European Sleep Research Society Research Articles

Cognitive-Behavioral and Pharmacological Treatments for Insomnia: A Combined Approach

Insomnia is the most prevalent sleep disorder (10-40%). It is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and that results in some form of daytime impairment. Among the typical symptoms, there are fatigue, decreased mood or irritability, general malaise, and cognitive impairment. According to the International Classification of Sleep Disorders 3rd edition, ICSD-3, it has been defined as chronic (lasting more than three months) or short-term insomnia (less than three months).In clinical practice, the usual therapeutic approach is pharmacological (benzodiazepines, z drugs, slow wave sleep enhancers), even if the American Academy of Sleep Medicine (AASM), the American College of Physicians (ACP), and the European Sleep Research Society (ESRS) guidelines suggest that the first clinical choice should be non-pharmacological (cognitive behavioral therapy). A combined (non-pharmacological and pharmacological)approach could be considered in poor responders to manage drug dependence and to increase compliance to treatment and patients’ quality of life.

The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment.

Insomnia, the most prevalent sleep disorder worldwide, confers marked risks for both physical and mental health. Furthermore, insomnia is associated with considerable direct and indirect healthcare costs. Recent guidelines in the US and Europe unequivocally conclude that cognitive behavioural therapy for insomnia (CBT-I) should be the first-line treatment for the disorder. Current treatment approaches are in stark contrast to these clear recommendations, not least across Europe, where, if any treatment at all is delivered, hypnotic medication still is the dominant therapeutic modality. To address this situation, a Task Force of the European Sleep Research Society and the European Insomnia Network met in May 2018. The Task Force proposed establishing a European CBT-I Academy that would enable a Europe-wide system of standardized CBT-I training and training centre accreditation. This article summarizes the deliberations of the Task Force concerning definition and ingredients of CBT-I, preconditions for health professionals to teach CBT-I, the way in which CBT-I should be taught, who should be taught CBT-I and to whom CBT-I should be administered. Furthermore, diverse aspects of CBT-I care and delivery were discussed and incorporated into a stepped-care model for insomnia.

Exploring the associations between shift work disorder, depression, anxiety and sick leave taken amongst nurses.

This study aimed to evaluate the association between shift work disorder and mental health in hospital-based nurses. Staff completed an online survey comprising demographic questions, the Shift Work Disorder Questionnaire, Patient Health-9 and the General Anxiety Disorder-7 scale. Sick leave data were collected from archival records from the Human Resources Department. Two hundred and two nurses (95% female; age M=35.28years±SD=12) participated (42% of eligible staff). Those at high risk of shift work disorder had higher depression (M=7.54±SD=4.28 vs. M=3.78±SD=3.24; p<0.001) and anxiety (M=5.66±SD=3.82 vs. M=2.83±SD=3.33, p<0.001) compared to those at low risk. Linear regression models showed that being at high risk of shift work disorder was the most significant predictor of depression, explaining 18.8% of the variance in depression (R2 =0.188, adjusted R2 =0.184, F(1, 200)=46.20, p<0.001). Shift work disorder combined with the number of night shifts and alcoholic drinks on non-work days accounted for 49.7% of the variance in anxiety scores (R2 =0.497, adjusted R2 =0.453, F(3, 35)=11.51, p<0.001). Mean sick leave in those with high risk of shift work disorder was 136.17hr (SD=113.11) versus 103.98hr (SD=94.46) in others (p=0.057). Depression and years of shift work accounted for 18.9% of the variance in sick leave taken (R2 =0.189, adjusted R2 =0.180, F(2, 175)=20.36, p<0.001). Shift work disorder is strongly associated with depression and anxiety, providing a potential target to improve mental health in shift workers. Depression, in turn, is a significant contributing factor to sick leave.

Associations between sleep disturbances, mental health outcomes and burnout in firefighters, and the mediating role of sleep during overnight work: A cross-sectional study.

