Effectiveness of Benzodiazepine Receptor Agonists in the Treatment of Insomnia: An Examination of Response and Remission Rates

Prevalence of co-morbid insomnia and obstructive sleep apnoea

INTRODUCTION

The coexistence of insomnia and obstructive sleep apnea (OSA) poses a complex and challenging clinical scenario, commonly referred to as comorbid insomnia and OSA (COMISA). The bidirectional relationship between these two sleep disorders is explored, illuminating how the presence of one can exacerbate the severity and manifestations of the other. We under took this study to understand the prevalence of COMISA in Indians which is never studied.

AIM

To study the prevalence of COMISA in tertiary hospital in India.

METHODS

All OSA patients diagnosed with polysomnography were interviewed with insomnia severity index. Patients having score of more than 15 were considered to have insomnia. Demographic factors, clinical and physical examination and polysomnography values were noted.

RESULTS

25% of 64 patients were diagnosed to have COMISA. Female gender, BMI, and STOP BANG score had positive association with COMISA, whereas age was not associated with increased risk.

CONCLUSION

COMISA can be more complex to diagnose and manage than insomnia or OSA alone. The symptoms and mechanisms of each condition have synergistic effect and is a barrier to treating COMISA.

A multidimensional investigation of sleep and biopsychosocial profiles with associated neural signatures

Sleep is essential for optimal functioning and health. Interconnected to multiple biological, psychological and socio-environmental factors (i.e., biopsychosocial factors), the multidimensional nature of sleep is rarely capitalized on in research. Here, we deployed a data-driven approach to identify sleep-biopsychosocial profiles that linked self-reported sleep patterns to inter-individual variability in health, cognition, and lifestyle factors in 770 healthy young adults. We uncovered five profiles, including two profiles reflecting general psychopathology associated with either reports of general poor sleep or an absence of sleep complaints (i.e., sleep resilience) respectively. The three other profiles were driven by sedative-hypnotics-use and social satisfaction, sleep duration and cognitive performance, and sleep disturbance linked to cognition and mental health. Furthermore, identified sleep-biopsychosocial profiles displayed unique patterns of brain network organization. In particular, somatomotor network connectivity alterations were involved in the relationships between sleep and biopsychosocial factors. These profiles can potentially untangle the interplay between individuals' variability in sleep, health, cognition and lifestyle - equipping research and clinical settings to better support individual's well-being.

Prognostic models for predicting insomnia treatment outcomes: A systematic review

OBJECTIVE

To identify and critically evaluate models predicting insomnia treatment response in adult populations.

METHODS

Pubmed, EMBASE, and PsychInfo databases were searched from January 2000 to January 2023 to identify studies reporting the development or validation of multivariable models predicting insomnia treatment outcomes in adults. Data were extracted according to CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) guidelines and study quality was assessed using the Prediction model study Risk Of Bias Assessment Tool (PROBAST).

RESULTS

Eleven studies describing 53 prediction models were included and appraised. Treatment response was most frequently assessed using wake after sleep onset (n = 10; 18.9%), insomnia severity index (n = 10; 18.9%), and sleep onset latency (n = 9, 17%). Dysfunctional Beliefs About Sleep (DBAS) score was the most common predictor in final models (n = 33). R2 values ranged from 0.06 to 0.80 for models predicting continuous response and area under the curve (AUC) ranged from 0.73 to 0.87 for classification models. Only two models were internally validated, and none were externally validated. All models were rated as having a high risk of bias according to PROBAST, which was largely driven by the analysis domain.

CONCLUSION

Prediction models may be a useful tool to assist clinicians in selecting the optimal treatment strategy for patients with insomnia. However, no externally validated models currently exist. These results highlight an important gap in the literature and underscore the need for the development and validation of modern, methodologically rigorous models.

Insomnia medications: History, characteristics, and guidelines for optimal use in clinical practice

This article reviews the history of insomnia pharmacotherapy, documenting the evolution that has occurred over time in the increasing availability of medications with novel mechanisms of action that more specifically target the neural systems that modulate sleep/wake function. This evolution provides an increasing capacity to improve the effectiveness of insomnia pharmacotherapy by allowing the selection of medications that specifically target the particular type of sleep difficulty present in each patient. As a result, they can achieve a therapeutic effect with fewer effects on aspects of brain function other than those needed to achieve benefit, thereby minimising adverse effects. The accumulated evidence-base is such that it can serve as the basis for a personalised insomnia pharmacotherapy paradigm. Here we outline a set of best-practice recommendations for how to carry out optimised personalised insomnia pharmacotherapy based on that evidence base in the hope that it will improve the treatment delivered to the many individuals suffering from insomnia.

