Insomnia Use Research Articles

Deprescribing benzodiazepine receptor agonists taken for insomnia: a review and key messages from practice guidelines.

Long‑term benzodiazepine receptor agonist (BZRA) use for insomnia is common and highly prevalent in adults in all care settings. Evidence syntheses suggest that the therapeutic benefits of benzodiazepines for insomnia are marginal and very short term. On the harm side, BZRAs are associated with daytime sedation and confusion. Long‑term use increases the risk of falls, fractures, cognitive impairment, and motor vehicle accidents. An evidence‑based clinical practice guideline has been developed to assist with deprescribing BZRAs. This review highlights the rationale for deprescribing BZRAs used for insomnia and summarizes key messages for clinicians from the new BZRA deprescribing guideline and their supporting evidence.

PIH11 - Anxiety and Insomnia Among Elderly People in Chonburi, Thailand 2017

1. To identify socio-economic and demographic data of elderly people in Chonburi, Thailand. 2. To collect data of sleep quality, anxiety and drug use for insomnia 3. To compare means of age, BMI, sleep quality and anxiety among elderly people in 11 districts. 4. To identify association between sleep quality and anxiety. A cross-sectional survey research by face to face interview and questionnaire was performed during 7 months in 2017. The 60 years of age and above people in 11 Chonburi districts were randomly selected using non-probability, purposive-sampling method. Population were all elderly people who could read and write Thai and willing to participate. Sample size was calculated via Jacob Cohen’s table 8.4.3, when α was set to 0.05, power 0.80, effect size 0.20, k (group)= 11, it yielded n = 30 in each group. therefore 30*11= 330 samples were collected. 100% samples were completely collected. Cronbach’s Alpha coefficient confirmed internal consistency of The Pittsburgh Sleep Quality Index (PSQI), 0.7447 and The Hospital Anxiety and Depression Scale (HADS), 0.7874. The average age of participants was 68.50±3.47, BMI 21.91±8.44, PQSI score 9.60±4.58, HAD score 11.42±3.71. Most were female 176 (53.33%), live with spouse 215 (65.15%), passed secondary school 117 (35.45%), employee 130 (39.39%). Anxiety elderly was classified as normal 233 (76.61%), mild 83 (25.61%), moderate 13 (3.94%) and severe 1 (0.30%). These senior citizens were sleet well 124 (35.58%) and not sleep well 206 (62.42%). Most insomnia drugs prescribed for elderly were, Lorazepam, Amitriptyline and Clonazepam (7,41%, 6.51% and 4.74%) respectively. Inference statistics proved: Anxiety and sleep quality of elderly in 11 districts were not significantly different (ANOVA, p=0.0741). Moreover, anxiety (HADS), BMI, marital status and occupation significantly associated with sleep quality (PSQI) (Chi Square, p=0.000, 0.045, 0.041 and 0.005 respectively). Anxiety was significantly associated with sleep quality.

Pharmacists' interventions to reduce sedative/hypnotic use for insomnia in hospitalized patients

BackgroundHospitalization can contribute to insomnia in many patients and is usually treated symptomatically. However, sedative/hypnotic misuse is associated with complications in this population, especially in the elderly. Such complications include dizziness, falls and over-sedation. Due to the implicit dangers, widespread use of these drugs for insomnia, particularly in older patients, has been discouraged by many hospitals. The aim of this study was to review and evaluate prescribing patterns and to optimize the use of the sedative/hypnotic agents through daily pharmacy interventions at a community hospital. MethodsThis was a biphasic before and after study. Data on sedative/hypnotic use was collected retrospectively for a 2-month period and a sample of 100 patients was randomly selected for analysis. A 2-month prospective phase followed, in which daily orders were reviewed by one pharmacy resident and recommendations made to discontinue any unnecessary, newly prescribed sedative/hypnotic orders when appropriate. Finally, results of both phases were compared for any differences in patient demographics, being prescribed more than one sedative/hypnotic, and complications documented. ResultsDuring the prospective phase, pharmacist interventions led to the discontinuation of 25% of a total of 97 sedative/hypnotic orders in 97 patients. The number of patients receiving more than one sedative/hypnotic agents in the intervention group was significantly lower than the retrospective control group (15 Vs. 34, P = 0.0026). The incidence of complications was not significantly different between the control and intervention groups for the following: over-sedation, falls and delirium (p = 0.835, p = 0.185, p = 0.697, respectively). ConclusionThis study suggests that the use of sedative/hypnotics in the inpatient units (excluding the critical care unit), is somewhat prevalent, and many patients may be on more than one sedative/hypnotic, which could potentially cause cumulative harm. During the intervention phase, 25% of the total in-hospital orders for sedative/hypnotics were discontinued following recommendations made by a pharmacist, and significantly lower number of patients receiving duplicate sedative/hypnotics was noted. Further efforts should be implemented to avoid unnecessary sedative/hypnotic initiation in hospitalized patients, and to ensure monitoring by pharmacists is optimized.

