Insomnia Medications Research Articles

Treatment Preferences for Internet-Based Cognitive Behavioral Therapy for Insomnia in Japan: Online Survey.

BackgroundThe internet has the potential to increase individuals’ access to cognitive behavioral therapy (CBT) for insomnia at low cost. However, treatment preferences regarding internet-based computerized CBT for insomnia have not been fully examined.ObjectiveThe aim was to conduct an anonymous online survey to evaluate treatment preferences for insomnia among patients with insomnia and individuals without insomnia.MethodsWe developed an online survey to recruit a total of 600 participants living in the Kanto district in Japan. There were three subgroups: 200 medicated individuals with insomnia, 200 unmedicated individuals with insomnia, and 200 individuals without insomnia. The survey asked questions about the severity of the respondent’s insomnia (using the Athens Insomnia Scale), the frequency of sleep medication use and the level of satisfaction with sleep medication use, the respondent’s knowledge of CBT, his or her preference for CBT for insomnia before drug therapy, preference for CBT versus drug therapy, and preference for internet-based CBT versus face-to-face CBT.ResultsOf the 600 respondents, 47.7% (286/600) indicated that they received CBT before drug therapy, and 57.2% (343/600) preferred CBT for insomnia to drug therapy. In addition, 47.0% (282/600) preferred internet-based CBT for insomnia to face-to-face CBT. Although the respondents with insomnia who were taking an insomnia medication had a relatively lower preference for internet-based CBT (40.5%, 81/200), the respondents with insomnia who were not taking an insomnia medication had a relatively higher preference for internet-based CBT (55.5%, 111/200).ConclusionsThe results of our online survey suggest that approximately half of the people queried preferred CBT for insomnia to drug therapy, and half of the respondents preferred internet-based CBT for insomnia to face-to-face CBT.

Melatonin use in an inpatient academic medical center: Factors affecting provider documentation of patients’ sleep quality

ObjectivesMelatonin is commonly prescribed for insomnia despite the 2017 American Academy of Sleep Medicine recommendation against its use due to lack of evidence for efficacy and information on adverse effects. The objectives of this study were to determine what percentage of prescribers document the impact of melatonin on sleep quality in hospitalized patients and to examine factors influencing provider documentation. MethodsIn this single-center retrospective study, electronic medical records of 200 adults with orders for melatonin over a 6-month period were reviewed. The primary outcome was to evaluate provider documentation of sleep and the impact of melatonin on patients’ reported sleep quality. Secondary outcomes included an evaluation of provider medication reconciliation (admission/discharge) and concomitant insomnia therapy. Descriptive and inferential statistics were performed (V13.1 Systat Software, Inc.). P values < 0.05 denoted significance. ResultsProviders documented overall sleep quality for 65 (32.5%) patients (15.47 ± 29.23, range 5 to 100%). Specific mention of melatonin’s impact on sleep quality was available for 16 (8%) patients. Fifty-four (27%) patients received melatonin prior to admission, and 73 (36.5%) continued therapy at discharge. For patients discharged on melatonin, the percentage of provider documentation related to patients’ sleep quality was higher compared to those discharged without melatonin (41.1% vs. 27.6%; P < 0.049). Fifty-nine (29.5%) patients had concomitant insomnia medications. Provider documentation was greater for patients receiving combination therapy (44.1%) compared to melatonin monotherapy (27.7%; P < 0.024). ConclusionDocumentation of patients’ reported sleep quality was lacking for 67.5% of patients. Prescriberswere more likely to document impressions of patients’ sleep quality when the patients received melatonin in combination with at least 1 other medication for insomnia. Melatonin was continued upon discharge for an additional 9.5% of study patients who had not been taking melatonin prior to admission. This study demonstrated that melatonin is widely used but narrowly monitored.

Circadian Preference as a Moderator of Depression Outcome Following Cognitive Behavioral Therapy for Insomnia Plus Antidepressant Medications: A Report From the TRIAD Study.

