Hypnotic medication in the treatment of chronic insomnia: non nocere! Doesn't anyone care?

Relationship of psychotropic medication use with physical function among postmenopausal women

To examine cross-sectional and longitudinal relationships of psychotropic medications with physical function after menopause. Analyses involved 4557 Women's Health Initiative Long Life Study (WHI-LLS) participants (mean age at WHI enrollment (1993-1998): 62.8 years). Antidepressant, anxiolytic, and sedative/hypnotic medications were evaluated at WHI enrollment and 3-year follow-up visits. Performance-based physical function [Short Physical Performance Battery (SPPB)] was assessed at the 2012-2013 WHI-LLS visit. Self-reported physical function [RAND-36] was examined at WHI enrollment and the last available follow-up visit-an average of 22 [±2.8] (range: 12-27) years post-enrollment. Multivariable regression models controlled for socio-demographic, lifestyle, and health characteristics. Anxiolytics were not related to physical function. At WHI enrollment, antidepressant use was cross-sectionally related to worse self-reported physical function defined as a continuous (β = -6.27, 95% confidence interval [CI]: -8.48, -4.07) or as a categorical (< 78 vs. ≥ 78) (odds ratio [OR] = 2.10, 95% CI: 1.48, 2.98) outcome. Antidepressant use at WHI enrollment was also associated with worse performance-based physical function (SPPB) [< 10 vs. ≥ 10] (OR = 1.53, 95% CI: 1.05, 2.21) at the 2012-2013 WHI-LLS visit. Compared to non-users, those using sedative/hypnotics at WHI enrollment but not at the 3-year follow-up visit reported a faster decline in physical function between WHI enrollment and follow-up visits. Among postmenopausal women, antidepressant use was cross-sectionally related to worse self-reported physical function, and with worse performance-based physical function after > 20 years of follow-up. Complex relationships found for hypnotic/sedatives were unexpected and necessitate further investigation.

Challenges and visions for managing pain-related insomnia in primary care using the hybrid CBT approach: a small-scale qualitative interview study with GPs, nurses, and practice managers

Background

Chronic pain and insomnia have a complex, bidirectional relationship – addressing sleep complaints alongside pain may be key to alleviating patient-reported distress and disability. Healthcare professionals have consistently reported wanting to offer psychologically informed chronic pain management at the primary care level. Research in secondary care has demonstrated good treatment efficacy of hybrid CBT for chronic pain and insomnia. However, primary care is typically the main point of treatment entry, hence may be better situated to offer treatments using a multidisciplinary approach. In this study, primary care service providers’ perception of feasibility for tackling pain-related insomnia in primary care was explored.

Methods

The data corpus originates from a feasibility trial exploring hybrid CBT for chronic pain and insomnia delivered in primary care. This formed three in-depth group interviews with primary care staff (n = 9) from different primary care centres from the same NHS locale. All interviews were conducted on-site using a semi-structured approach. Verbal data was recorded, transcribed verbatim and analysed using the thematic analysis process.

Results

Eight themes were identified – 1) Discrepant conceptualisations of the chronic pain-insomnia relationship and clinical application, 2) Mismatch between patients’ needs and available treatment offerings, 3) Awareness of psychological complexities, 4) Identified treatment gap for pain-related insomnia, 5) Lack of funding and existing infrastructure for new service development, 6) General shortage of psychological services for complex health conditions, 7) Multidisciplinary team provision with pain specialist input, and 8) Accessibility through primary care. These mapped onto four domains - Current understanding and practice, Perceived facilitators, Perceived barriers, Ideal scenarios for a new treatment service – which reflected the focus of our investigation. Taken together these provide key context for understanding challenges faced by health care professionals in considering and developing a new clinical service.

Conclusions

Primary care service providers from one locale advocate better, multidisciplinary treatment provision for chronic pain and insomnia. Findings suggest that situating this in primary care could be a feasible option, but this requires systemic support and specialist input as well as definitive trials for success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01552-3.

A Review of Psychiatric Comorbidity in Myasthenia Gravis

This study aimed to review studies focused on the affective comorbidities associated with myasthenia gravis and to determine the extent to which neuromuscular treatment modalities address non-somatic aspects of autoimmune myasthenia gravis. Depression, anxiety, and emotional hyperactivity can aggravate myasthenia gravis, hinder accurate diagnoses, and presumably influence overall health-related quality of life.