Toward personalized care for insomnia in the US Army: development of a machine-learning model to predict response to pharmacotherapy

STUDY OBJECTIVES

Although many military personnel with insomnia are treated with prescription medication, little reliable guidance exists to identify patients most likely to respond. As a first step toward personalized care for insomnia, we present results of a machine-learning model to predict response to insomnia medication.

METHODS

The sample comprised n = 4,738 nondeployed US Army soldiers treated with insomnia medication and followed 6-12 weeks after initiating treatment. All patients had moderate-severe baseline scores on the Insomnia Severity Index (ISI) and completed 1 or more follow-up ISIs 6-12 weeks after baseline. An ensemble machine-learning model was developed in a 70% training sample to predict clinically significant ISI improvement, defined as reduction of at least 2 standard deviations on the baseline ISI distribution. Predictors included a wide range of military administrative and baseline clinical variables. Model accuracy was evaluated in the remaining 30% test sample.

RESULTS

21.3% of patients had clinically significant ISI improvement. Model test sample area under the receiver operating characteristic curve (standard error) was 0.63 (0.02). Among the 30% of patients with the highest predicted probabilities of improvement, 32.5.% had clinically significant symptom improvement vs 16.6% in the 70% sample predicted to be least likely to improve (χ21 = 37.1, P < .001). More than 75% of prediction accuracy was due to 10 variables, the most important of which was baseline insomnia severity.

CONCLUSIONS

Pending replication, the model could be used as part of a patient-centered decision-making process for insomnia treatment, but parallel models will be needed for alternative treatments before such a system is of optimal value.

CITATION

Gabbay FH, Wynn GH, Georg MW, et al. Toward personalized care for insomnia in the US Army: development of a machine-learning model to predict response to pharmacotherapy. J Clin Sleep Med. 2023;19(8):1399-1410.

Use of Sleep Aids in Insomnia: The Role of Time Monitoring Behavior

Objective: Over-the-counter (OTC) and prescription sleep medications are frequently used as treatments for chronic insomnia, despite risks and limited long-term efficacy. Investigating mechanisms underlying this predilection for pharmacotherapy may uncover strategies to decrease reliance on sleep aids. The objective of this study was to determine how time monitoring behavior (TMB; clock-watching) and associated frustration may interact with insomnia symptoms to drive the use of sleep aids.

Methods: Patients (N = 4,886) presenting for care at a community-based, private sleep medical center between May 2003 and October 2013 completed the Insomnia Severity Index (ISI) and Time Monitoring Behavior-10 (TMB-10) and reported their frequency of sleep medication use (OTC and prescription, separately). Mediation analyses examined how clock-watching and related frustration could be associated with insomnia symptoms and medication use.

Results: The relationship between TMB and sleep medication use was significantly explained by ISI (P < .05), in that TMB (especially related frustration) appears to aggravate insomnia, which in turn leads to sleep aid use. Similarly, but to a lesser extent, the relationship between ISI and sleep medication use was explained by TMB, in that ISI may lead to increased TMB, which may in turn lead to sleep aid use.

Conclusions: TMB and the associated frustration it engenders may perpetuate a negative cycle of insomnia and sleep aid use. Future longitudinal and interventional research is necessary to examine the developmental course of these clinical symptoms and behaviors and to test whether decreasing frustration by limiting TMB reduces the proclivity for pharmacotherapy.

Clinical Spectrum and Trajectory of Innovative Therapeutic Interventions for Insomnia: A Perspective

Increasing incidences of insomnia in adults, as well as the aging population, have been reported for their negative impact on the quality of life. Insomnia episodes may be associated with neurocognitive, musculoskeletal, cardiovascular, gastrointestinal, renal, hepatic, and metabolic disorders. Epidemiological evidence also revealed the association of insomnia with oncologic and asthmatic complications, which has been indicated as bidirectional. Two therapeutic approaches including cognitive behavioral therapy (CBT) and drugs-based therapies are being practiced for a long time. However, the adverse events associated with drugs limit their wide and long-term application. Further, Traditional Chinese medicine, acupressure, and pulsed magnetic field therapy may also provide therapeutic relief. Notably, the recently introduced cryotherapy has been demonstrated as a potential candidate for insomnia which could reduce pain, by suppressing oxidative stress and inflammation. It seems that the synergistic therapeutic approach of cryotherapy and the above-mentioned approaches might offer promising prospects to further improve efficacy and safety. Considering these facts, this perspective presents a comprehensive summary of recent advances in pathological aetiologies of insomnia including COVID-19, and its therapeutic management with a greater emphasis on cryotherapy.

