwan.
| | - Jwo-Huei Jou
- Department of Materials Science and Engineering, National Tsing Hua University, Taiwan
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18
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Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910222. [PMID: 34639523 PMCID: PMC8508349 DOI: 10.3390/ijerph181910222] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 01/23/2023]
Abstract
Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.
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19
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Abstract
Insomnia can have significant health and economic impacts. In contrast, sleep disturbance is common but does not usually affect daytime activity Short-term approaches for acute insomnia are often appropriate. These include dealing with precipitating factors such as stress Chronic insomnia has a high relapse and recurrence rate. It is best managed with cognitive behavioural therapy which includes sleep hygiene, stimulus control and sleep restriction In primary care, brief behavioural therapy for insomnia is an accessible and effective management strategy. If there is no response, referral should be considered Adjuvant use of drugs in insomnia may be appropriate in some cases. Prescription should be for a limited duration
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20
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Matsui K, Kuriyama K, Kobayashi M, Inada K, Nishimura K, Inoue Y. The efficacy of add-on ramelteon and subsequent dose reduction in benzodiazepine derivatives/Z-drugs for the treatment of sleep-related eating disorder and night eating syndrome: a retrospective analysis of consecutive patients. J Clin Sleep Med 2021; 17:1475-1483. [PMID: 33704048 DOI: 10.5664/jcsm.9236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVES The objective of this study was to determine the efficacy of ramelteon in treating abnormal eating behavior in patients with sleep-related eating disorder and/or night eating syndrome. METHODS We retrospectively reviewed the medical records of patients with sleep-related eating disorder/night eating syndrome at the Yoyogi Sleep Disorder Center from November 2013 to November 2018. We categorized patients as ramelteon treatment responders when the frequency of nighttime eating per week decreased to less than half of that before treatment. RESULTS Forty-nine patients were included in the analysis. The mean frequency of eating behavior (per week) (standard deviation) at baseline and post-ramelteon treatment was significantly different, at 5.3 (2.2) and 3.2 (3.0), respectively (P < .001). Twenty-one patients (42.9%) were classified as responders. Adverse events, all of which were mild daytime somnolence, were observed in 5 patients. There were significantly more individuals using benzodiazepine derivatives and Z-drugs before treatment and those with coexisting delayed sleep-wake phase disorder in the responder group than in the nonresponder group (P < .001 and P < .05, respectively). The mean benzodiazepine derivatives and Z-drugs dose significantly decreased from baseline to post-ramelteon treatment within the responder group (P < .05). This trend was not observed in the nonresponder group. Meanwhile, the sleep midpoint of patients with sleep-related eating disorder/night eating syndrome and delayed sleep-wake phase disorder did not significantly change after treatment. CONCLUSIONS Our results indicate that ramelteon is a candidate treatment for sleep-related eating disorder/night eating syndrome. The effects of ramelteon might have occurred primarily through the reduction in benzodiazepine derivatives and Z-drugs rather than through the improvement in sleep-wake rhythm dysregulation.
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Affiliation(s)
- Kentaro Matsui
- Department of Clinical Laboratory, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan.,Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan.,Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
| | - Kenichi Kuriyama
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Mina Kobayashi
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan.,Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
| | - Katsuji Nishimura
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuichi Inoue
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan.,Department of Somnology, Tokyo Medical University, Tokyo, Japan
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21
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Takeshima M, Otsubo T, Funada D, Murakami M, Usami T, Maeda Y, Yamamoto T, Matsumoto T, Shimane T, Aoki Y, Otowa T, Tani M, Yamanaka G, Sakai Y, Murao T, Inada K, Yamada H, Kikuchi T, Sasaki T, Watanabe N, Mishima K, Takaesu Y. Does cognitive behavioral therapy for anxiety disorders assist the discontinuation of benzodiazepines among patients with anxiety disorders? A systematic review and meta-analysis. Psychiatry Clin Neurosci 2021; 75:119-127. [PMID: 33448517 PMCID: PMC8048602 DOI: 10.1111/pcn.13195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 12/18/2022]
Abstract
Long-term use of benzodiazepines (BZD) is not recommended for the treatment of anxiety disorders. Cognitive behavioral therapy (CBT) is an effective treatment option for discontinuation of BZD in patients with anxiety disorders. This systematic review and meta-analysis sought to clarify whether CBT is effective for discontinuing BZD anxiolytics in patients with anxiety disorders. This study was preregistered with PROSPERO (registration number: CRD42019125263). A literature search of major electronic databases was conducted in December 2018. Three randomized controlled trials were included in this review, and meta-analyses were performed. The proportion of discontinuing BZD anxiolytics was significantly higher in the CBT plus gradual tapering group than in the gradual tapering alone group, both in the short term (3 months after allocation; number needed to treat: 3.2, 95% confidence interval [CI]: 2.1 to 7.1; risk ratio: 1.96, 95%CI: 1.29 to 2.98, P = 0.002, three studies) and long term (6 to 12 months after allocation; number needed to treat: 2.8, 95%CI: 1.9 to 5.3; risk ratio: 2.16, 95%CI: 1.41 to 3.32, P = 0.0004, three studies). CBT may be effective for discontinuing BZD anxiolytics, both in the short term and in the long term after the allocation. Further studies with larger sample sizes are necessary to draw definitive conclusions regarding the efficacy and safety of CBT for discontinuing BZD anxiolytics in patients with anxiety disorders.
