Sedative-hypnotic Medications Research Articles

Pharmacotherapy for Chronic Insomnia: A Brief Survey of PCP Attitudes and Preferences

Purpose: To examine primary care professionals’ (PCP) attitudes and prescribing preferences toward hypnotic medications to treat chronic insomnia. Methods: An online survey was sent to members of the Dartmouth CO-OP, a practice-based primary care research network in Maine, Vermont, and New Hampshire. The survey begins with a case vignette of a 64-year old woman suffering from chronic insomnia. Clinicians were then presented with eight questions about management of the patient and their attitudes toward prescribing medications, focusing on benzodiazepines/benzodiazepine receptor agonists (BDZ/BZRAs). Results: 103 of 198 clinicians (52%) responded. Regarding choice of medication for the case vignette, 81% of respondents preferred the off-label use of hypnotics such as trazodone or melatonin; 11% stated they would choose BDZs and 22% would choose BZRAs. Strong majorities expressed that negative consequences would occur with use of BDZ/BZRAs, including tolerance (77%), dependence (68%), other side effects (53%), and addiction (51%). PCP preference for off- label prescribing was correlated to levels of concern about harms (addiction, dependence, tolerance, side effects) of BDZ/BZRAs as measured on a global medication risk score in this survey. In addition, 14% of respondents felt that pharmacotherapy was not an appropriate therapeutic option for chronic insomnia in the case vignette. Conclusion: Most of the clinicians surveyed acknowledged a legitimate role for hypnotic medications in chronic insomnia but expressed reservations toward BDZ/BZRAs despite their FDA-approval and proven efficacy. There appears to be a gap between published guidelines for selection of sedative-hypnotic medications and PCP preferences.

Implementing Computer-Based Psychotherapy Among Veterans in Outpatient Treatment for Substance Use Disorders.

Computer-based psychotherapy interventions (CBPIs) are increasingly offered as first-level access to evidence-based mental health treatment. However, their implementation has not been evaluated in public-sector outpatient settings. An evidence-based CBPI for insomnia was implemented with provider and patient education sessions, on-site Internet access, and clinician telephone support. Persons receiving care at a Veterans Health Administration substance abuse treatment clinic were screened for chronic insomnia and offered CBPI access. The feasibility of this strategy was evaluated in a pre-post design, which assessed engagement and completion rates, participant-reported acceptability, and clinical outcomes. Of 100 veterans referred, 51 enrolled in the program, of whom 22 (43%) completed all sessions, 13 (26%) partially completed the program, and 16 (31%) did not engage. There were no statistically significant differences between these three groups in baseline characteristics. In the total sample, Insomnia Severity Index (ISI) scores decreased (improved) by 32% (mean±SD of 6.3±6.2 points, t=6.82, df=44, p<.001). Veterans who completed all six sessions displayed clinically and statistically significant improvements on the ISI compared with those who did not engage, as shown in a regression analysis that controlled for baseline insomnia severity, time between assessments, and sedative-hypnotic medication use (F=3.87, df=4 and 40, p≤.004). Among all participants, 67% agreed that they would engage in another CBPI in the future. When questioned about potential barriers, 36% of the full sample endorsed a preference for face-to-face therapy. A strategy of brief provider and patient education, on-site Internet access, and telephone support was feasible and effective for implementing CBPIs in outpatient substance abuse treatment settings for veterans.

Propofol facilitates excitatory inputs of cerebellar Purkinje cells by depressing molecular layer interneuron activity during sensory information processing in vivo in mice.