A protocol for a randomized controlled trial comparing Sleepwell, EMPOWER, and treatment-as-usual for benzodiazepine receptor agonist discontinuation in older adults: the your answers when needing sleep in New Brunswick (YAWNS NB) study

Background

Chronic benzodiazepine receptor agonist (BZRA) use among older adults is a public health concern given cognitive and physical risks. One in four older adults in New Brunswick, Canada, is a long-term user of BZRAs. Previous studies using a direct-to-patient approach as the primary intervention target have shown promise in reducing BZRA use. The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study aims to reduce the long-term use of BZRAs in older adults and increase the use of cognitive behavioural therapy for insomnia (CBTi), which is the recommended first line treatment.

Methods

The trial (ClinicalTrials.gov registration NCT04406103) is a three arm, open-label, parallel randomized controlled trial in NB, Canada. Eligible participants 65 years and older using BZRAs long-term will be randomly allocated to: the Eliminating Medications through Patient Ownership of End Results (EMPOWER) information package group; the Sleepwell information package group; or treatment-as-usual (TAU). Information packages will be mailed via Canada Post. The primary outcome of BZRA discontinuation at 6 months will be compared across groups. Secondary outcomes include participants with ≥25% BZRA dose reduction, and switching to newly prescribed alternate sedative-hypnotics. Several exploratory outcomes will also be examined.

Discussion

Targeting participants with information packages informing them of appropriate use, dangers, and approaches to reducing BZRA use and increasing CBTi use may be beneficial in a region of Canada with the highest rate of chronic BZRA use in older adults. Comparing information packages and TAU will provide insights into the effectiveness of direct-to-patient interventions for BZRA reduction.

Pharmacotherapeutic management of insomnia and effects on sleep processes, neural plasticity, and brain systems modulating stress: A narrative review

Introduction

Insomnia is a stress-related sleep disorder, may favor a state of allostatic overload impairing brain neuroplasticity, stress immune and endocrine pathways, and may contribute to mental and physical disorders. In this framework, assessing and targeting insomnia is of importance.

Aim

Since maladaptive neuroplasticity and allostatic overload are hypothesized to be related to GABAergic alterations, compounds targeting GABA may play a key role. Accordingly, the aim of this review was to discuss the effect of GABAA receptor agonists, short-medium acting hypnotic benzodiazepines and the so called Z-drugs, at a molecular level.

Method

Literature searches were done according to PRISMA guidelines. Several combinations of terms were used such as “hypnotic benzodiazepines” or “brotizolam,” or “lormetazepam” or “temazepam” or “triazolam” or “zolpidem” or “zopiclone” or “zaleplon” or “eszopiclone” and “insomnia” and “effects on sleep” and “effect on brain plasticity” and “effect on stress system”. Given the complexity and heterogeneity of existing literature, we ended up with a narrative review.

Results

Among short-medium acting compounds, triazolam has been the most studied and may regulate the stress system at central and peripheral levels. Among Z-drugs eszopiclone may regulate the stress system. Some compounds may produce more “physiological” sleep such as brotizolam, triazolam, and eszopiclone and probably may not impair sleep processes and related neural plasticity. In particular, triazolam, eszopiclone, and zaleplon studied in vivo in animal models did not alter neuroplasticity.

Conclusion

Current models of insomnia may lead us to revise the way in which we use hypnotic compounds in clinical practice. Specifically, compounds should target sleep processes, the stress system, and sustain neural plasticity. In this framework, among the short/medium acting hypnotic benzodiazepines, triazolam has been the most studied compound while among the Z-drugs eszopiclone has demonstrated interesting effects. Both offer potential new insight for treating insomnia.

Effectivity of (Personalized) Cognitive Behavioral Therapy for Insomnia in Mental Health Populations and the Elderly: An Overview

Insomnia is very prevalent in psychiatry and is considered a transdiagnostic symptom of mental disorders. Yet, it is not only a consequence of a mental condition but may also exert detrimental effects on psychiatric symptom severity and therapeutic response; thus, adequate insomnia treatment is particularly important in psychiatric populations. The first choice of intervention is cognitive behavioral therapy for insomnia (CBT-I) as it is rather effective, also in the long run without side effects. It is offered in various forms, ranging from in-person therapy to internet-delivered applications. CBT-I protocols are typically developed for individuals with insomnia disorder without co-occurring conditions. For an optimal therapeutic outcome of CBT-I in individuals with comorbid mental disorders, adaptations of the protocol to tailor the treatment might be beneficial. Based on a literature search using major search engines (Embase; Medline; APA Psych Info; and Cochrane Reviews), this paper provides an overview of the effectiveness of the different CBT-I applications in individuals with diverse comorbid mental conditions and older adults and describes the functionality of CBT-I protocols that have been personalized to specific psychiatric populations, such as depression, substance abuse, and schizophrenia spectrum disorder. Finally, we discuss urgent needs for insomnia therapy targeted to improve both sleep and psychopathologies.