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.

Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system

Objective To examine off-label indications for antidepressants in primary care and determine the level of scientific support for off-label prescribing.Design Descriptive study of antidepressant prescriptions written by primary care physicians...

Payer Perspective of the American Academy of Sleep Medicine Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia

Payer Perspective of the American Academy of Sleep Medicine Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia

Evaluating the Impact of Pharmacists on Reducing Use of Sedative/Hypnotics for Treatment of Insomnia in Long-Term Care Facility Residents.

To determine if pharmacist intervention can decrease the use of inappropriate sedative/hypnotics in the elderly population in the long-term care facility setting. A multicenter, prospective chart review of sedative/hypnotic use for insomnia among long-term care facility residents. Eleven regional long-term care facilities in Northeastern Tennessee. Long-term care facility residents older than 65 years of age, with confirmed insomnia diagnoses and no history of seizure or recent psychotropic gradual-dose reduction attempts. Consultant pharmacist recommendations to decrease inappropriate use of sedative/hypnotics. Acceptance rates for discontinuation/tapering of the selected sedative/hypnotics. A total of 36 patients were enrolled in the study based on inclusion/exclusion criteria. Overall, 39 interventions were performed. Gradual dose reductions/ discontinuation of select sedative/hypnotics were accepted for 19 residents (48.7%). Of the other recommendations, 8 (20.5%) were denied and 12 (30.8%) were left unanswered. Primary reasons for denial included family refusal, satisfactory response to current dose, and requirement of increased dose as a result of worsening insomnia. Overall, pharmacist intervention can have a meaningful impact on reducing inappropriate sedative/ hypnotic use in the elderly population through concise, evidence-based recommendations to physicians.

Investigation of sedative and hypnotic effects of Amygdalus communis L. extract: behavioral assessments and EEG studies on rat.

Amygdalus communis L. (almond) has been traditionally used as a natural medicine in the treatment of various diseases. The present research studied the sedative and hypnotic effects of the aqueous fraction of seeds of almond in rats. In order to investigate these effects, a combination of behavioral methods (open field test and loss of righting reflex test) as well as quantitative and analytic methods (EEG and EMG) were applied. The results of the open field test showed that a dose of 400 mg/kg of the almond extract significantly inhibited the locomotion activity of rats compared to normal. The results also illustrated that the almond extract affected pentobarbital-induced sleep through increasing the number of fallings asleep and prolongation of sleeping time. Analysis of EEG recordings of the animals which had received the same dose of the almond extract as the open field test demonstrated marked changes in the animals' sleep architecture. Significant prolongation of total sleeping time as well as significant increase in NREM sleep were the main observed changes compared to the normal condition. These results suggest that the aqueous extract of almond has significant sedative and hypnotic effects, which may support its therapeutic use for insomnia.

Frances Kathleen Oldham Kelsey

Instrumental in stopping thalidomide use for insomnia and nausea and vomiting in pregnancy in the US

Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study.

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use. In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis. Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0% were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change. Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.

Pharmacotherapeutic options for treatment of insomnia

Insomnia is a functionally debilitating condition characterized by repeated difficulty with sleep initiation, maintenance, or quality of sleep despite adequate opportunity. If left untreated, it can lead to increased risk of depression, poor memory, reduced concentration, poor work performance, and poor general health. Although gamma-aminobutyric acid (GABA) ergic system remains the primary target for current insomnia treatments, still over-the-counter (OTC) drugs with a different mechanism of action are in use for insomnia. OTC drugs target only one of the parallel arousing systems and may improve mild insomnia for a short period. They are not likely to improve symptoms over long-term and thus are not the ideal agents. Studies evaluating the efficacy and outcomes of sedative hypnotic drugs beyond 1 year are limited. Currently, there are no Food and Drug Administration approved pharmacotherapies for insomnia in the pediatric population. Increased understanding of complex neuronal networks involved in sleep and wake has led to the development of new drugs for insomnia that target a diverse range of receptors. Potential agents under investigations are targeting mechanisms and pathways including histamine (H 1 ) receptor, melatonin, and orexin receptors. This review describes the pharmacotherapy of insomnia and the drugs under development for the treatment of insomnia.