Propofol is a rapid-acting sedative-hypnotic medication that has been widely used for the induction and maintenance of anesthesia; it has specific actions on different areas of the brain, such as sensory information transmission in the somatosensory cortex. However, the effects of propofol on the properties of sensory stimulation-evoked responses in cerebellar Purkinje cells (PCs) are currently unclear. In the present study, we studied the effects of propofol on facial stimulation-evoked responses in cerebellar PCs and molecular level interneurons (MLIs) in urethane-anesthetized mice using electrophysiological and pharmacological methods. Our results showed that cerebellar surface perfusion with propofol induced a decrease in the amplitude of the gamma-aminobutyric acid (GABA)-ergic component (P1) in a dose-dependent manner, but induced a significant increase in the amplitude of the excitatory response (N1). The IC50 of propofol-induced inhibition of P1 was 217.3 μM. In contrast, propofol (100 μM) depressed the spontaneous activity and tactile-evoked responses in MLIs. In addition, blocking GABA(A) receptor activity abolished the propofol (300 μM)-induced inhibition of the tactile-evoked inhibitory response and the increase in the sensory stimulation-evoked spike firing rate of PCs. These results indicated that propofol depressed the tactile stimulation-evoked spike firing of MLIs, resulting in a decrease in the amplitude of the tactile-evoked inhibitory response and an increase in the amplitude of the excitatory response in the cerebellar PCs of mice. Our results suggest that propofol modulates sensory information processing in cerebellar cortical PCs and MLIs through the activation of GABA(A) receptors.

Propofol protects against opioid-induced hyperresponsiveness of airway smooth muscle in a horse model of target-controlled infusion anaesthesia

General anaesthesia in horses is associated with elevated mortality rate in subjects suffering of heaves. Target-controlled infusion (TCI) of sedative–hypnotic medications and opioids represents a total intravenous anaesthesia (TIVA) method validated in veterinary medicine. Since there are no data concerning the impact of these classes of drugs in inducing bronchial hyperresponsiveness (BHR) in horses, the aim of this study was to investigate the effect propofol and remifentanil on the contractile response of equine airway smooth muscle.The influence of propofol and remifentanil on the contractile response of equine isolated bronchi to electrical field stimulation (EFS) was assessed. The role of capsaicin-sensitive sensory nerves, inducible nitric oxide synthase (iNOS) and neurokinin 2 (NK2) receptor was also assessed. The interaction analysis was performed by Bliss Independence theory. Experiments were repeated in desensitized and passively sensitized airways.Remifentanil induced BHR in both non-sensitized and passively sensitized bronchi, (+56.33±8.01% and +99.10±14.52%, respectively; P<0.01 vs. control) and propofol significantly prevented this effect (P>0.05 vs. remifentanil). The inactivation of capsaicin-sensitive sensory nerves via desensitization and blocking NK2 receptor inhibited the BHR remifentanil-induced (P>0.05 vs. controls). The inhibition of iNOS reverted the protective effect of propofol on the BHR induced by remifentanil (non-sensitized: +47.11±7.70%; passively sensitized: +70.51±11.39%; P<0.05 vs. control). Propofol synergistically interacted (overall ≈40%) in preventing the remifentanil-induced BHR.Remifentanil induces BHR via stimulating capsaicin-sensitive sensory nerves that facilitate the cholinergic neurotransmission through the activation of NK2 receptor. The propofol/remifentanil combination may be safely administered in course of TCI–TIVA procedures also in heaves affected horses.

Sedative Hypnotic Medication Use and the Risk of Motor Vehicle Crash.

We sought to estimate the association between sedative hypnotic use and motor vehicle crash risk. We conducted a new user cohort study of 409 171 adults in an integrated health care system. Health plan data were linked to driver license and collision records. Participants were aged 21 years or older, licensed to drive in Washington State, had at least 1 year of continuous enrollment between 2003 and 2008, and were followed until death, disenrollment, or study end. We used proportional hazards regression to estimate the risk of crash associated with 3 sedatives. We found 5.8% of patients received new sedative prescriptions, with 11 197 person-years of exposure. New users of sedatives were associated with an increased risk of crash relative to nonuse: temazepam hazard ratio (HR) = 1.27 (95% confidence interval [CI] = 0.85, 1.91), trazodone HR = 1.91 (95% CI = 1.62, 2.25), and zolpidem HR = 2.20 (95% CI = 1.64, 2.95). These risk estimates are equivalent to blood alcohol concentration levels between 0.06% and 0.11%. New use of sedative hypnotics is associated with increased motor vehicle crash risk. Clinicians initiating sedative hypnotic treatment should consider length of treatment and counseling on driving risk.