Effect of Long-Term Benzodiazepines for Chronic Insomnia on Cognitive Function and Waking Electroencephalography: A Case-Control Study

OBJECTIVE

The relationship between benzodiazepine use and cognitive decline in insomnia patients has been reported, but still conflicting. Thus, we tried to determine whether long-term exposure of benzodiazepine might be associated with changes of cognition and electroencephalography (EEG) findings in patients with chronic insomnia.

METHODS

Insomniacs using benzodiazepines (n=29), drug-free insomniacs (n=27), and age- and sex-matched controls (n=28) were recruited. Neurocognitive function tested with Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet Neuropsychological Assessment Battery, quantitative EEG in awake state, and information of benzodiazepine usage were obtained.

RESULTS

Drug-free insomniacs reported more severe symptoms than insomniacs using benzodiazepine (p<0.001). Insomniacs using benzodiazepine showed a decrease of executive function in Trail Making Test A than drug-free insomniacs and controls (0.73±0.66 vs. 1.27±0.38 vs. 1.09±0.47, p<0.001) and in categorical fluency than drug-free insomniacs (-0.01±0.99 vs. 1.26±0.97, p=0.002). However, such decrease of executive function was not proportional to daily dose or cumulative dose of benzodiazepine. The EEG was not significantly different between insomniacs using benzodiazepine and drug-free insomniacs, while EEG of insomniacs showed low relative theta power in frontal and parietal regions but high relative beta power in frontal region than that of controls.

CONCLUSION

Benzodiazepine users with chronic insomnia showed an impairment of executive function compared to drug-free insomniacs and controls although they showed relatively decreased severity of insomnia symptoms. Chronic insomniacs showed a hyper-arousal manifestation in front-parietal region of brain regardless of benzodiazepine exposure.

Management of chronic insomnia using hypnotics: a friend or a foe?

Epidemiological studies suggest that 10-15% adults meet the present criteria for the diagnosis of insomnia disorder; however, there may be geographical variations. Untreated insomnia disorders have a number of adverse health consequences in addition to economic burden caused by it. Available guidelines mention that CBT-I should be preferred over hypnotics. However, several patients of chronic insomnia are not candidate for CBT-I and for them, hypnotics are the only answer. This paper reviews the literature to answer following questions: What is the current understanding regarding place of hypnotics for in management of insomnia disorder? How many patients misuse or abuse hypnotics, especially benzodiazepines, as commonly believed? Do we have data from human studies regarding low-dose benzodiazepine dependence? What does hypnotics produce-withdrawal insomnia, rebound insomnia or end of dose phenomenon? Are adverse effects of benzodiazepines worse than other psychotropic medications? Is prescription of hypnotics more troublesome than untreated insomnia disorder? Available literature suggests that there is an unreasonable negative bias attached to the use of hypnotics. Only a sub-set of patients who are prescribed hypnotics, meet the criteria for "dependence" in long term. Other patients either discontinue it (as insomnia remits) or change to occasional use (since insomnia may be relapsing remitting disorder), or continue using it in low dose (since insomnia reappears as hypnotics are discontinued, similar to increase in blood sugar after hypoglycemics are discontinued). Meta-analysis shows that adverse effects of hypnotics are comparable to that of other psychotropic medications. Considering the consequences and risks associated with untreated insomnia disorder, even long-term use of hypnotics is justified, however with the careful watch that patients are not increasing the dose. This approach is especially important in geographical areas where trained CBT-I therapists are not available.

Effects of mindful breathing combined with sleep-inducing exercises in patients with insomnia

BACKGROUND

Insomnia is the most common sleep disorder. It disrupts the patient’s life and work, increases the risk of various health issues, and often requires long-term intervention. The financial burden and inconvenience of treatments discourage patients from complying with them, leading to chronic insomnia.

AIM

To investigate the long-term home-practice effects of mindful breathing combined with a sleep-inducing exercise as adjunctive insomnia therapy.

METHODS

A quasi-experimental design was used in the present work, in which the patients with insomnia were included and grouped based on hospital admission: 40 patients admitted between January and April 2020 were assigned to the control group, and 40 patients admitted between May and August 2020 were assigned to the treatment group. The control group received routine pharmacological and physical therapies, while the treatment group received instruction in mindful breathing and a sleep-inducing exercise in addition to the routine therapies. The Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Insomnia Severity Index (ISI) were utilized to assess sleep-quality improvement in the patient groups before the intervention and at 1 wk, 1 mo, and 3 mo postintervention.