Hypno-Sedative Activity of Gymnema sylvestre Extract in Sodium Barbiturate - Induced Hypnosis in Rattus novergicus

Gymnema sylvestre is a rare herb with significant medical attributes and ethno-botanical uses. Insomnia is one of the most common sleep disorders around the world. In this study, the effect of the aqueous extracts of this plant was investigated for its hypno-sedative effect in rats as well as acute toxicity. Leaf, stem and flowers of G.sylvestre have several therapeutic applications in folk medicine in curing or managing of a wide range of diseases including insomnia. Sleep was induced using sodium barbiturate in albino rats. Rats of either sex weighing between 100-115g were grouped into five groups A,B,C,D and E of four animals each. Group A was the negative control and received only water, groups B the positive control received 10mg/kg b.w of diazepam .Groups C,D and E were administered 150,700 and 1500mg/kg b.w of extracts respectively, each of the rat was placed in individual cage and observed over a period of 24 hours at 6 hours interval .The aqueous extracts produced significant sedative effect at the dose of 150mg/kg b.w and was more effective than diazepam. The extracts at the doses of 150 and 700mg/kg b.w exhibited hypno-sedative activity comparable to the reference drug. The stem extract at 1500mg/kg produced no sedative effect. No toxicity signs were observed following acute toxicity evaluation. The extracts showed hypno-sedative activity at lower doses of 150mg/kg b.w in this increasing order, stem→leaf →flower. In conclusion, these results suggest that the aqueous extract of G. sylvestre is relatively non-toxic and possess potent sedative and hypnotic effects which could support its therapeutic use for insomnia in folk medicine.

Pharmacological evaluation of sedative and hypnotic activities of methanolic extract of Lycopus europaeus in mice.

The methanolic extract of Lycopus europaeus was evaluated on central nervous system. The methanolic extract produced significant sedative effect at the doses of 200, 400 and 600 mg/kg (by oral route), compared to reference substance diazepam in hole board and thiopental -induced sleeping time methods. While the hypnotic effect was calculated at the doses of 800 and 1000 mg/kg via oral pathway significantly reduced in both the reestablishment time and number of head dips during the traction and hole-board tests. In conclusion, these results suggest that the methanolic extract of Lycopus europaeus possess potent sedative and hypnotic activities, which supported its therapeutic use for insomnia.

Use of Relaxation Techniques and Complementary and Alternative Medicine by American Adults with Insomnia Symptoms: Results from a National Survey

Though relaxation training is recommended for insomnia, national patterns of use remain unknown. Similarly, rates of complementary and alternative medicine (CAM) use by adults with insomnia are not well established. We sought to elucidate the patterns and reasons for use of relaxation techniques and CAM use by adults with insomnia symptoms. We used the 2007 National Health Interview Survey (n = 23,358) to estimate prevalence of use among adults by self-reported insomnia symptom status. Among adults reporting insomnia symptoms (n = 4,415), we examined reasons for use and disclosure to medical professionals. We employed logistic regression to determine the adjusted associations between relaxation techniques use, CAM use, and insomnia symptoms. Among adults with insomnia symptoms, 23% used relaxation techniques and 45% used CAM annually. After adjustment, adults with insomnia symptoms had higher likelihood of using relaxation techniques (aOR 1.48, 95% CI 1.32, 1.66) and CAM (aOR 1.29, 95% CI 1.15, 1.44) compared with adults without insomnia. Deep breathing exercise was the most commonly used relaxation technique. Fewer than 2% of adults with insomnia used CAM specifically for insomnia. Only 26% of adults with insomnia symptoms disclosed their relaxation techniques use to medical professionals. Being male, lower educational and physical activity levels, income < $20,000, living in South, and hypertension were associated with lower likelihood of relaxation techniques use among adults with insomnia symptoms. While adults with insomnia symptoms commonly use relaxation techniques and CAM, few are using for their insomnia. Facilitating discussions about relaxation techniques may foster targeted use for insomnia.

Increase in psychotropic drug use between 2006 and 2010 among adolescents in Norway: a nationwide prescription database study

BackgroundThe purposes of this study were to investigate the prevalence of psychotropic (hypnotic, antidepressant, and anxiolytic) drug use among adolescents aged 15–16 years during the period 2006–2010 according to gender and subcategories of psychotropics, and to study psychotropic drug use over the period 2007–2010 among incident users in 2007.MethodsThis was a one-year prevalence and follow-up study based on information retrieved from the nationwide Norwegian prescription database for the period 2006–2010. The study population consisted of adolescents aged 15–16 years who had filled at least one prescription for a psychotropic drug in the study period. The main outcome measures were filling of hypnotic, antidepressant, and/or anxiolytic drug prescriptions.ResultsOverall use of psychotropic drugs increased from 13.9 to 21.5 per 1000 among boys and from 19.7 to 24.7 per 1000 among girls during the 2006– 2010 period. Hypnotic drugs, and melatonin in particular, accounted for most of the increase. For melatonin, the annual median amount dispensed was 180 defined daily doses through the period until 2010, at which time it decreased to 90 defined daily doses. In total, 16.4% of all incident psychotropic drug users in 2007 were still having prescriptions dispensed in 2010.ConclusionThis study shows an increase in hypnotic drugs dispensed for adolescents in Norway, mainly attributable to the increasing use of melatonin. The amount of melatonin dispensed indicates more than sporadic use over longer periods, despite melatonin only being licensed in Norway for use in insomnia for individuals aged 55 years or older.