Treatment of sleep-related eating disorder.

Sleep-related eating disorder (SRED) is classified as an NREM-related parasomnia characterized by recurrent episodes of dysfunctional eating that occur after an arousal from the main sleep period with partial or complete amnesia for the event, resulting in weight gain from eating high calorie foods and causing various injuries due to consumption of inedible or toxic items. SRED can be idiopathic or commonly associated with other primary sleep disorders such as sleepwalking, restless legs syndrome (RLS), obstructive sleep apnea syndrome (OSAS), other clinical conditions, or use of sedative-hypnotic medications. First-line treatment of idiopathic SRED includes selective serotonin reuptake inhibitors (SSRIs) at mean dosages of 20 to 30mg/day. Topiramate at 100-300mg/day and clonazepam at 0.5-2.0mg/day can be valid alternative options. SRED related to other parasomnias or sleep disturbances that cause sleep fragmentation benefit most from treatment of the associated sleep disorder. In particular, RLS-related SRED is best treated with dopamine agonists such as pramipexole, while sleepwalking-related SRED benefits from low-dose benzodiazepines such as clonazepam. Different kinds of drug associations have been proposed in a limited number of cases, especially in the past. We strongly recommend that all patients suffering from SRED should undergo consistent and regular follow-up about 2-3 times per year or otherwise according to the physician's judgment, in order to assess the evolution of symptom severity and frequency and re-evaluate treatment efficacy and any side effects that may arise.

Rightward dominance in temporal high-frequency electrical asymmetry corresponds to higher resting heart rate and lower baroreflex sensitivity in a heterogeneous population.

ObjectiveExplore potential use of a temporal lobe electrical asymmetry score to discriminate between sympathetic and parasympathetic tendencies in autonomic cardiovascular regulation.Methods131 individuals (82 women, mean age 43.1, range 13–83) with diverse clinical conditions completed inventories for depressive (CES-D or BDI-II) and insomnia-related (ISI) symptomatology, and underwent five-minute recordings of heart rate and blood pressure, allowing calculation of heart rate variability and baroreflex sensitivity (BRS), followed by one-minute, two-channel, eyes-closed scalp recordings of brain electrical activity. A temporal lobe high-frequency (23–36 Hz) electrical asymmetry score was calculated for each subject by subtracting the average amplitude in the left temporal region from amplitude in the right temporal region, and dividing by the lesser of the two.ResultsDepressive and insomnia-related symptomatology exceeding clinical threshold levels were reported by 48% and 50% of subjects, respectively. Using a cutoff value of 5% or greater to define temporal high-frequency asymmetry, subjects with leftward compared to rightward asymmetry were more likely to report use of a sedative-hypnotic medication (42% vs. 22%, P = 0.02). Among subjects with asymmetry of 5% or greater to 30% or greater, those with rightward compared to leftward temporal high-frequency asymmetry had higher resting heart rate (≥5% asymmetry, 72.3 vs. 63.8, P = 0.004; ≥10%, 71.5 vs. 63.0, P = 0.01; ≥20%, 72.2 vs. 64.2, P = 0.05; ≥30%, 71.4 vs. 64.6, P = 0.05). Subjects with larger degrees of rightward compared to leftward temporal high-frequency asymmetry had lower baroreflex sensitivity (≥40% asymmetry, 10.6 vs. 16.4, P = 0.03; ≥50% asymmetry, 10.4 vs. 16.7, P = 0.05).ConclusionIn a heterogeneous population, individuals with rightward compared to leftward temporal high-frequency electrical asymmetry had higher resting heart rate and lower BRS. Two-channel recording of brain electrical activity from bilateral temporal regions appears to hold promise for further investigation as a means to assess cortical activity associated with autonomic cardiovascular regulation.