This study investigated whether sleep disorder risk and mental health outcomes in firefighters were associated with burnout, particularly emotional exhaustion, and examined the mediating role of sleep at work in these relationships. A secondary aim was to investigate associations between habitual sleep characteristics and burnout. North American firefighters (n = 6,307) completed the Maslach Burnout Inventory (emotional exhaustion, depersonalisation, personal accomplishment), and were screened for sleep disorders and self-reported current mental health conditions and sleep characteristics. Multiple logistic regression analyses examined associations between sleep, mental health outcomes and burnout. Firefighters screening positive for a sleep disorder, particularly insomnia, had increased risk of emotional exhaustion (adjusted odds ratio 3.78, 95% confidence interval 2.97-4.79). Firefighters self-reporting a current mental health condition were at greater risk of emotional exhaustion (adjusted odds ratio 3.45, 95% confidence interval 2.79-4.27). Sleep during overnight work mediated the impact of having a sleep disorder and mental health condition on high burnout. Sleepiness and sleep deficit (difference between required and actual sleep), even in firefighters without sleep disorder risk, were associated with depersonalisation (adjusted odds ratio 1.65, 95% confidence interval 1.34-2.03 and adjusted odds ratio 1.29, 95% confidence interval 1.06-1.57, respectively) and low personal accomplishment (adjusted odds ratio 1.25, 95% confidence interval 1.07-1.47 and adjusted odds ratio 1.17, 95% confidence interval 1.01-1.35, respectively). Sleep and mental health problems were associated with increased risk of burnout in firefighters, and sleep during overnight work mediated these relationships. The results suggest the need to examine the effectiveness of occupational interventions that improve the opportunity for sleep, together with screening for and treating sleep disorders, to reduce burnout risk.

ERJ September Podcast: Challenges and perspectives in obstructive sleep apnoea.

As part of the September issue, the European Respiratory Journal presents the latest in its series of podcasts. Section Editor David Gozal interviews Walter McNicholas (St Vincent's University Hospital and University College Dublin, Ireland) about a report by an ad hoc working group of the Sleep Disordered Breathing Group of the European Respiratory Society and the European Sleep Research Society.

Author Index

Journal of Sleep ResearchVolume 27, Issue S1 e12752 Author IndexFree Access Author Index First published: 11 September 2018 https://doi.org/10.1111/jsr.12752AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume27, IssueS1Special Issue: Abstracts of the 24th Congress of the European Sleep Research Society, 25–28 September 2018, Basel, SwitzerlandSeptember 2018e12752 RelatedInformation

Challenges and perspectives in obstructive sleep apnoea: Report by an ad hoc working group of the Sleep Disordered Breathing Group of the European Respiratory Society and the European Sleep Research Society.

Obstructive sleep apnoea (OSA) is a major challenge for physicians and healthcare systems throughout the world. The high prevalence and the impact on daily life of OSA oblige clinicians to offer effective and acceptable treatment options. However, recent evidence has raised questions about the benefits of positive airway pressure therapy in ameliorating comorbidities.An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field, and proposed topics for future research on epidemiology, phenotyping, underlying mechanisms, prognostic implications and optimal treatment of patients with OSA.The group concluded that a revision to the diagnostic criteria for OSA is required to include factors that reflect different clinical and pathophysiological phenotypes and relevant comorbidities (e.g. nondipping nocturnal blood pressure). Furthermore, current severity thresholds require revision to reflect factors such as the disparity in the apnoea-hypopnoea index (AHI) between polysomnography and sleep studies that do not include sleep stage measurements, in addition to the poor correlation between AHI and daytime symptoms such as sleepiness. Management decisions should be linked to the underlying phenotype and consider outcomes beyond AHI.

Pharmacotherapy treatment principles for insomnia

Pharmacotherapy of insomnia is an integral part of the treatment of this clinical syndrome. The range of drugs used for the treatment of sleep disorders is quite extensive, and not all of them are “true” sleeping pills”. Such pills often belong to the various classes of psychotropic medications. Advanced sleeping pills taken in compliance with the necessary rules provide the necessary sleeping effect without accompanied negative changes in the sleep structure and the quality of the subsequent waking. The domestic and foreign studies, the leading professional community guidelines (the Russian Society of Somanologists – 2016, the European Sleep Research Society – 2017, the American Academy of Sleep Medicine – 2017, the American College of Physicians – 2016) show that normalization of sleep in patients with insomnia by various methods, including pharmacotherapy, neutralizes its negative effects, improves the adaptive capacity of the individual and prevents the chronic sleep disorders with severe adverse effects.

Editorial introductions

Editorial introductions

European guideline for the diagnosis and treatment of insomnia.