Studies were identified using PubMed Medline and Web of Science to assess the effects of psychological factors on myasthenia gravis, encompassing 49 years of research worldwide. After analysis, approximately 6,060 patients from 32 studies worldwide between 1971 and 2020 were included. Standard-of-care approaches to diagnosis and treatment continue to under-appreciate the prevalence or impact of mood disorders in myasthenia gravis.

The majority of studies evaluated demonstrated an association between myasthenia gravis and mood disorders. However, the initiative to detect and treat affective comorbidities probably remains suboptimal. Although treatments for the somatic effects of myasthenia gravis have evolved over the past century, the paradigm of clinical practice has yet to adequately address the management of psychological impacts on the disease. This review is hoped to raise the necessary awareness in this regard.

Group cognitive-behavioral therapy in insomnia: a cross-sectional case-controlled study

BACKGROUND

Group cognitive-behavioral therapy (GCBT) might meet the considerable treatment demand of insomnia, but its effectiveness needs to be addressed.

PARTICIPANTS

This study recruited 27 insomnia patients treated with 16-weeks of zolpidem (zolpidem group), 26 patients treated with 4-weeks of zolpidem and also treated with 12-weeks of GCBT (GCBT group), and 31 healthy control volunteers.

METHODS

Before treatment and 16 weeks after intervention, participants were evaluated using the Patient Health Questionnaires (Patient Health Questionnaire-9 [PHQ-9] and Patient Health Questionnaire-15 [PHQ-15]), the Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16), and the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Compared to the zolpidem and healthy control groups, the scale scores of PHQ-9, PHQ-15, DBAS-16 and PSQI were significantly reduced after intervention in the GCBT group. Regarding the score changes, there were correlations between PSQI, DBAS-16, PHQ-9, and PHQ-15 scales in the zolpidem group, but there were limited correlations between PSQI and some DBAS-16 scales in the GCBT group.

CONCLUSION

Our results indicate that GCBT is effective to treat insomnia by improving sleep quality and reducing emotional and somatic disturbances; thus, the study supports the advocacy of applying group psychotherapy to the disorder.

An approach to long-term sedative-hypnotic use

Insomnia is a common, often chronic medical disorder with significant medical and socioeconomic repercussions. However, unlike other medical conditions, there is intense debate as to whether the long-term treatment of insomnia is clinically appropriate. The perceived deleterious side effect of sedative-hypnotic medications may result in patients remaining untreated or undertreated. This review proposes that a more subtle approach needs to be taken in the management of patients with chronic insomnia and that long-term use of the newer sedative-hypnotics may be a feasible and effective treatment option when used in conjunction with thorough medical assessment and regular patient follow-up. This review discusses these issues and discusses the pros and cons of long-term sedative-hypnotic use.

Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia

STUDY OBJECTIVES

to evaluate the efficacy and safety of doxepin 1 mg and 3 mg in elderly subjects with chronic primary insomnia.

DESIGN AND METHODS

the study was a randomized, double-blind, parallel-group, placebo-controlled trial. Subjects meeting DSM-IV-TR criteria for primary insomnia were randomized to 12 weeks of nightly treatment with doxepin (DXP) 1 mg (n = 77) or 3 mg (n = 82), or placebo (PBO; n = 81). Efficacy was assessed using polysomnography (PSG), patient reports, and clinician ratings. Objective efficacy data are reported for Nights (N) 1, 29, and 85; subjective efficacy data during Weeks 1, 4, and 12; and Clinical Global Impression (CGI) scale and Patient Global Impression (PGI) scale data after Weeks 2, 4, and 12 of treatment. Safety assessments were conducted throughout the study.

RESULTS

DXP 3 mg led to significant improvement versus PBO on N1 in wake time after sleep onset (WASO; P < 0.0001; primary endpoint), total sleep time (TST; P < 0.0001), overall sleep efficiency (SE; P < 0.0001), SE in the last quarter of the night (P < 0.0001), and SE in Hour 8 (P < 0.0001). These improvements were sustained at N85 for all variables, with significance maintained for WASO, TST, overall SE, and SE in the last quarter of the night. DXP 3 mg significantly improved patient-reported latency to sleep onset (Weeks 1, 4, and 12), subjective TST (Weeks 1, 4, and 12), and sleep quality (Weeks 1, 4, and 12). Several global outcome-related variables were significantly improved, including the severity and improvement items of the CGI (Weeks 2, 4, and 12), and all 5 items of the PGI (Week 12; 4 items after Weeks 2 and 4). Significant improvements were observed for DXP 1 mg for several measures including WASO, TST, overall SE, and SE in the last quarter of the night at several time points. Rates of discontinuation were low, and the safety profiles were comparable across the 3 treatment groups. There were no significant next-day residual effects; additionally, there were no reports of memory impairment, complex sleep behaviors, anticholinergic effects, weight gain, or increased appetite.