Restless legs syndrome in hemodialysis patients in Iran.

Restless legs syndrome (RLS) is a common sleep disorder that can present secondary to medical conditions such as renal failure. This study aimed to evaluate RLS frequency and its related factors in chronic renal failure patients treated with hemodialysis. In a cross-sectional design, 163 patients with chronic renal failure were consecutively enrolled from hemodialysis center at Rasool-Akram hospital. Demographics, clinical and laboratory data were recorded. Patients were screened for presence and severity of RLS according to the four International Restless Legs Syndrome Group (IRLSSG) diagnostic criteria and severity scale. Patients with and without RLS were compared using SPSS statistical software (Version 16.0). Sixty-one patients (37.4 %) were diagnosed with RLS. Mean age in RLS group was significantly higher (65.2 ± 9.3 years) than RLS-negative group (59.0 ± 14.7 years; P = 0.004). Serum creatinine level was significantly higher in patients with RLS (7.6 ± 2.1 mg/dl vs. 6.7 ± 1.8 mg/dl; P = 0.009). Glomerular filtration rate in RLS patients was lower than other patients (9.2 ± 3.1 ccs/min vs. 11.6 ± 4.8 ccs/min; P = 0.0001). Patients with RLS had shorter sleep duration, and higher incidence of insomnia, daytime sleepiness, and sedative-hypnotic medication usage (P < 0.05). There was no significant difference between RLS-positive and RLS-negative patients in terms of renal failure pathology, dialysis frequency per week, dose of dialysis, duration of dialysis, renal transplantation, and history of diabetes and hypertension. Hemodialysis patients have a high prevalence of RLS which deserves special attention and specific treatment.

Pharmacokinetics of zolpidem from sublingual zolpidem tartrate tablets in healthy elderly versus non-elderly subjects.

Pharmacokinetic parameters of sedative-hypnotic medications can be influenced by age and gender. This study analyzed pharmacokinetic parameters of zolpidem, formulated as a sublingual zolpidem tartrate tablet (ZST; Intermezzo®), in healthy elderly males and females (mean age 72 years) and in non-elderly males and females (34 years). This was a randomized, single-dose, open-label, two-way crossover study evaluating pharmacokinetic parameters of 1.75 and 3.5 mg dosages of ZST in elderly subjects (n = 22), and 3.5 mg dosages of ZST in non-elderly subjects (n = 24). Main outcome measures were pharmacokinetic parameters, including area under the plasma concentration-time curve (AUC), maximum observed concentration (C(max)), time to reach C(max) (T(max)), elimination half-life (T(½)), and apparent oral clearance (CL/F). Dose proportionality in zolpidem exposure was maintained between 1.75 and 3.5 mg doses for both elderly females and males. With administration of the 3.5 mg dose of ZST to elderly and non-elderly subjects, significantly higher systemic exposure was seen in elderly females (C(max) +44.6 %, P < 0.01; AUC +40.4 %) compared with non-elderly females. However, systemic exposure was only modestly higher in elderly males compared with non-elderly males. Greater exposure was seen in elderly females compared to males (C(max) +46.8 %, P < 0.01; AUC +31.4 %). In this study, exposure between non-elderly females and males was equivalent. Changes in T(½) and T(max) values were not observed, with no significant age effect on oral clearance. There were no apparent differences in tolerability among age and gender groups. Elderly individuals were found to have higher C(max) and AUC values compared with non-elderly subjects. C(max) and AUC were greater in elderly women compared with elderly men.