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

Editorial introductions

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Stefan KlöppelStefan KlöppelStefan Klöppel is Director of the University Hospital of Old Age Psychiatry in Bern, Switzerland. Until recently, he has been head of the Freiburg Brain Imaging research unit which is dedicated to MRI research with a clinical focus. After medical school, Stefan Klöppel took positions as clinical research fellow at the Department of Neurology in Hamburg, Germany and at University College London, UK. He finished his specialisation in Psychiatry and Psychotherapy in Freiburg with a clinical focus on old age psychiatry and dementia. His research is focused on neurodegenerative disorders. One aspect is the modification of machine learning techniques to apply them to MRI for an early and accurate diagnosis. These methods are highly flexible and are able to separate patients with a wide range of diseases. More recently, he took interest in non-invasive brain stimulation techniques where he seeks to identify protocols sufficiently robust for the application in clinical routine. He currently combines these stimulation methods with imaging to gain insight into the underlying mechanisms. Claudio L. BassettiClaudio L. BassettiProfessor Claudio L. Bassetti was born and raised in Ticino (Southern Switzerland), is married and father of three boys. He speaks six languages and enjoys history, literature, music, sports, and travelling. Claudio Bassetti received his MD degree from the University of Basel in 1984 and trained in neurology in Bern and Lausanne (FMH degree in 1992). He performed two research fellowships in basic neurophysiology (Basel, 1985–1986) and sleep medicine (Ann Arbor-Michigan, USA, 1995–6). In 1997 he became “Privatdozent” (associate professor) at the University of Bern. In 2000 he was appointed Professor of neurology at the university of Zurich and Director of the neurological outpatient clinics of the university hospital. In 2009 he founded the neurocenter of Southern Switzerland in Lugano which he directed until 2012. Since 2012 he is full professor of neurology at the university of Bern and director of the neurology department at the university hospital. Claudio Bassetti has authored eight books and over 350 scientific publications. His topics of interest include general neurology, sleep, stroke, movement disorders, and translational/animal research. He served as president of the European Neurological Society (ENS, 2013–4), European Sleep Research Society (ESRS, 2008–12) and Swiss Neurological Society (SNG, 2008–12). He was one of the founders and first president of the Swiss Federation of Clinical Neurosocieties (SFCNS, 2009–2013). Currently he is a board member of the Swiss Academy of Medical Sciences (SAMW). Since 2016 he is also Vice-Dean Research of the Medical Faculty-University Bern. Panagiotis BargiotasPanagiotis BargiotasDr Panagiotis Bargiotas is an attending physician at the Department of Neurology and the Sleep-Wake-Epilepsy Center at the University Hospital Bern, Switzerland. He specializes in the interdisciplinary management of patients with sleep-wake disturbances and neurodegenerative disorders. He is currently involved in various clinical trials and preclinical research with main focus on the mechanisms underlying sleep-wake disturbances in patients with Parkinson's disease and especially in the context of deep brain stimulation.

Editorial introductions

Editorial introductions

Author Index

Journal of Sleep ResearchVolume 25, Issue S1 p. 378-401 Author IndexFree Access Author Index First published: 29 August 2016 https://doi.org/10.1111/jsr.12447AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume25, IssueS1Special Issue: Abstracts of the 23rd Congress of the European Sleep Research Society, 13–16 September 2016, Bologna, ItalySeptember 2016Pages 378-401 RelatedInformation

Variability in recording and scoring of respiratory events during sleep in Europe: a need for uniform standards.

Uniform standards for the recording and scoring of respiratory events during sleep are lacking in Europe, although many centres follow the published recommendations of the American Academy of Sleep Medicine. The aim of this study was to assess the practice for the diagnosis of sleep-disordered breathing throughout Europe. A specially developed questionnaire was sent to representatives of the 31 national sleep societies in the Assembly of National Sleep Societies of the European Sleep Research Society, and a total of 29 countries completed the questionnaire. Polysomnography was considered the primary diagnostic method for sleep apnea diagnosis in 10 (34.5%), whereas polygraphy was used primarily in six (20.7%) European countries. In the remaining 13 countries (44.8%), no preferred methodology was used. Fifteen countries (51.7%) had developed some type of national uniform standards, but these standards varied significantly in terms of scoring criteria, device specifications and quality assurance procedures between countries. Only five countries (17.2%) had published these standards. Most respondents supported the development of uniform recording and scoring criteria for Europe, which might be based partly on the existing American Academy of Sleep Medicine rules, but also take into account differences in European practice when compared to North America. This survey highlights the current varying approaches to the assessment of patients with sleep-disordered breathing throughout Europe and supports the need for the development of practice parameters in the assessment of such patients that would be suited to European clinical practice.