CONCLUSIONS

DXP 1 mg and 3 mg administered nightly to elderly chronic insomnia patients for 12 weeks resulted in significant and sustained improvements in most endpoints. These improvements were not accompanied by evidence of next-day residual sedation or other significant adverse effects. DXP also demonstrated improvements in both patient- and physician-based ratings of global insomnia outcome. The efficacy of DXP at the doses used in this study is noteworthy with respect to sleep maintenance and early morning awakenings given that these are the primary sleep complaints of the elderly. This study, the longest placebo-controlled, double-blind, polysomnographic trial of nightly pharmacotherapy for insomnia in the elderly, provides the best evidence to date of the sustained efficacy and safety of an insomnia medication in older adults.

Persistent insomnia in chronic hypnotic users presenting to a sleep medical center: a retrospective chart review of 137 consecutive patients

Chronic insomnia patients may fail pharmacotherapy. We reviewed charts on 137 chronic insomnia patients new to our sleep medical center who reported persisting insomnia despite long-term usage of pharmacotherapy. We examined 4 areas: (1) patient views on encounters with prescribing physicians; (2) self-reported medication efficacy; (3) treatment-seeking goals; and (4) completion of a sleep medicine workup. Insomnia chronicity averaged 13 years; use of prescription medication for sleep averaged 3.81 years. Encounters with prescribing physicians yielded few options beyond drugs. Drug efficacy was not optimal for most of these patients. Sleeping better or drug-free were their chief goals. Subjective and objective sleep measures confirmed moderately severe residual insomnia as well as fair to poor waking impairment and quality of life. Sleep workup revealed high rates of maladaptive behavioral influences (96%), psychiatric complaints (89%), and obstructive sleep apnea (71%). In chronic insomnia patients who failed pharmacotherapy, comorbid mental and physical factors indicated a sleep disturbance complexity unlikely to respond fully to medication.

Patients with treatment-resistant insomnia taking nightly prescription medications for sleep: a retrospective assessment of diagnostic and treatment variables

BACKGROUND

Some chronic insomnia patients who take nightly prescription medication achieve less than optimal results. The US Food and Drug Administration (FDA) and the American Academy of Sleep Medicine (AASM) recommend reevaluation of this type of patient to assess for potential psychiatric or medical causes to explain this "failure for insomnia to remit."

METHOD

A retrospective chart review examined a consecutive series of chronic insomnia patients with persistent insomnia complaints despite current nightly use of prescription medication from May 2005 to February 2008. To assess the role of psychiatric influences on insomnia symptoms, our sample (N = 218) was divided into 2 subgroups: a group with a history of psychiatric complaints (psychiatric insomnia, n = 189) and a control group of no psychiatric complaints (insomnia, n = 29).

RESULTS

The average patient reported insomnia for a decade and took prescription medication for sleep for a mean of 4.5 years. Although 100% of the sample used nightly sleep drugs, only 20% believed medication was the best solution for their condition. As evaluated by self-report and polysomnography, these patients exhibited moderately severe insomnia across most measures. Only a few differences were noted between groups. Subjective perception of insomnia severity was worse in the psychiatric insomnia group, which also reported significantly more insomnia-related interference in daily functioning, symptoms of sleep maintenance insomnia, and a trend toward greater daytime fatigue. The mean Apnea-Hypopnea Index score was 19.5 events/hour, yielding an obstructive sleep apnea diagnosis in 75% of patients per conservative AASM nosology (79% in the insomnia group and 74% in the psychiatric insomnia group, P = .22).

CONCLUSIONS

In this treatment-seeking sample of patients regularly taking sleep medications, residual insomnia was widespread, and patients with psychiatric insomnia may have perceived their condition as more problematic than a control group of insomnia patients without mental health complaints. Both groups exhibited high rates of objectively diagnosed obstructive sleep apnea, a medical condition associated with pervasive sleep fragmentation. These findings support FDA and AASM guidelines to reassess chronic insomnia patients who manifest residual symptoms despite nightly use of prescription medication for sleep.