Advances in the management of insomnia

Insomnia is highly prevalent and associated with considerable morbidity. Several very efficacious treatments, both pharmacologic and non-pharmacologic, exist for the management of insomnia. New modes of delivery and new formulations of existing sedative-hypnotic medications have been introduced. Novel agents are still being developed and tested to arrive at a hypnotic that has limited side effects while still being efficacious. Innovations with respect to behavioral interventions, which are drastically under-utilized, have focused mainly on making these interventions more widely available through dissemination efforts, briefer formats and more accessible platforms.

Insomnia severity is associated with decreased executive functioning in patients with suicidal ideation and drug abuse.

To the Editor: Insomnia has been associated with decreased executive functioning in those without substance use disorders.1 Although numerous studies have linked impulsivity with substance abuse and suicidal ideation, its relationship with insomnia in the substance-abusing population is unclear.2–6 In this preliminary study, we explore the relationship of insomnia severity with objective and subjective impulsivity measured by computerized behavioral tests and a self-report questionnaire, respectively, in patients with suicidal ideation/behavior attending a psychiatric emergency department. We hypothesized that a higher insomnia severity would be associated with increased objective impulsivity (a decrease in executive functioning) and higher subjective impulsivity scores. Method. This investigation involved secondary analyses of cross-sectional data from an ongoing study (N.S., J.L.E., unpublished data, 2012). Subjects were adults (N = 21, ≤ 65 years of age) who presented with suicidal ideation/behavior between July 2012 and December 2012 to the emergency department, where they were observed until their symptoms stabilized. We excluded patients with any motor response, visual or hearing disorders, psychotic symptoms, or inability to read or comprehend English. The instruments used in this study included the following: The Stop-Signal Reaction-Time Task,7 which assesses objective impulsivity through response inhibition (a facet of executive functioning) based on correct responses and reaction times7,8; The UPPS Impulsive Behavior Scale,9 which is a 45-item self-report measure that assesses personality aspects of subjective impulsivity (the “S” sensation-seeking component was excluded in this protocol); The sleep question from the Center for Epidemiology Studies-Depression Scale (CES-D),10 which assesses insomnia by inquiring, “Over last week, my sleep was restless….” with the responses arrayed as “less than a day,” “1–2 days,” “3–4 days,” and “5–7 days.” The responses were categorized into “frequent” (ie, those with restless sleep for ≥ 5 nights/wk) or “infrequent” (those with ≤ 4 nights/wk) insomnia on the basis of the distribution of responses, clinical significance, and similarity to analyses from prior literature11; The remaining CES-D items, which assess depressive symptoms. The institutional review board approved the study, and subjects signed informed consent prior to participation. Results. The demographic variables included the following: the mean age was 38.3 (SD = 10.1) years, 18 (85.7%) identified themselves as African American, 18 (85.7%) were male, 9 (42.9%) were single, 16 (76.2%) were unemployed, 8 (38.1%) had ≥ 12 years of education, and 12 (57.1%) reported being homeless. Urine drug screens at admission were positive in 14 (66.7%) for cocaine, 6 (28.6%) for cannabis, 5 (23.8%) for phencyclidine, 4 (19.0%) for sedative-hypnotic medications, and 3 (14.3%) for opioids. Four subjects (19.0%) reported use of only 1 drug (cocaine). Subjects with frequent insomnia had significantly higher CES-D scores. In analyses adjusted for demographic and mood covariates, those with frequent insomnia (as compared to those with infrequent insomnia) had a significantly decreased number of correct responses and a higher mean reaction time at 160 ms. Similarly, a higher reaction time was seen at 320 ms for this group, although this was not statistically significant. Those with frequent insomnia (in comparison to those with infrequent insomnia) had nonsignificantly lower scores on the UPPS impulsivity scales (see Table 1). Table 1 Measures of Impulsivity Across Insomnia Groups The limitations associated with this preliminary study include the lack of a formal standardized insomnia rating instrument, the small sample size, and its cross-sectional nature. Despite the limitations, we observed that frequent sleep impairment was associated with a lower response inhibition on the Stop Signal Reaction Time Task without any difference in the personality aspects of impulsivity in this complex sample. These results suggest that improving sleep in this population might help improve mood and executive functioning and thus reduce the likelihood of behaviors precipitating visits to the emergency department. Future studies should assess for subjective and objective insomnia using standardized instruments and expand the range of impulsivity facets being assessed.