We previously presented results from a randomized controlled trial that examined the effects of antidepressant medication plus cognitive behavioral therapy for insomnia (CBT-I) among patients with major depressive disorder (MDD) and insomnia. The current secondary analysis aims to examine whether circadian preference moderated the reduction in depression and insomnia symptom severity during this trial. A total of 139 adult participants with MDD and insomnia disorder were treated with antidepressant medication and randomized to receive 7 sessions of CBT-I or a control therapy (CTRL). Circadian preference (eveningness) was measured using the Composite Scale of Morningness (CSM). Depression symptom severity was assessed using the Hamilton Depression Rating Scale (HDRS); insomnia symptom severity was assessed using the Insomnia Severity Inventory (ISI). The moderating role of circadian preference on changes in HRSD and ISI was assessed via latent growth models within the framework of structural equation modeling. Greater evening preference was associated with smaller reduction in HDRS (P = .03) from baseline to week 6 across treatment groups. The interaction between CSM and treatment group was also significant (P = .02), indicating that participants with greater evening preference in the CTRL group had significantly smaller HDRS reduction than those with greater evening preference in the CBT-I group. Circadian preference did not share significant associations with ISI (all P > .30). Individuals with MDD and insomnia who have an evening preference are at increased risk for poor response to pharmacological depression treatment augmented with either CBT-I or CTRL behavioral insomnia treatment. However, evening types have better depression outcomes when treated with CBT-I than with CTRL for insomnia.

SAFETY OF LEMBOREXANT IN ELDERLY SUBJECTS WITH INSOMNIA: RESULTS FROM A PHASE 3 STUDY (SUNRISE 1)

Introduction Increased risk of falls and other safety concerns such as abuse potential, tolerance and aberrant nocturnal behaviors are associated with currently available insomnia medications. Here we report safety parameters in elderly individuals with insomnia from a Phase 3 study of the dual orexin receptor antagonist lemborexant Methods SUNRISE 1 was randomized, double-blind, placebo- and active-controlled, 1-month, global Phase 3 study. Eligible subjects were females age 55 and older, and males age 65 and older. This report will summarize safety data from the subgroup of elderly subjects age 65 and older. Subjects met DSM-5 criteria for insomnia disorder, and had a primary complaint of sleep maintenance insomnia. Current insomnia symptoms were confirmed with both a sleep diary and PSG. Subjects with symptoms of other sleep disorders (e.g., moderate to severe sleep apnea, periodic limb movement disorder, restless legs syndrome) were excluded, but those with sufficiently-treated comorbid medical or psychiatric conditions could be included. After an approximately 2-week single-blind Run-in Period when all received placebo (PBO), subjects were randomized to PBO, zolpidem tartrate extended release (ZOL [6.25mg])or lemborexant (LEM; 5mg [LEM5] or 10mg [LEM10]) for 1 month. Study drug was taken within 5 min of the start of the sleep period, which was calculated based on the mean habitual bedtime from the sleep diary. Adverse events were obtained throughout the study. Additional safety parameters included: clinical laboratories, electrocardiograms (ECGs), vital signs and weight; potential rebound insomnia assessed via the sleep diary during a 2-week Follow-up Period; postural stability immediately upon morning awakening after the first 2 nights and last 2 nights of treatment using an ataxiameter measuring amount of body sway in 60 seconds (in units of 1/3 degree angle of arc, with higher values indicating more body sway), and tests of attention and memory immediately upon morning awakening at 8 hours postdose. Self-ratings of sleepiness/alertness were assessed on the sleep diary. Analyses of safety relating to study disposition, adverse events, and postural stability are reported here; all other safety-related assessments will be presented once subgroup analyses by age have been completed. Results A total of 1006 were randomized into the study. Of these, 453 (45%) were 65 years or older (137 males, 316 females) and are included in the results presented below. Most elderly subjects (433/453; 95.6%) completed the study. A total of 8 (1.8%) elderly subjects discontinued due to an adverse event, including 1 in PBO, 3 in ZOL, 2 in LEM5, and 2 in LEM10. There were 3 subjects with SAEs, all on ZOL; none were considered treatment-related, and all resolved without sequelae. Most AEs were mild to moderate in severity. The most common AEs (>2% in any active treatment group and >PBO) are listed in Table 1. At each visit, subjects were explicitly asked whether they had experienced a fall since the last visit. There were 4 falls in elderly subjects, all in the LEM5 treatment group. All were considered mild in severity, and none were considered treatment-related. An expert committee adjudicated all falls; none was classified as cataplexy. When postural stability was assessed immediately upon awakening, there was no significant treatment difference in body sway for either LEM treatment group compared to PBO at either the beginning (LEM5 difference from PBO 0.16 units, N.S.; LEM10 difference from PBO 2.69 units, N.S.) or end of treatment (LEM5 difference from PBO -0.87 units, N.S.; LEM10 difference from PBO 0.87 units, N.S.). In contrast, after the first 2 doses of ZOL, the change from baseline in body sway was significantly greater than PBO (difference from PBO 6.97 units, p Conclusions Lemborexant appeared to be well-tolerated in this population of older individuals. Combined with robust efficacy of LEM in this Phase 3 study (data showing that lemborexant significantly improved both sleep onset and sleep maintenance compared to both placebo and zolpidem will be presented separately), safety-related results from Phase 3 suggest that lemborexant, if approved, may be an optimal treatment for the population of older patients with sleep maintenance insomnia. This research was funded by Eisai Inc. and Purdue Pharma L.P.