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Affiliation(s)
- Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Tempei Otsubo
- Department of Psychiatry, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Daisuke Funada
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Maki Murakami
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Takashi Usami
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoshihiro Maeda
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Taisuke Yamamoto
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Toshihiko Matsumoto
- Department of Drug Dependence Research, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Takuya Shimane
- Department of Drug Dependence Research, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yumi Aoki
- Psychiatric & Mental Health Nursing, Graduate School of Nursing, St. Luke's International University, Tokyo, Japan
| | - Takeshi Otowa
- Department of Psychiatry, NTT Medical Center Tokyo, Tokyo, Japan
| | - Masayuki Tani
- Department of Psychiatry, Oouchi Hospital, Tokyo, Japan
| | - Gaku Yamanaka
- Department of Psychiatry, Yokohama Clinic, Yokohama, Japan
| | - Yojiro Sakai
- Department of Psychiatry, Akasaka Clinic, Tokyo, Japan
| | - Tomohiko Murao
- Department of Psychiatry, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroki Yamada
- Department of Psychiatry, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Toshiaki Kikuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Tsukasa Sasaki
- Laboratory of Health Education, Graduate School of Education, The University of Tokyo, Tokyo, Japan
| | - Norio Watanabe
- Department of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan.,Department of Neuropsychiatry, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
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22
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Effects of Cognitive Behavioral Therapy for Insomnia on Subjective-Objective Sleep Discrepancy in Patients with Primary Insomnia: a Small-Scale Cohort Pilot Study. Int J Behav Med 2021; 28:715-726. [PMID: 33629218 DOI: 10.1007/s12529-021-09969-x] [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] [Accepted: 02/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cognitive behavioral therapy for insomnia (CBT-I) is a first-line therapy for insomnia disorders. We assessed changes in discrepancies between subjective and objective sleep measures and correlations between discrepancy changes and clinical insomnia severity for CBT-I in patients with primary insomnia METHODS: Fifty-two outpatients (mean age, 60.3 years; 26 women) with primary insomnia were treated by individual CBT-I (50 min, maximum six sessions, once every 1-2 weeks). One week before and after CBT-I, patients recorded a sleep log and wore an actigraphy device. Subjective and objective time in bed (TIB), total sleep time (TST), sleep-onset latency (SOL), wake time after sleep onset (WASO), and sleep efficiency (SE) were evaluated by averaging 1-week records. Relative values of sleep discrepancy in TIB, TST, SOL, WASO, and SE were calculated for estimating effects of CBT-I. The therapeutic effects were also evaluated using psychological scales before and after CBT-I. RESULTS Subjective and objective discrepancies in sleep measures decreased by 36, 25, and 37 min in TST, SOL, and WASO, respectively, and 7% in SE (all P < 0.001) after CBT-I. Seven patients transitioned from underestimating SE before CBT-I to overestimating SE after CBT-I. Although CBT-I improved relative values of discrepancy in WASO and SE, alongside ISI, the improvement in insomnia severity only correlated with SOL discrepancy. CONCLUSIONS CBT-I may reduce the discrepancy between subjective and objective sleep measures in patients with primary insomnia. However, a greater therapeutic effect of CBT-I was observed in reducing the ISI, which was slightly influenced by improvements in sleep discrepancies.
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23
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Sweetman A, Putland S, Lack L, McEvoy RD, Adams R, Grunstein R, Stocks N, Kaambwa B, Van Ryswyk E, Gordon C, Vakulin A, Lovato N. The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep Med Rev 2020; 56:101404. [PMID: 33370637 DOI: 10.1016/j.smrv.2020.101404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/12/2020] [Accepted: 07/26/2020] [Indexed: 01/09/2023]
Abstract
Although cognitive behavioural therapy for insomnia (CBTi) is the recommended 'first-line' treatment for insomnia, most patients are initially treated with sedative-hypnotic medications. Given the risk of impaired cognitive and psychomotor performance, serious adverse events, and long-term dependence associated with sedative-hypnotics, guidelines recommend that prescriptions should be limited to short-term use and that patients are provided with support for withdrawal where possible. CBTi is an effective insomnia treatment in the presence of sedative-hypnotic use. Furthermore, guidelines recommended that CBTi techniques are utilised to facilitate withdrawal from sedative-hypnotics. However, there is very little research evaluating the effect of CBTi on reduced medication use. The current narrative review integrates 95 studies including over 10,000 participants, investigating the effect of CBTi on reduced sedative-hypnotic use in different populations (e.g., hypnotic-dependent patients, older adults, military personnel), settings (e.g., primary care settings, psychiatric inpatients), CBTi modalities (e.g., self-administered reading/audio materials, digital, and therapist-administered), and in combination with gradual dose reduction programs. Based on this research, we discuss the theoretical mechanistic effects of CBTi in facilitating reduced sedative-hypnotic use, provide clear recommendations for future research, and offer pragmatic clinical suggestions to increase access to CBTi to reduce dependence on sedative-hypnotics as the 'default' treatment for insomnia.
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Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.
| | | | - Leon Lack
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Robert Adams
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; The Health Observatory, Discipline of Medicine, The Queen Elizabeth Hospital Campus, University of Adelaide, Woodville, South Australia, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Ron Grunstein
- Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- Health Economics, College of Medicine and Public Health, Bedford Park, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Emer Van Ryswyk
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW, Australia; Sleep and Chronobiology Research Group, Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Vakulin
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
| | - Nicole Lovato
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia; National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia
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