Parasomnias: an updated review.

Parasomnias are abnormal behaviors emanating from or associated with sleep. Sleepwalking and related disorders result from an incomplete dissociation of wakefulness from nonrapid eye movement (NREM) sleep. Conditions that provoke repeated cortical arousals, or promote sleep inertia lead to NREM parasomnias by impairing normal arousal mechanisms. Changes in the cyclic alternating pattern, a biomarker of arousal instability in NREM sleep, are noted in sleepwalking disorders. Sleep-related eating disorder (SRED) is characterized by a disruption of the nocturnal fast with episodes of feeding after an arousal from sleep. SRED is often associated with the use of sedative-hypnotic medications; in particular, the widely prescribed benzodiazepine receptor agonists. Recently, compelling evidence suggests that nocturnal eating may in some cases be a nonmotor manifestation of Restless Legs Syndrome (RLS). rapid eye movement (REM) Sleep Behavior Disorder (RBD) is characterized by a loss of REM paralysis leading to potentially injurious dream enactment. The loss of atonia in RBD often predates the development of Parkinson's disease and other disorders of synuclein pathology. Parasomnia behaviors are related to an activation (in NREM parasomnias) or a disinhibition (in RBD) of central pattern generators (CPGs). Initial management should focus on decreasing the potential for sleep-related injury followed by treating comorbid sleep disorders. Clonazepam and melatonin appear to be effective therapies in RBD, whereas paroxetine has been reported effective in some cases of sleep terrors. At this point, pharmacotherapy for other parasomnias is less certain, and further investigations are necessary.

An approach to long-term sedative-hypnotic use

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

First prescription of new elderly patients attending the psychiatry outpatient of a tertiary care institute in North India

There is lack of data on prescription patterns in elderly patients from developing countries. The aim of this study is to examine the first prescription given to elderly patients (age >60 years) attending the psychiatry outpatient clinic of a tertiary care hospital. In this retrospective study, data on patients older than 60 years attending the psychiatric outpatient clinic of a tertiary care hospital between 1 January 2009 and 30 November 2010 were extracted from the computer-based registry and analyzed. During the study period, 1192 new patients older than and equal to 60 years registered with the psychiatric outpatient clinic. Exact prescription data was available for 975 patients. The most common major diagnostic group was mood disorders (33.9%), followed by neurotic, stress-related and somatoform disorders (23.1%). Across all diagnostic groups, olanzapine was the most commonly prescribed antipsychotic medication (20.7% of patients with an organic mental disorder, 40.8% with psychotic disorder, 30.2% with bipolar disorder); quetiapine and risperidone were the other commonly prescribed antipsychotics. Across all diagnostic groups, escitalopram was the most commonly prescribed antidepressant, and sertraline was the second most frequently prescribed SSRI. Among mood stabilizers, valproate was preferred over lithium (25.4% vs.12.7%). Sedative-hypnotic medications were frequently prescribed across all diagnostic groups. Clonazepam and lorazepam were the most often prescribed benzodiazepines. The mean number of psychotropic medications was highest among bipolar disorder patients (1.84) and least among the patients with an organic mental disorder (1.25). Olanzapine, SSRI and clonazepam were the most commonly prescribed antipsychotic, antidepressant, and benzodiazepine, respectively, and valproate was preferred over lithium among elderly patients with bipolar disorder.