Antidepressants as medication for insomnia?

Antidepressants as medication for insomnia?

Zopiclone versus placebo for short-term treatment of insomnia in patients with advanced cancer: study protocol for a double-blind, randomized, placebo-controlled, clinical multicenter trial

BackgroundDespite the high prevalence of insomnia in patients with advanced cancer, there are no randomized controlled trials on pharmacological interventions for insomnia in this group of patients. A variety of pharmacological agents is recommended to manage sleep disturbance for insomnia in the general population, but their efficacy and safety in adults with advanced cancer are not established. Thus, there is a need to evaluate the effectiveness of medications for insomnia in order to improve the evidence in patients with advanced cancer. One of the most used sleep medications at present in patients with cancer is zopiclone.MethodsThis is a randomized, double-blind, placebo-controlled, parallel-group, multicenter trial. A total of 100 patients with metastatic cancer who report insomnia will be randomly allocated to zopiclone or placebo. The treatment duration with zopiclone/placebo is 6 consecutive nights. The primary endpoint is patient-reported sleep quality during the final study night (night 6) assessed on a numerical rating scale of 0–10, where 0 = Best sleep and 10 = Worst possible sleep. Secondary endpoints include the mean patient-reported total sleep time and sleep onset latency during the final study night (night 6).DiscussionResults from this study on treatment of insomnia in advanced cancer will contribute to clinical decision-making and improve the treatment of sleep disturbance in this patient cohort.Trial registrationClinicalTrials.gov, NCT02807922. Registered on 21 June 2016.

Trends in Insomnia Diagnosis and Treatment Among Medicare Beneficiaries, 2006–2013

ObjectiveInsomnia is an important clinical problem affecting the elderly. We examined trends in insomnia diagnosis and treatment among Medicare beneficiaries over an eight-year period. MethodsThis was a time-series analysis of Medicare administrative data for years 2006–2013. Insomnia was defined as the presence of at least one claim containing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 307.41, 307.42, 307.49, 327.00, 327.01, 327.09, 780.52, or V69.4 in any given year. Insomnia medications were identified by searching the Part D prescription drug files in each year for barbiturates, benzodiazepines, chloral hydrate, hydroxyzine, nonbenzodiazepine sedative hypnotics, and sedating antidepressants. ResultsPrevalence of physician-assigned insomnia diagnoses increased from 3.9% in 2006 to 6.2% in 2013. Prevalence of any insomnia medication use ranged from 21.0% in 2006 to 29.6% in 2013 but remained steady. A sharp increase in use of benzodiazepines from 2012–2013 (1.1% to 17.6%) drove up total insomnia medication use for 2013. Prevalence of both insomnia diagnosis and medication use ranged from 3.5% in 2006 to 5.5% in 2013, while prevalence of either insomnia diagnosis or medication use ranged from 22.7% in 2006 to 31.0% in 2013. ConclusionIn this large national analysis of Medicare beneficiaries, prevalence of physician-assigned insomnia diagnoses was low but increased over time. Prevalence of insomnia medication use was up to four-times higher than insomnia diagnoses and remained steady over time. Notably, prevalence of benzodiazepine use increased dramatically from 2012–2013 after these medications were included in the Medicare Part D formulary.