RESULTS

The PSQI, GAD-7, and ISI scores before the intervention and at 1 wk postintervention were not significantly different between the groups. However, compared with the control group, the treatment group exhibited significant improvements in sleep quality, daytime functioning, negative emotions, sleep latency, sleep duration, sleep efficiency, anxiety level, and insomnia severity at 1 and 3 mo postintervention (P < 0.05). The results showed that mindful breathing combined with the sleep-inducing exercise significantly improved the long-term effectiveness of insomnia treatment. At 3 mo, the PSQI scores for the treatment vs the control group were as follows: Sleep quality 0.98 ± 0.48 vs 1.60 ± 0.63, sleep latency 1.98 ± 0.53 vs 2.80 ± 0.41, sleep duration 1.53 ± 0.60 vs 2.70 ± 0.56, sleep efficiency 2.35 ± 0.58 vs 1.63 ± 0.49, sleep disturbance 1.68 ± 0.53 vs 2.35 ± 0.53, hypnotic medication 0.53 ± 0.64 vs 0.93 ± 0.80, and daytime dysfunction 1.43 ± 0.50 vs 2.48 ± 0.51 (all P < 0.05). The GAD-7 scores were 2.75 ± 1.50 vs 7.15 ± 2.28, and the ISI scores were 8.68 ± 2.26 vs 3.38 ± 1.76 for the treatment vs the control group, respectively (all P < 0.05).

CONCLUSION

These simple, cost-effective, and easy-to-implement practices used in clinical or home settings could have profound significance for long-term insomnia treatment and merit wide adoption in clinical practice.

Pneumonia Risk Associated with the Use of Individual Benzodiazepines and Benzodiazepine Related Drugs among the Elderly with Parkinson's Disease

Most patients with Parkinson's disease (PD) gradually develop oropharyngeal dysphagia which is often associated with pneumonia risk. The possible association of benzodiazepine (BZD) and benzodiazepine related drugs (BZRD) use with pneumonia risk has received increasing attention but remains controversial. We investigated pneumonia risk associated with the use of BZDs and BZRDs in older adult patients with PD. This case-control study analyzed data of 551,975 older adult patients with PD between 2001 and 2018 in Taiwan. To minimize potential confounding, we used 1:4 propensity score matching to include older adult patients without pneumonia as controls. Incident pneumonia risk was significantly higher in current (adjusted odds ratio (aOR) = 1.25, 95% CI = 1.23-1.27) and past (aOR = 1.13, 95% CI = 1.11-1.15) users of BZDs. Regarding BZRDs, recent (aOR = 1.08, 95% CI = 1.06-1.11) and past (aOR = 0.89, 95% CI = 0.88-0.91) users had higher and lower risks of incident pneumonia, respectively. Pneumonia risk varied based on their use of BZDs and BZRDs. In these individuals, incident pneumonia risk was high in users of BZDs, such as midazolam, lorazepam, flunitrazepam, estazolam, and clonazepam. Regarding the use of BZRDs, zopiclone increased incident pneumonia risk.

Pharmacological and non-pharmacological treatments for insomnia: A protocol for a systematic review and network meta-analysis

BACKGROUND

Although nonpharmacological therapies are recommended as first-line treatments for insomnia, they do not widely implement in practice owing to costly or time-consuming. As a result, pharmacotherapy remains to be commonly prescribed for patients with the sleep disorder. Pharmacotherapy for insomnia consists of different types of drugs. Few studies focused on comprehensively evaluating all available drugs for insomnia. Our review aims to compare efficacy and safety of pharmacological and nonpharmacological treatments by synthesizing direct evidence and indirect evidence to help clinicians and patients make informed decisions for insomnia.

METHODS

We will search the MEDLINE, EMBASE, and Cochrane Register of Controlled Trials between January 2000 and June 12, 2021. Randomized controlled trials of pharmacological and nonpharmacological interventions for insomnia will be included. Study quality will be assessed on the basis of the methodology and categories described in the Cochrane Collaboration Handbook. Eight network meta-analyses were conducted. A Bayesian network meta-analysis would be performed, and relative ranking of agents would be assessed. A node splitting method will be used to examine the inconsistency between direct and indirect comparisons when a loop connecting 3 arms exists.

RESULTS

The results of this paper will be submitted to a peer-reviewed journal for publication.

CONCLUSION

The conclusion of our study will provide updated evidence to rank the effectiveness and safety of pharmacological and nonpharmacological interventions for insomnia.

ETHICS AND DISSEMINATION

Ethical approval is not applicable, as this study is a network meta-analysis based on published trials.

INPLASY REGISTRATION NUMBER

INPLASY202160031.