Phenotyping interindividual variability in obstructive sleep apnoea response to temazepam using ventilatory chemoreflexes during wakefulness

Centrally active agents have a variable impact in patients with obstructive sleep apnoea (OSA) that is unexplained. How to phenotype the individual OSA response is clinically important, as it may help to identify who will be at risk of respiratory depression and who will benefit from a centrally active agent. Based on loop gain theory, we hypothesized that OSA patients with higher central chemosensitivity have higher breathing instability following the use of a hypnosedative, temazepam. In 20 men with OSA in a double-blind, placebo-controlled cross-over trial we tested the polysomnographically (PSG) measured effects of temazepam 10 mg versus placebo on sleep apnoea. Treatment nights were at least 1 week apart. Ventilatory chemoreflexes were also measured during wakefulness in each subject. The patients (mean ± standard deviation; 44 ± 12 years) had predominantly mild-to-moderate OSA [baseline apnoea-hypopnoea index (AHI) = 16.8 ± 14.1]. Patients' baseline awake central chemosensitivity correlated significantly with both the change of SpO₂ nadir between temazepam and placebo (r = -0.468, P = 0.038) and oxygen desaturation index (ODI; r = 0.485, P = 0.03), but not with the change of AHI (r = 0.18, P = 0.44). Peripheral chemosensitivity and ventilatory recruitment threshold were not correlated with the change of SpO₂ nadir, ODI or AHI (all P > 0.05). Mild-moderate OSA patients with higher awake central chemosensitivity had greater respiratory impairment during sleep with temazepam. Relatively simple daytime tests of respiratory control may provide a method of determining the effect of sedative-hypnotic medication on breathing during sleep in OSA patients.

Association of sedative–hypnotic medications with suicidality

Evaluation of: Brower KJ, McCammon RJ, Wojnar M, Ilgen MA, Wojnar J, Valenstein M. Prescription sleeping pills, insomnia, and suicidality in the National Comorbidity Survey Replication. J. Clin. Psychiatry DOI: 10.4088/JCP.09m05484gry (2010) (Epub ahead of print).Several studies have investigated the association between sedative–hypnotics and suicidality, as such medications not only serve as a method for suicide, but are also involved in the usual options for treating psychiatric and medico–surgical disorders. According to population-based studies in Europe, Asia and the USA, sedative–hypnotic medications were significantly associated with suicide. However, these studies failed to address psychiatric comorbidities, new hypnotic medications, such as zolpidem, and the specific times at which such medications were used. Recently, Brower and colleagues have investigated the association of the prescription of sedative–hypnotic drugs with suicidality, to determine whether such medications were associated with suicidal ideation, suicide plans and suicide attempts in a large-cohort sample. They found that the use of sedative–hypnotic medications was significantly associated with suicidal ideation, suicide plans and suicide attempts. In addition, the use of sedative–hypnotic medications was a stronger predictor than insomnia of both suicidal ideation and suicide attempts. This article will discuss the relationship between prescription of sedative–hypnotic medications and suicide in the context of the potential limitations and significance of this recent research.

Attitudes et perception de contrôle des personnes âgées envers la prise de médicaments à action anxiolytique, sédative et hypnotique (ASH)

This study examines the importance of variables from the Theory of Planned Behaviour (i.e., attitudes toward behaviour, subjective norms, and perceived control) for the prediction of consumption of anxiolytic and sedative-hypnotic (ASH) medications in a sample of older persons, aged 69 years on average, 62 consumers and 92 non-consumers. A favourable attitude toward ASH and a sense of having less control regarding these drugs predict both current usage and intention to continue. Perceived control predicts intention to start consumption of ASH in current non-consumers. This study underlines the importance of considering the role of the older person's decisional power in the consumption of these medications.

Nonpharmacologic approaches to the management of insomnia.