Association of Chronic Insomnia With Mortality and Adverse Renal Outcomes

ObjectiveTo examine whether chronic insomnia is associated with an increased risk of adverse renal outcomes and all-cause mortality. Patients and MethodsWe examined associations of chronic insomnia (defined as the presence of both International Classification of Diseases, Ninth Revision codes 307.42, 307.49, and 780.52 and long-term use of insomnia medications) with adverse renal outcomes (end-stage renal disease, incidence of estimated glomerular filtration rate [eGFR] ≤45 mL/min per 1.73 m2, and eGFR slopes <−3.0 mL/min per 1.73 m2 per year) and all-cause mortality in a national cohort of 1,639,090 US veterans by using Cox proportional hazards and logistic regression models with multivariable adjustments. ResultsA total of 36,741 patients (2.24%) had chronic insomnia; 32,985 (89.8%) were male and 28,090 (76.5%) were white, with a mean baseline eGFR of 84.1±16.4 mL/min per 1.73 m2. Chronic insomnia was associated with a significantly higher risk of eGFR 45 mL/min per 1.73 m2 or less (multivariable-adjusted hazard ratio [HR], 1.39; 95% CI, 1.34-1.44; P<.001), and rapid loss of kidney function (odds ratio, 1.07; 95% CI, 1.03-1.12; P=.002), but not end-stage renal disease (HR, 1.25; 95% CI, 0.81-1.93; P=.32). Chronic insomnia was not associated with a higher risk of all-cause mortality (HR, 1.00; 95% CI, 0.97-1.03; P=.99). ConclusionChronic insomnia is associated with a higher risk of development and progression of chronic kidney disease, but not ESRD. Further studies are needed to establish the underlying mechanisms of action and to determine whether treatment of insomnia could be beneficial to prevent deteriorating kidney function.

Outcomes of Pharmacists' Involvement with Residents of Special Nursing Homes for the Elderly

The current study aimed to examine the outcomes of pharmacists' involvement with elderly people in special nursing homes. We analyzed 58 cases involving regular visits by community pharmacists to 41 residents. The residents' mean age was 87.8±6.9 years, and 68.3% were prescribed 6 or more types of medication. Antipsychotic and insomnia medication was taken by 24.4% and 31.8% of residents, respectively. Pharmaceutical consultation following medication use accounted for 60.3% of pharmacists' involvement with residents. The outcomes of these consultations included improvements in prescription content; the identification and prevention of adverse drug events; improvement in activities of daily living; and improvement in test results, sleep, and urination/bowel control. The results also suggested that pharmacists' intervention reduced drug costs. Information that facilitated involvement was most frequently acquired via conversations (67.2%) and conferences (24.1%) in the facilities. The most common information sources were care workers (72.4%), followed by nurses (37.9%), physicians (6.9%), and functional training instructors (6.9%). Information was also acquired from patients (3.4%) and their family members (5.2%). The findings indicated that regular visits by pharmacists to facilities for elderly people and conversations between residents, their family members, and physicians, nurses and various other professionals improved various pharmacotherapy outcomes.