Sleepiness at the wheel across Europe: a survey of 19 countries.

The European Sleep Research Society aimed to estimate the prevalence, determinants and consequences of falling asleep at the wheel. In total, 12 434 questionnaires were obtained from 19 countries using an anonymous online questionnaire that collected demographic and sleep-related data, driving behaviour, history of drowsy driving and accidents. Associations were quantified using multivariate logistic regression. The average prevalence of falling asleep at the wheel in the previous 2 years was 17%. Among respondents who fell asleep, the median prevalence of sleep-related accidents was 7.0% (13.2% involved hospital care and 3.6% caused fatalities). The most frequently perceived reasons for falling asleep at the wheel were poor sleep in the previous night (42.5%) and poor sleeping habits in general (34.1%). Falling asleep was more frequent in the Netherlands [odds ratio = 3.55 (95% confidence interval: 1.97; 6.39)] and Austria [2.34 (1.75; 3.13)], followed by Belgium [1.52 (1.28; 1.81)], Portugal [1.34 (1.13, 1.58)], Poland [1.22 (1.06; 1.40)] and France [1.20 (1.05; 1.38)]. Lower odds were found in Croatia [0.36 (0.21; 0.61)], Slovenia [0.62 (0.43; 0.89)] and Italy [0.65 (0.53; 0.79)]. Individual determinants of falling asleep were younger age; male gender [1.79 (1.61; 2.00)]; driving ≥20 000 km year [2.02 (1.74; 2.35)]; higher daytime sleepiness [7.49 (6.26; 8.95)] and high risk of obstructive sleep apnea syndrome [3.48 (2.78; 4.36) in men]. This Pan European survey demonstrates that drowsy driving is a major safety hazard throughout Europe. It emphasizes the importance of joint research and policy efforts to reduce the burden of sleepiness at the wheel for European drivers.

Author Index

Journal of Sleep ResearchVolume 23, Issue s1 p. 332-347 Author IndexFree Access Author Index First published: 08 September 2014 https://doi.org/10.1111/jsr.12214AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume23, Issues1Special Issue: Abstracts of the 22nd Congress of the European Sleep Research Society, 16–20 September 2014, Tallinn, EstoniaSeptember 2014Pages 332-347 RelatedInformation

Catalogue of knowledge and skills for sleep medicine

Sleep medicine is evolving globally into a medical subspeciality in its own right, and in parallel, behavioural sleep medicine and sleep technology are expanding rapidly. Educational programmes are being implemented at different levels in many European countries. However, these programmes would benefit from a common, interdisciplinary curriculum. This 'catalogue of knowledge and skills' for sleep medicine is proposed, therefore, as a template for developing more standardized curricula across Europe. The Board and The Sleep Medicine Committee of the European Sleep Research Society (ESRS) have compiled the catalogue based on textbooks, standard of practice publications, systematic reviews and professional experience, validated subsequently by an online survey completed by 110 delegates specialized in sleep medicine from different European countries. The catalogue comprises 10 chapters covering physiology, pathology, diagnostic and treatment procedures to societal and organizational aspects of sleep medicine. Required levels of knowledge and skills are defined, as is a proposed workload of 60 points according to the European Credit Transfer System (ECTS). The catalogue is intended to be a basis for sleep medicine education, for sleep medicine courses and for sleep medicine examinations, serving not only physicians with a medical speciality degree, but also PhD and MSc health professionals such as clinical psychologists and scientists, technologists and nurses, all of whom may be involved professionally in sleep medicine. In the future, the catalogue will be revised in accordance with advances in the field of sleep medicine.