Insomnia is one of the more common complaints patients present to their physicians. Sleep problems affect up to one-third of all Americans, and the loss of workplace productivity and increased healthcare utilization result in costs approaching $100 billion a year. Patients with acute insomnia generally respond well to various sedative hypnotic medications, but chronic insomnia is a different challenge. Physicians and patients may raise concerns about the long-term use of sedative hypnotic medications. Even in light of these concerns, however, the chronic insomnia remains, ostensibly leaving the physician few choices. A number of promising nonpharmacologic strategies are available that physicians can easily implement. Through the use of self-rating instruments and a sleep log, physicians can bring the sleep problem into better focus and monitor the efficacy of clinical interventions. Certain behavioral techniques, such as sleep hygiene, stimulus control, and sleep restriction, can be effective remedies for chronic insomnia. The use of cranial electric stimulation for insomnia is also showing promising results. Through careful assessment and the adoption of simple nonpharmacologic strategies, the physician's interventions may result in a good night's sleep.

Clinic visits and prescribing patterns among Veterans Affairs Maryland Health Care System dementia patients.

Our objective was to determine how patient demographics and outpatient referrals to specialized dementia (DEM) or mental health (MH) clinics influence receipt of anti-dementia (AD), antidepressant (ADEP), antipsychotic (APSY) and sedative-hypnotic (SEDH) medications among veterans with dementia. Retrospective, cross-sectional observational study. Veterans Affairs Maryland Health Care System (VAMHCS). Veterans aged ≥ 60 years with Alzheimer's or related dementia diagnosis after 1999 with minimum of one-year follow-up or death were included. Retrospective analysis of VAMHCS electronic medical records were used to determine predictors of AD, ADEP, APSY, and SEDH prescribing using logistic regression models that examined visits to DEM or MH clinics, patient age, follow-up time, race/ethnicity and marital status. Among 1209 veterans with average follow-up of 3.2 (SD 1.9) years, 36% percent had MH visits, 38% had DEM visits and 19% visited both clinics. DEM visits were associated with AD and ADEP but not APSY medication receipt (OR(AD:DEM) = 1.47, 95% CI = (1.052, 2.051); OR(ADEP:DEM) = 1.66, 95% CI = (1.193, 2.302); OR(APSY:DEM) = 1.35, 95% CI = (0.941, 1.929)). MH visit was associated with ADEP and APSY medication receipt (OR(AD:MH)\ = 1.16, 95% CI = (0.821, 1.631); OR(ADEP:MH) = 2.83, 95% CI = (2.005, 4.005); OR (APSY:MH) = 4.41, 95% CI = (3.109, 6.255)). In the VAMHCS dementia population, visits to DEM or MH specialty clinics increase the odds of receiving AD, ADEP, and APSY medications.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

This study sought to identify and characterize rates of clinically questionable prescribing in New York State. As part of a quality improvement initiative, 34 national psychopharmacology experts identified a set of questionable prescribing practices recognizable from pharmacy claims data. Indicators of such practices were applied to Medicaid claims data for 217,216 beneficiaries in New York State who had an active psychotropic prescription on April 1, 2008. A total of 156,103 (72%) of these beneficiaries had one or more continuing (>90 days) prescriptions for a psychotropic. About 10% of adults were prescribed four or more psychotropics concurrently, and 13% of children and 2% of older adults were prescribed three or more concurrently. Prescribing an antipsychotic with a moderate-to-high risk of causing metabolic abnormalities approached 50% (46%) among individuals who had existing cardiometabolic conditions. Among beneficiaries prescribed second-generation antipsychotics with a moderate-to-high risk of causing metabolic abnormalities, over half (60%) had not received a metabolic screening test in the past year. Among women of reproductive age prescribed mood stabilizers, over one-quarter (30%) were prescribed a valproic acid-based formulation despite its potential for teratogenicity. Only 2% of youths under age 18 were prescribed benzodiazepines; however, about half (48%) had trials over 90 days' duration. Examination of pharmacy claims from Medicaid beneficiaries in New York State indicated that prescribing practices deemed clinically questionable by pharmacology experts are common. Aggregated pharmacy claims data can identify such practices, and reviews of these data can be a core component of efforts to improve prescribing practices.