Insomnia Is Associated with an Increased Risk of Type 2 Diabetes in the Clinical Setting

Aims: Determine association between insomnia and risk of type 2 diabetes (T2DM). Methods: We conducted a retrospective panel cohort study to examine risk of developing T2DM among prediabetes patients with and without insomnia (physician identified or insomnia medication dispense). Participants with prediabetes (physician identified or by 2 laboratory tests) between 1/1/2007 and 12/31/2015 were followed until 12/31/2016. Patients were determined to have T2DM when two of the following occurred within 2 years: physician-entered outpatient T2DM diagnosis, dispensing of an anti-hyperglycemia agent, A1C ≥6.5%, or fasting plasma glucose &amp;gt;125 mg/dl. One hospital inpatient stay with an associated T2DM diagnosis was also sufficient for T2DM classification. Results: Our cohort comprised 79,608 persons with prediabetes. Almost 30% (23,370) were classified as having insomnia during the observation period. After adjustment for traditional risk factors, those with insomnia were 28% more likely to develop T2DM than those without. This estimate was essentially unchanged after adjusting for baseline A1C level (Table). Conclusions: The association of insomnia with increased T2DM risk is similar to that of traditional risk factors such as overweight and nonwhite race. This finding has the potential to be of great value as a modifiable factor in diabetes prevention efforts. Disclosure E. LeBlanc: None. N. Smith: None. M. Allison: None. G. Nichols: Research Support; Self; Boehringer Ingelheim GmbH, Amarin Corporation, Janssen Pharmaceuticals, Inc., Sanofi. G. Clarke: None.

Management of Pediatric Delirium in Pediatric Cardiac Intensive Care Patients: An International Survey of Current Practices.

The purpose of this study was to describe how pediatric cardiac intensive care clinicians assess and manage delirium in patients following cardiac surgery. Descriptive self-report survey. A web-based survey of pediatric cardiac intensive care clinicians who are members of the Pediatric Cardiac Intensive Care Society. Pediatric cardiac intensive care clinicians (physicians and nurses). None. One-hundred seventy-three clinicians practicing in 71 different institutions located in 13 countries completed the survey. Respondents described their clinical impression of the occurrence of delirium to be approximately 25%. Most respondents (75%) reported that their ICU does not routinely screen for delirium. Over half of the respondents (61%) have never attended a lecture on delirium. The majority of respondents (86%) were not satisfied with current delirium screening, diagnosis, and management practices. Promotion of day/night cycle, exposure to natural light, deintensification of care, sleep hygiene, and reorientation to prevent or manage delirium were among nonpharmacologic interventions reported along with the use of anxiolytic, antipsychotic, and medications for insomnia. Clinicians responding to the survey reported a range of delirium assessment and management practices in postoperative pediatric cardiac surgery patients. Study results highlight the need for improvement in delirium education for pediatric cardiac intensive care clinicians as well as the need for systematic evaluation of current delirium assessment and management practices.

Antidepressants for insomnia in adults.