Multimodal sleep, an innovation for treating chronic insomnia: case report and literature review

The authors present the clinical case of a 67-year-old man with severe insomnia for 5 years with an exacerbation about 1 year before consultation. He did not have enough concentration and energy for his daily work and developed depression and anxiety because of his excessive daytime sleepiness. During his insomniac state, a drug treatment provided partial relief, but the effects were not long-lasting. Consequently, the drug dosage increased, and major side effects gradually manifested. We decided to use a completely new therapeutic strategy for this patient to improve his sleep quality and mental symptoms. In time, the patient could stop oral medications and that is multimodal sleep. After the end of multimodal sleep, the patient typically experiences improvement in sleep quality and architecture. Additionally, the dosage of hypnotics used before multimodal sleep is discontinued without severe withdrawal symptoms.

CITATION

Zhang J-F, Williams JP, Zhao Q-N, et al. Multimodal sleep, an innovation for treating chronic insomnia: case report and literature review. J Clin Sleep Med. 2021;17(8):1737-1742.

Cost-effectiveness of digital cognitive behavioral therapy (Sleepio) for insomnia: a Markov simulation model in the United States

STUDY OBJECTIVES

To examine the cost-effectiveness and potential net monetary benefit (NMB) of a fully automated digital cognitive behavioral therapy (CBT) intervention for insomnia compared with no insomnia treatment in the United States (US). Similar relative comparisons were made for pharmacotherapy and clinician-delivered CBT (individual and group).

METHODS

We simulated a Markov model of 100,000 individuals using parameters calibrated from the literature including direct (treatment) and indirect costs (e.g. insomnia-related healthcare expenditure and lost workplace productivity). Health utility estimates were converted into quality-adjusted life years (QALYs) and one QALY was worth $50,000. Simulated individuals were randomized equally to one of five arms (digital CBT, pharmacotherapy, individual CBT, group CBT, or no insomnia treatment). Sensitivity was assessed by bootstrapping the calibrated parameters. Cost estimates were expressed in 2019 US dollars.

RESULTS

Digital CBT was cost beneficial when compared with no insomnia treatment and had a positive NMB of $681.06 (per individual over 6 months). Bootstrap sensitivity analysis demonstrated that the NMB was positive in 94.7% of simulations. Relative to other insomnia treatments, digital CBT was the most cost-effective treatment because it generated the smallest incremental cost-effectiveness ratio (-$3,124.73).

CONCLUSIONS

Digital CBT was the most cost-effective insomnia treatment followed by group CBT, pharmacotherapy, and individual CBT. It is financially prudent and beneficial from a societal perspective to utilize automated digital CBT to treat insomnia at a population scale.

Multitargeting the sleep-pain interaction with pharmacological approaches: A narrative review with suggestions on new avenues of investigation

The multimorbidity formed by sleep disturbances and pain conditions is highly prevalent and has a significant impact in global health and in the socioeconomic system. Although different approaches have been directed toward its management, evidence regarding an optimal treatment is lacking, and pharmacological options are often preferred. Health professionals (e.g., pain and sleep clinicians) tend to focus on their respective expertise, targeting a single symptom with a single drug. This may increase polypharmacy and the risk of drug interactions, adverse events, and mortality. Hence, the use of medications that can directly or indirectly improve sleep, pain, and other possible accompanying conditions without exacerbating them becomes especially relevant. The objectives of this comprehensive review are to: a) describe the beneficial or deleterious effects that some commonly used medications to manage pain have on sleep and sleep disorders; and b) describe the beneficial or deleterious effects that frequently prescribed medications for sleep may have on pain. Moreover, medications targeting some specific sleep-pain interactions will be suggested and future directions for improving sleep and alleviating pain of these patients will be provided with clinical and research perspectives.

Evaluation of sedative effects of an intranasal dosage form containing saffron, lettuce seeds and sweet violet in primary chronic insomnia: A randomized, double-dummy, double-blind placebo controlled clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Persian Medicine (TPM) has been established as a valuable source of medicinal plants for the treatment of insomnia for thousands of years. Accordingly, oil extracts from plants' parts have been widely used to alleviate central nervous system (CNS) ailments including sleep disorders. A number of preparations have been recommended by TPM for the treatment of insomnia. Among them, an intranasal formulation containing oily macerates of Viola odorata L., Crocus sativus L. and Lactuca sativa L. stands out.

AIM OF THE STUDY

In the present double-dummy, double-blind placebo controlled clinical trial, we aim to evaluate the effectiveness of a combination of violet oil, saffron oil, and lettuce seeds oil nasal drop compared with the placebo (sesame oil).