Global and local actions in the sleep domain: the ESRS perspective

As an active and long-standing member of the World Sleep Federation (WSF), the European Sleep Research Society (ESRS) is pleased to support the open letter written by the current and immediate past WSF presidents, published today in the Journal of Sleep Research, the official journal of the ESRS. In this letter, the WSF presidents encourage us to act both locally and globally in the sleep domain, learn from each other and share existing resources. In particular, they call for increased sleep education and training opportunities throughout the world, including certification programmes for sleep specialists and technicians, especially for those individuals living in developing countries. We agree wholeheartedly with such goals, and believe that existing education and training initiatives that have been developed by the ESRS at the European level can contribute significantly to this, while at the same time avoiding any overlap between the ESRS and WSF initiatives. Indeed, the ESRS is currently involved actively in the development of sleep medicine throughout Europe and is developing certification and training opportunities, especially in European countries where sleep is not yet an acknowledged speciality. In this respect, we recently organized the first European Examination in Sleep Medicine at the ESRS conference (Paris, September 2012). The examination was taken successfully by 50 selected international sleep experts, who received the certification: ‘ESRS Somnologist–Expert in Sleep Medicine’. This grandparenting initiative will be repeated at the forthcoming ERS–ESRS Sleep and Breathing Conference (Berlin, April 2013). This will lead to the constitution of an international body of certified sleep experts able to take the lead in future national and international activities to promote sleep medicine professionals. The certification process will also lead to the organization of the first open examination to all sleep professionals at the 2014 ESRS Congress in Tallinn, Estonia. In association with certification, coordinated and unified educational training initiatives also have to be taken, including publication of guidelines [as already published in the Journal of Sleep Research (Fischer et al., 2012; Pevernagie et al., 2006, 2009)] and textbooks in sleep medicine. In this respect, the ESRS believes that the future of sleep research and sleep medicine in Europe necessitates the creation and development of academic multi-disciplinary sleep centres across Europe (Bassetti et al., 2012). This will promote the integration of clinical and basic sleep science, and constitute a basis for the education and training of sleep experts, as advocated in the ESRS 40th anniversary book (Bassetti et al., 2012). We also believe that definition and publication of common guidelines between the WSF and ESRS would be an extremely useful accomplishment that is achievable through fruitful collaboration. These are only a few of the many ways in which we can develop sleep medicine and sleep research throughout Europe and the world, and we commend the WSF's initiative to establish special interest groups in key areas such as sleep genetics, insomnia and sleep and breathing. Similarly, the ESRS promotes sleep networks aimed at gathering both clinical and basic sleep researchers around key topics such as insomnia, sleep apnoea, narcolepsy and restless legs syndrome. We also believe that the existing sleep networks must communicate globally at all levels, and not be limited to specific regions. We would be happy to see the special interest groups and networks initiated by WFS and ESRS share common interests and experience, while bearing in mind that appropriate actions are needed both locally and globally, ranging from national to European and world levels. In conclusion, the ESRS warmly welcomes the initiative of the Presidents of the WSF. The ESRS will be happy to contribute to all the initiatives facilitating sleep training and research to make sleep a stronger and more unified field. This will greatly benefit the development of sleep science, as well as the care of those many patients suffering from recognized, but also too often unrecognized, sleep disorders.

An open letter to the sleep and circadian rhythms community: Presidents’ viewpoints of the World Sleep Federation (WSF)

An open letter to the sleep and circadian rhythms community: Presidents’ viewpoints of the <scp>W</scp>orld <scp>S</scp>leep <scp>F</scp>ederation (<scp>WSF</scp>)

European guidelines on management of restless legs syndrome: report of a joint task force by the European Federation of Neurological Societies, the European Neurological Society and the European Sleep Research Society

Since the publication of the first European Federation of Neurological Societies (EFNS) guidelines in 2005 on the management of restless legs syndrome (RLS; also known as Willis-Ekbom disease), there have been major therapeutic advances in the field. Furthermore, the management of RLS is now a part of routine neurological practice in Europe. New drugs have also become available, and further randomized controlled trials have been undertaken. These guidelines were undertaken by the EFNS in collaboration with the European Neurological Society and the European Sleep Research Society. To provide an evidence-based update of new treatments published since 2005 for the management of RLS. First, we determined what the objectives of management of primary and secondary RLS should be. We developed the search strategy and conducted a review of the scientific literature up to 31 December 2011 (print and electronic publications) for the drug classes and interventions employed in RLS treatment. Previous guidelines were consulted. All trials were analysed according to class of evidence, and recommendations made according to the 2004 EFNS criteria for rating. Level A recommendations can be made for rotigotine, ropinirole, pramipexole, gabapentin enacarbil, gabapentin and pregabalin, which are all considered effective for the short-term treatment for RLS. However, for the long-term treatment for RLS, rotigotine is considered effective, gabapentin enacarbil is probably effective, and ropinirole, pramipexole and gabapentin are considered possibly effective. Cabergoline has according to our criteria a level A recommendation, but the taskforce cannot recommend this drug because of its serious adverse events.