Insomnia disorder is a subjective condition of unsatisfactory sleep (e.g. sleep onset, maintenance, early waking, impairment of daytime functioning). Insomnia disorder impairs quality of life and is associated with an increased risk of physical and mental health problems including anxiety, depression, drug and alcohol abuse, and increased health service use. hypnotic medications (e.g. benzodiazepines and 'Z' drugs) are licensed for sleep promotion, but can induce tolerance and dependence, although many people remain on long-term treatment. Antidepressant use for insomnia is widespread, but none is licensed for insomnia and the evidence for their efficacy is unclear. This use of unlicensed medications may be driven by concern over longer-term use of hypnotics and the limited availability of psychological treatments. To assess the effectiveness, safety and tolerability of antidepressants for insomnia in adults. This review incorporated the results of searches to July 2015 conducted on electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 6), MEDLINE (1950 to 2015), Embase (1980 to 2015) and PsycINFO (1806 to 2015). We updated the searches to December 2017, but these results have not yet been incorporated into the review. Randomised controlled trials (RCTs) of adults (aged 18 years or older) with a primary diagnosis of insomnia and all participant types including people with comorbidities. Any antidepressant as monotherapy at any dose whether compared with placebo, other medications for insomnia (e.g. benzodiazepines and 'Z' drugs), a different antidepressant, waiting list control or treatment as usual. Two review authors independently assessed trials for eligibility and extracted data using a data extraction form. A third review author resolved disagreements on inclusion or data extraction. The search identified 23 RCTs (2806 participants).Selective serotonin reuptake inhibitors (SSRIs) compared with placebo: three studies (135 participants) compared SSRIs with placebo. Combining results was not possible. Two paroxetine studies showed significant improvements in subjective sleep measures at six (60 participants, P = 0.03) and 12 weeks (27 participants, P < 0.001). There was no difference in the fluoxetine study (low quality evidence).There were either no adverse events or they were not reported (very low quality evidence).Tricyclic antidepressants (TCA) compared with placebo: six studies (812 participants) compared TCA with placebo; five used doxepin and one used trimipramine. We found no studies of amitriptyline. Four studies (518 participants) could be pooled, showing a moderate improvement in subjective sleep quality over placebo (standardised mean difference (SMD) -0.39, 95% confidence interval (CI) -0.56 to -0.21) (moderate quality evidence). Moderate quality evidence suggested that TCAs possibly improved sleep efficiency (mean difference (MD) 6.29 percentage points, 95% CI 3.17 to 9.41; 4 studies; 510 participants) and increased sleep time (MD 22.88 minutes, 95% CI 13.17 to 32.59; 4 studies; 510 participants). There may have been little or no impact on sleep latency (MD -4.27 minutes, 95% CI -9.01 to 0.48; 4 studies; 510 participants).There may have been little or no difference in adverse events between TCAs and placebo (risk ratio (RR) 1.02, 95% CI 0.86 to 1.21; 6 studies; 812 participants) (low quality evidence).'Other' antidepressants with placebo: eight studies compared other antidepressants with placebo (one used mianserin and seven used trazodone). Three studies (370 participants) of trazodone could be pooled, indicating a moderate improvement in subjective sleep outcomes over placebo (SMD -0.34, 95% CI -0.66 to -0.02). Two studies of trazodone measured polysomnography and found little or no difference in sleep efficiency (MD 1.38 percentage points, 95% CI -2.87 to 5.63; 169 participants) (low quality evidence).There was low quality evidence from two studies of more adverse effects with trazodone than placebo (i.e. morning grogginess, increased dry mouth and thirst). We identified relatively few, mostly small studies with short-term follow-up and design limitations. The effects of SSRIs compared with placebo are uncertain with too few studies to draw clear conclusions. There may be a small improvement in sleep quality with short-term use of low-dose doxepin and trazodone compared with placebo. The tolerability and safety of antidepressants for insomnia is uncertain due to limited reporting of adverse events. There was no evidence for amitriptyline (despite common use in clinical practice) or for long-term antidepressant use for insomnia. High-quality trials of antidepressants for insomnia are needed.

0411 Trends in Insomnia Prescription MedicTrends in Insomnia Prescription Medication Use Among Medicare Beneficiaries, 2006–2013

Traditional pharmacotherapy for insomnia has known adverse outcomes among older adults, including falls and cognitive impairment. However, few studies have characterized longitudinal insomnia-related medication trends among Medicare beneficiaries. These characteristics are of particular interest given the recent (2012) inclusion of benzodiazepines in the Medicare prescription drug formulary. The objective of this study was to characterize trends in insomnia-related prescription medication use among Medicare beneficiaries over a seven-year period. We conducted a time-series analysis to estimate the annual prevalence of use of insomnia medications using a 5% sample of Medicare fee-for-service beneficiaries from 2006–2013. Insomnia medication use (defined as at least 1 fill annually) was identified by searching the Part D prescription drug claims and included insomnia-related medication classes and drugs: barbiturates, benzodiazepines, chloral hydrate, hydroxyzine, non-benzodiazepine sedative hypnotics (NBSH), and sedating anti-depressants. Prevalence of insomnia medication use ranged from 20.8% in 2006 to 23.4% in 2013 (p>.10). Benzodiazepine use increased from 0.5% in 2012 to 8.0% in 2013 (p = 0.03). Use of sedating antidepressants and NBSH decreased modestly from 9% and 8%, respectively, in 2006 through 2013. Prevalence of sedating antidepressant, NBSH, and hydroxyzine use was higher among women than men (p<0.001 for all). Benzodiazepine and sedating antidepressant use was most common among those age <65 and ≥85 years. NBSH use was most common among those age <65 years. Use of all drugs was similar among those ages 65 - 74 years and 75 - 84 years. Prevalence of insomnia medication use remained high among Medicare beneficiaries from 2006 - 2013, particularly among women. Benzodiazepine use increased sharply following inclusion in the Medicare formulary. Future studies should examine population-level outcomes associated with this increased use of benzodiazepines. Merck Investigator Initiated Studies Program (PI: Wickwire).