MATERIALS AND METHODS

Fifty patients with primary chronic insomnia were randomly assigned in TPM-treatment or placebo groups, received either two drops of the herbal oil or placebo into each nostril every noon and evening for 8 weeks. Before the study commencement and after 1, 4 and 8 weeks of treatment, Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) questionnaires were completed by all patients. The primary outcome measure was considered as any changes in ISI scores between the first visit and after 8 weeks. Changes in PSQI scores during the study and possible side effects were also assessed. The multicompound herbal oil was standardized using HPLC analysis and contained 0.02 mg/mL crocin and 4 μg/mL isoquercitrin.

RESULTS

Our study revealed a significant reduction in the ISI and PSQI scores from baseline by the study endpoint (P ≤ 0.01). The mean ISI scores in week 8 decreased significantly for the intervention group (P = 0.001) and also the placebo group (P < 0.01) when compared with baseline. Moreover, the use of hypnotic drugs in the intervention group was significantly reduced (P < 0.001), while in the control group was maintained at baseline level.

CONCLUSIONS

It seems that intranasal use of the multi-herbal preparation can be used to improve chronic insomnia and to reduce the dose of conventional hypnotic medications in insomniac patients.

Pharmacologic Approach to Insomnia

Sleep management is essential to effective treatment of pain symptoms. Identification of the precise nature of sleep complaint, awareness of patient's age and co-morbid conditions and choice of the hypnotic medication class can help guide treatment approach. In addition to benzodiazepine and non-benzodiazepine medications acting at the GABA receptor, novel approaches, including orexin receptor agonists, may be safer and more promising pharmacologic approaches. Pharmacologic interventions, when used cautiously for a limited period of time and in complement with behavioral and cognitive approaches, can serve to improve sleep quality and significantly help in management of pain.

Safety profile and clinical course of patients with insomnia administered suvorexant by initial treatment status in a post-marketing survey

Objectives: Suvorexant is a dual orexin receptor antagonist used for treating insomnia. The authors elucidated the safety profiles and clinical course of insomnia therapy with suvorexant under different initial treatment status seen in daily routine practice. Methods: Subgroup analysis of a post-marketing survey (PMS; 2015-2017) divided patients based on their initial treatment status with suvorexant into 'hypnotic-naïve (Group N)', 'switching from a prior sleep medication (Group S),' 'add-on therapy (Group A),' and 'others (Group O).' Results: Among 3248 patients analyzed in the PMS, the number of patients in Groups N, S, A, and O was 1946 (59.9%), 703 (21.6%), 536 (16.5%), and 63 (1.9%), respectively. The incidence of insomnia-related adverse drug reactions (ADRs) in Group S (5.3%) tended to be higher than that in Groups N (0.46%) and A (1.5%). Discontinuation rate due to an inadequate effect at 6 months in Group S (14.9%) tended to be higher than that in Groups N (9.6%) and A (10.4%). Conclusion: The results suggest that initiating suvorexant treatment after switching from other insomnia medication must require careful monitoring of insomnia-related ADRs, which might be due to abrupt discontinuation of the prior insomnia medication use.

Effects and clinical feasibility of a behavioral treatment for sleep problems in adult attention deficit hyperactivity disorder (ADHD): a pragmatic within-group pilot evaluation

BACKGROUND

Sleep disturbances, including insomnia, are common in adult Attention Deficit Hyperactivity Disorder (ADHD). Treatment of choice for insomnia is cognitive behavioral therapy (CBT-i), but evidence is lacking for CBT-i in patients with ADHD. The purpose of this study was to investigate if patients with insomnia and other sleep problems, at a specialist clinic for ADHD, benefit from a group delivered behavioral treatment based on CBT-i; whether insomnia severity improves following this treatment.

METHODS

This pragmatic within-group pilot study with a pre to post and three-month follow-up design was set at a specialist psychiatric out-patient clinic for adult ADHD. As an adjunct to care-as-usual at the clinic, a CBT-i-based group treatment targeting several sleep problems prevalent in the ADHD-population, was offered as 10 weekly 90-min group sessions and scheduled telephone support. All outcome measures were subjectively reported by participants. Data analyzed with dependent t-tests according to intent-to-treat.

RESULTS

Nineteen patients (37 [SD 13.7] years; 68% female) with ADHD and subjectively reported sleep problems provided informed consent and pre-treatment measures. Patients had suffered from sleep problems for 15.3 [SD 13.4] years, 42% used sleep medications, 79% used stimulant medication(s). At post-treatment, insomnia severity (Insomnia Severity Index; score range 0-28) had improved with 4.5 points (95% CI, 2.06-6.99, p = .002), at 3 months with 6.8 points (95% CI, 4.71-8.91, p < .0001) from pre-treatment.