A systematic review of research examining benzodiazepine-related mortality

PURPOSE

This paper will review literature examining the association of benzodiazepine use and mortality.

METHODS

An extensive literature review was undertaken to locate all English-language published articles that examine mortality risk associated with use of benzodiazepines from 1990 onwards.

RESULTS

Six cohort studies meeting the criteria above were identified. The results were mixed. Three of the studies assessed elderly populations and did not find an increased risk of death associated with benzodiazepine use, whereas another study of the general population did find an increased risk, particularly for older age groups. A study of a middle aged population found that regular benzodiazepine use was associated with an increased mortality risk, and a study of 'drug misusers' found a significant relationship between regular use of non-prescribed benzodiazepines and fatal overdose. Three retrospective population-based registry studies were also identified. The first unveiled a high relative risk (RR) of death due to benzodiazepine poisoning versus other outcomes in patients 60 or older when compared to those under 60. A positive but non-significant association between benzodiazepine use and driver-responsible fatalities in on-road motor vehicle accidents was reported. Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug.

CONCLUSION

On the basis of existing research there is limited data examining independent effects of illicit benzodiazepine use upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use.

Long-term efficacy and safety of zolpidem extended-release 12.5 mg, administered 3 to 7 nights per week for 24 weeks, in patients with chronic primary insomnia: a 6-month, randomized, double-blind, placebo-controlled, parallel-group, multicenter study

STUDY OBJECTIVES

To evaluate long-term efficacy and safety of zolpidem extended-release 3 to 7 nights/week for chronic primary insomnia.

DESIGN

Multicenter, 25-week, phase IIIb, randomized, double-blind, placebo-controlled, parallel-group.

SETTING

Outpatient; visits every 4 weeks.

PATIENTS

Aged 18 to 64 years; DSM-IV criteria for chronic primary insomnia; > or =3 months of difficulty initiating or maintaining sleep or experiencing nonrestorative sleep.

INTERVENTIONS

Single-dose zolpidem extended-release 12.5 mg (n = 669) or placebo (n = 349), self-administered from a minimum of 3 nights/week to a maximum of 7 nights/week.

MEASUREMENTS AND RESULTS

Patient's Global Impression (PGI) and Clinical Global Impression-Improvement (CGI-I) were assessed every 4 weeks up to week 24. Patient Morning Questionnaire (PMQ), recorded daily, assessed subjective sleep measures-sleep onset latency (SOL), total sleep time (TST), number of awakenings (NAW), wake time after sleep onset (WASO), and quality of sleep (QOS)-and next-day functioning. At week 12, PGI, Item 1 (aid to sleep), the primary endpoint, was scored as favorable (i.e., "helped me sleep") by 89.8% of zolpidem patients vs. 51.4% of placebo patients (P < 0.0001, based on rank score) and at week 24 by 92.3% of zolpidem extended-release patients vs. 59.7% of placebo patients. Zolpidem extended-release also was statistically significantly superior to placebo at every time point for PGI (Items 1-4) and CGI-I (P < 0.0001, rank score), TST, WASO, QOS (P < 0.0001), and SOL (P < or = 0.0014); NAW (Months 2-6; P < 0.0001). Sustained improvement (P < 0.0001, all time points) was observed in morning sleepiness and ability to concentrate (P = 0.0014, month 6) with zolpidem extended-release compared with placebo. Most frequent adverse events for zolpidem extended-release were headache, anxiety and somnolence. No rebound effect was observed during the first 3 nights of discontinuation.

CONCLUSIONS

These findings establish the efficacy of 3 to 7 nights per week dosing of zolpidem extended-release 12.5 mg for up to 6 months. Treatment provided sustained and significant improvements in sleep onset and maintenance and also improved next-day concentration and morning sleepiness.

Mood and anxiety disorders in patients with myasthenia gravis: aetiology, diagnosis and treatment