Predictors for return to work after multimodal rehabilitation in persons with persistent musculoskeletal pain

Aims: To identify factors explaining return to work (RTW) 12 months after a multimodal rehabilitation (MMR) intervention in the REHSAM II project. Methods: The present study is a secondary assessment of the data from the randomized controlled trial REHSAM II. A total of 97 participants with persistent musculoskeletal pain were randomly allocated to MMR + web-based education or only MMR. The subjects were followed from baseline to 12 months. The baseline variables from the outcome measures were used to identify predictors. The associations between the dependent variable (i.e., RTW) and independent variables (i.e., baseline variables) were analyzed with univariate and multiple logistic regression models. Results: The univariate regression analyses showed that pain and disability level, the capacity to perform a task in relation to pain, hospital and psychiatric care, medication for insomnia, catastrophizing, self-assessed work ability compared with lifetime best, satisfaction with life, ability for coping and controlling work situation, ability for coping with life outside work, and sense of responsibility for managing health condition were significantly associated with RTW. In the final multiple regression model, RTW was predicted by the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ score) (p=0.003, OR=0.961) and EuroQol (EQ-5D index) (p=0.017, OR=7.283) Conclusion: Psychosocially related pain and health-related quality of life predicted RTW in the final model. The results confirm that RTW is a multidimensional problem involving a complex interaction of many factors.

Clinical Practice Guideline on Management of Sleep Disorders in the Elderly.

Clinical Practice Guideline on Management of Sleep Disorders in the Elderly.

Pharmacological and nonpharmacological treatment of insomnias with regard to sleep medicine

Insomnia - one of the most prevalent sleep complain - has a great impact on the everyday life. Basically two different form of insomnia can be defined: the insomnia disorder and the co-morbid insomnias. To treat adequately determination of background pathology is essential, which is based on the help of Sleep Medicine Centers. According to the newest guidelines, the treatment of insomnia disorder is based on cognitive behavioural therapies followed by pharmaceutical intervention. In this review we provide the short description of cognitive behavioural therapies and basic principles of hypnotic drugs. Despite the availability of insomnia guidelines the huge variation of the insomnia medication can be seen in the daily practice. Due to the above mentioned reasons we summarize the good clinical practice of hypnotic drug administration for insomnia patients.

Pharmacotherapy of Insomnia.

Insomnia remains a common clinical concern that is associated with negative daytime consequences for patients and represents a significant public health problem for our society. Although a variety of therapies may be employed to treat insomnia, the use of medications has been a dominant approach. Regulatory agencies have now classified insomnia medications into 4 distinct pharmacodynamics classes. Medications with indications approved for insomnia treatment include benzodiazepine receptor agonists, a melatonin receptor agonist, a selective histamine receptor antagonist, and a dual orexin/hypocretin receptor antagonist. Both pharmacodynamic and pharmacokinetic advances with hypnotic medications in recent years have expanded the pharmacopoeia to allow personalized treatment approaches for different patient populations and individual sleep disturbance patterns.

Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities.