CONCLUSIONS

CBT-i adjusted for ADHD is promising for improving insomnia severity in adult patients at specialist psychiatric out-patient clinics, who suffer from ADHD and sleep disturbances.

TRIAL REGISTRATION

Study registered with the Regional ethical review board in Stockholm, January 13th 2016, Study id: 2015/2078-31/1. Study registered retrospectively with Clinicaltrials.org, February 21st 2019, ID: NCT03852966.

Anesthesia and sleep disorders – a new problem in modern anesthesiology (literature review)

Sleep is an active state that is as complex as wakefulness. The main tasks of sleep are the adaptation and restoration of physical and mental strength. Sleep regulation is a complex multimodal process involving not only neurotransmitters, but also releasing­factors, hormones, cytokines, signaling molecules and metabolites. Having a lot of physiological effects, postoperative sleep plays a role not only in quality of life, but also in the recovery of the patient. The characteristics of the patient, the type of surgical intervention, the methods of anesthesia and their interaction affects postoperative sleep, but the relationship and the level of influence of these factors are not clear. Therefore, given the high prevalence of postoperative insomnia, this problem is relevant for modern anesthesiology.

The acute effects of aerobic exercise on sleep in patients with depression: study protocol for a randomized controlled trial

BACKGROUND

Unipolar depression is one of the most important mental disorders. Insomnia is a symptom of cardinal importance in depression. It increases the risk to develop depression, negatively affects disease trajectory, is the most common symptom after remission, increases the risk of relapse, and is associated with higher suicide rates. Existing therapies for insomnia in depression have limitations. Further adjuvant therapies are therefore needed. Acute aerobic exercise has been shown to have beneficial effects on sleep in healthy individuals and patients with insomnia. We therefore hypothesize that a single session of aerobic exercise has a positive impact on sleep in patients with unipolar depression. This trial aims to investigate the effects of a single bout of aerobic exercise on the subsequent night's sleep in patients with depression.

METHODS/DESIGN

This is a two-arm parallel group, randomized, outcome assessor blinded, controlled, superiority trial. Patients between 18 and 65 years of age with a primary diagnosis of unipolar depression (without a psychotic episode) are included. Exclusion criteria are regular use of hypnotic agents, opioids, and certain beta-blockers, as well as the presence of factors precluding exercise, history of epilepsy, restless legs syndrome, moderate obstructive sleep apnea, and a BMI > 40. The intervention is a single bout of aerobic exercise, performed for 30 min on a bicycle ergometer at 80% individual anaerobic threshold. The control group sits and reads for 30 min. The primary outcome is sleep efficiency measured by polysomnography. Secondary outcomes include further polysomnographic variables, subjective pre-sleep arousal, nocturnal cardiovascular autonomic modulation, subjective sleep quality, daytime sleepiness, and adverse events. According to the sample size calculation, a total of 92 patients will be randomized using minimization.

DISCUSSION

This trial will add new information to the body of knowledge concerning the treatment of insomnia in patients with depression. Thereby, the results will inform decision makers on the utility of acute aerobic exercise.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03673397 . Protocol version 1 registered on 17 September 2018.

Insomnia in patients with schizophrenia: current understanding and treatment options

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

Medicinal Plants for Management of Insomnia: A Systematic Review of Animal and Human Studies

Insomnia is one of the most troubling sleep disorders and can be characterized by an inability to fall asleep and/or inadequate sleep duration and/or waking up multiple times during the night. Herbal medicine has been used to treat a range of sleep disorders for centuries. This study aimed to review medicinal plants investigated experimentally or clinically for sleep disorders, as well as their potential mechanisms of action and active components. Electronic databases and literature were systematically investigated to assess all in vitro and in vivo trials and clinical evidence of the efficacy and potential mechanisms of actions playing major roles in sleep induction or insomnia treatment. Among many herbal studies and trials on insomnia, some showed no significant difference between herbal remedies and placebos. While others showed improvements in sleep parameters (sleep latency, total sleep, non-rapid eye movement (NREM) and rapid eye movement (REM) sleep duration, delta activity in NREM sleep, wakefulness anxiety-associated insomnia). In this study, in vitro, animal, and clinical studies investigating a variety of herbal treatments for insomnia were systematically reviewed. The mechanisms of action of herbal medicines in treating insomnia are mainly related to gamma-aminobutyric acid (GABA)-synthesizing and GABA-metabolizing enzymes that influenced sleep outcomes. Overall, herbal remedies were not associated with more benefits than nonbenzodiazepines, although side effects were less. The results suggest that herbs have some benefits in improving the quantity and quality of sleep and could be a promising alternative therapy.