Myasthenia gravis (MG) is a chronic, autoimmune disease involving neuromuscular junctions. It is frequently associated with symptoms such as loss of muscle strength, difficulty in respiration and swallowing, diplopia and ptosis. All chronic diseases, including MG, may have psychiatric consequences in terms of coping and adaptation. Psychiatric morbidity usually appears as anxiety disorders, such as panic disorder and generalised anxiety disorder, and as depressive disorders. However, there are very few data on the prevalence and aetiology of such psychiatric symptoms in patients with MG, and those available in the literature are generally from old studies with poor methodology. The interaction between MG and psychiatric disorders needs to be appreciated, especially in the primary care setting, since the symptoms may overlap. MG may be under-recognised initially because the psychiatric symptoms may coincide with those of the actual disease, such as fatigue, lack of energy and shortness of breath. On the other hand, co-morbid psychiatric symptoms that appear during the course of the illness may be misdiagnosed as true myasthenic symptoms; thus, leading to unnecessary drug treatment. Differentiation of the aetiology of these symptoms might alter the treatment choice and, therefore, affect the treatment success rate and patients' well-being. Psychiatric treatments must be carefully planned because of the risk of aggravating the underlying neurological disease. Even though there appears to be an intricate relationship between MG and psychiatric symptoms, there is very limited information on this subject. As such, prospective, randomised, controlled pharmaco/psychotherapy studies are needed to better direct the management of patients and, thus, improve quality of life during the course of the illness.

Insomnia: conceptual issues in the development, persistence, and treatment of sleep disorder in adults

This paper critically reviews the evidence base for previously reported conceptual models of the development and persistence of insomnia. Although a number of perspectives have some empirical support, no one approach emerges as preeminent. Importantly, the efficacy of any particular psychological intervention cannot be taken as confirmation of presumed, underlying mechanisms. An integrated psychobiological inhibition model of insomnia is developed that accounts for the research data. The model views insomnia as arising from inhibition of de-arousal processes associated with normal sleep. It is proposed that sleep homeostatic and circadian factors are compromised by impairment of the automaticity and plasticity associated with good sleep, and that cognitive/affective processes activate the clinical complaint of insomnia. Common pathways for the action of cognitive-behavioral interventions are identified, and a research agenda is set for further conceptual and clinical study.

Sleep disturbances in patients with Alzheimer's disease: epidemiology, pathophysiology and treatment

Older adults represent an ever-growing proportion of the population of the industrialised nations, with a corresponding increase in the numbers of patients with dementing disorders. A common complaint in both normal aging and the dementias is that of significant sleep disturbance. The major causes of sleep disruption in aging and dementia include: (i) physiological changes that arise as part of normal, 'nonpathological' aging; (ii) sleep problems due to one of many physical or mental health conditions and their treatments; (iii) primary sleep disorders; (iv) poor 'sleep hygiene', that is, sleep-related practices and habits; and (v) some combination of these factors. Disrupted sleep in patients with dementia is a significant cause of stress for caregivers and frequently leads to institutionalisation of patients. It should be a target of clinical management when the goal is sustained home care, and when it is associated with disturbances of mood or behaviour. While the neuropathology of dementia can directly disrupt sleep, sleep disturbances in patients with dementia often have multiple causes that require systematic evaluation. Thorough assessment of associated psychopathology, day-time behaviour, medical disorders, medications, pain and environmental conditions is needed for optimal management. Differential diagnosis of a sleep problem in dementia is the basis of rational pharmacotherapy. However, patients with dementia are likely to be more sensitive than elderly persons without dementia to adverse cognitive and motor effects of drugs prescribed for sleep. Clinicians need to: (i) evaluate sleep outcomes when treating medical, psychiatric and behavioural disorders in older adults; (ii) be alert to emerging behavioural and environmental approaches to treatment; (iii) combine nonpharmacological strategies with drug therapies, when required, for added value; and (iv) avoid use of multiple psychotropic medications unless they prove essential to the adequate management of sleep disturbances.

Treatment of sleep disturbance in Alzheimer's disease

The prevalence of Alzheimer's disease (AD) is rapidly increasing as growing numbers of people around the world are living to old age. Sleep disturbances are a common, and often highly disruptive, behavioral symptom associated with AD. Nevertheless, the study of sleep in AD is relatively new. Little is known about the moderating factors that may alter a given patient's risk for developing sleep problems, or that may influence severity of presentation and persistence. Current treatments for improving sleep in AD fall into three broad categories: (i) pharmacological; (ii) cognitive-behavioral or psycho-educational strategies; and (iii) biological/circadian therapies. There are few studies demonstrating the efficacy of these treatments with community-dwelling AD patients, although studies with persons in institutional settings are promising. In this review, it is suggested that sleep problems in AD are multi-factorial, and influenced by a variety of demographic, physical, psychiatric and situational factors. These factors vary in how readily they can be modified and in how relevant they are to any individual case. Thus, when developing a treatment plan for sleep problems in a dementia patient, it is important to evaluate the underlying causes as well as the context in which the problems are occurring, and to target the intervention accordingly.