Sleep disturbances, in particular insomnia, represent a common problem in children with neurodevelopmental disabilities (NDDs). Currently, there are no approved medications for insomnia in children by the US Food and Drug Administration or European Medicines Agency and therefore they are prescribed off-label. We critically reviewed pediatric literature on drugs as well as nonpharmacological (behavioral) interventions used for sleep disturbances in children with NDDs. PubMed, Ovid (including PsycINFO, Ovid MEDLINE® , and Embase), and Web of Knowledge databases were searched through February 12, 2017, with no language restrictions. Two authors independently and blindly performed the screening. Good sleep practices and behavioral interventions, supported by moderate-to-low level evidence, are the first recommended treatments for pediatric insomnia but they are often challenging to implement. Antihistamine agents, such as hydroxyzine or diphenhydramine, are the most widely prescribed sedatives in the pediatric practice but evidence supporting their use is still limited. An increasing body of evidence supports melatonin as the safest choice for children with NDDs. Benzodiazepines are not recommended in children and should only be used for transient insomnia, especially if daytime anxiety is present. Only few studies have been carried out in children's and adolescents' zolpidem, zaleplon, and eszopiclone, with contrasting results. Limited evidence supports the use of alpha-agonists such as clonidine to improve sleep onset latency, especially in attention deficit/hyperactivity disorder subjects. Tricyclic antidepressants, used in adults with insomnia, are not recommended in children because of their safety profile. Trazodone and mirtazapine hold promise but require further studies. Here, we provided a tentative guide for the use of drugs for insomnia in children with NDDs. Well-controlled studies employing both objective polysomnography and subjective sleep measures are needed to determine the efficacy, effectiveness, and safety of the currently prescribed pediatric sleep medicines in children with NDDs.

Gender-specific Correlations of Insomnia and Attitudes toward Treatment among Community-dwelling Elderly in Northern Taiwan

Summary Background This is the first study to examine gender-specific correlations and attitudes toward treatment among community-dwelling elderly individuals with insomnia in northern Taiwan. Methods A cross-sectional survey was conducted among 1358 adults aged ≥65 years who underwent a senior citizen health examination between March and November 2009 at a medical center. Results The overall prevalence of insomnia was 41.4%, with a higher rate in women (63.3%) than in men (36.7%). Difficulty falling asleep was the most commonly reported symptom (61.7%). About 60% of the elderly individuals had insomnia for longer than 1 year. In women, gender was an independent correlation. Higher scores on the 5-item Brief Symptom Rating Scale were associated with insomnia in both genders (odds ratio [OR] = 1.41–1.44, 95% confidence interval [CI]: 1.31–1.57). The use of medication for a chronic illness increased the correlation of insomnia in women (OR = 1.9, 95% CI: 1.39–2.59), and living with family decreased the correlation of insomnia in men (OR = 0.42, 95% CI: 0.21–0.82). Further, 47.9% of individuals reported using insomnia medication. Of those, 49.3% and 82.3% with untreated insomnia desired complementary/alternative medicine and sleep hygiene as treatments, respectively. Conclusion Early intervention to halt the progress of sleep disturbance and avoid unnecessary medication use are important. We identified a need for improved attitudes toward sleep hygiene and treatment among elderly Taiwanese individuals.

Chronic Insomnia Disorder.

Neurologists, along with all health care providers, commonly encounter patients with insomnia, which is a condition that impacts patients' underlying neurologic conditions in a bidirectional manner. While chronic insomnia is one of the most common sleep disturbances, only a small proportion of individuals with this condition discuss their sleep problems with their providers. When insomnia is described, it is more often in relationship to another medical problem, as opposed to an independent condition. In neurology practice, multiple factors including pain, movement disorders, sleep apnea, and medications that act on the central nervous system often contribute to insomnia. An all-inclusive approach is necessary when evaluating sleep problems in patients with insomnia. The US Food and Drug Administration (FDA) has approved several medications for the treatment of insomnia that target specific receptor systems in the brain and incorporate several unique pharmacodynamic and pharmacokinetic profiles that can represent customized therapy for specific insomnia phenotypes. FDA-approved medications for insomnia include γ-aminobutyric acid (GABA)-modulating benzodiazepine receptor agonists, a melatonin receptor agonist, a histamine receptor antagonist, and the newest approved option, a hypocretin (orexin) receptor antagonist. This article provides an evidence-based multidisciplinary approach to the treatment of insomnia, highlighting the rationale and utility of cognitive-behavioral therapy and pharmacologic interventions. Neurologists should be proactive in assessing the impact of underlying comorbidities on insomnia, particularly in the setting of psychiatric conditions such as depression, sleep disorders such as circadian rhythm disorders, and medical problems such as nocturia.