Insomnia and its Symptoms in Adolescents: Comparing DSM-IV and ICSD-II Diagnostic Criteria

Many studies of adolescent insomnia use experience of insomnia-like symptoms to categorize "caseness." This is likely to lead to inflated prevalence and may have important ramifications for the research using individual symptoms to operationalize insomnia. The aim of the present study was to contrast the occurrence of insomnia symptoms with cases of insomnia diagnosed using criteria from the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) and the second edition of the International Classification of Sleep Disorders (ICSD-II) in a sample of Australian adolescents. Data were collected from 384 representative Australian adolescents aged 13-18 years old (59% male). During school hours, adolescents completed a comprehensive questionnaire battery targeting insomnia criteria and then completed a sleep diary for 7 days. Insomnia symptoms were frequently reported by adolescents (e.g., 34.6% for frequent sleep-related daytime consequences). The proportion of adolescents meeting the diagnositc criteria for insomnia was much smaller: 10.9% of adolescents were classified as having General Insomnia using ICSD-II criteria, and 7.8% were classified as having Primary Insomnia according to DSM-IV criteria. ICSD-II Psychophysiological Insomnia was observed in 3.4% of adolescents. Insomnia diagnoses did not vary according to age, gender, school grade, or socioeconomic status. Using the ICSD-II criteria for General Insomnia resulted in a significantly higher number of insomnia diagnoses than did DSM-IV criteria for Primary Insomnia (p < 0.001) and ICSD-II Psychophysiological Insomnia (p < 0.001). These results reveal that approximately 3 adolescents in the average classroom of 30 are likely to meet the diagnostic criteria for insomnia, while many more will have insomnia symptoms. There were significant differences in prevalence rates, depending on how insomnia was operationalized.

Melatonergic Drugs for Therapeutic Use in Insomnia and Sleep Disturbances of Mood Disorders

Insomnia is common among elderly people and nearly 30 to 40% of the adult population also suffer from insomnia. Pharmacological treatment of insomnia include the use of benzodiazepine and non-benzodiazepine drugs like zolpidem, zaleplon, Zopiclone. Although these drugs improve sleep, their usage is also associated with number of adverse effects, Melatonin, the hormone secreted by the pineal gland of all animals and human beings has been used for treatment of insomnias, since the timing of its secretion in humans as well as in most of the animals coincides with the increase of nocturnal sleep propensity. Because of its short half life, melatonin slow release preparations were introduced for treatment of insomnia. Recently ramelteon, a selective MT1, MT2 receptor agonist with greater efficacy of action in treating insomnia has been used clinically and has been found effective in improving sleep quality, sleep efficacy and also in reducing the sleep onset time when compared to melatonin or slow melatonin preparations. The mechanism of action of ramelteon in improving sleep is discussed in the paper. Another melatonergic drug agomelatine besides acting on MT1/MT2 receptors also displays 5-HT2c antagonism and this drug has been found effective as a novel antidepressant for treating major depressive disorders. Agomelatine besides causing remission of depressive symptoms also improves sleep quality and efficiency. Other antidepressants depressants that are in clinical use today do not improve sleep. There are other melatonergic drugs like tasimelteon, 6-chloromelatonin. But ramelteon and agomelatine deserve special attention for treatment of insomnia and sleep disturbances associated with depressive disorders and have promising role for treatment of sleep disorders.

Sedative and Hypnotic Activities of the Methanolic and Aqueous Extracts of Lavandula officinalis from Morocco.

We evaluate the sedative and hypnotic activities of the methanolic and aqueous extract of Lavandula officinalis L. on central nervous system (CNS). In this study, the effect of the methanolic and aqueous extracts of this plant was investigated in a battery of behavioural models in mice. Stems and flowers of Lavandula officinalis L. have several therapeutic applications in folk medicine in curing or managing a wide range of diseases, including insomnia. The methanolic extract produced significant sedative effect at the doses of 200, 400, and 600 mg/kg (by oral route), compared to reference substance diazepam (DZP), and an hypnotic effect at the doses of 800 and 1000 mg/kg while the treatment of mice with the aqueous extract at the doses of 200 and 400 mg/kg via oral pathway significantly reduced in both the reestablishment time and number of head dips during the traction and hole-board tests. In conclusion, these results suggest that the methanolic and aqueous extracts of Lavandula officinalis possess potent sedative and hypnotic activities, which supported its therapeutic use for insomnia.

Prevalence and factors associated with off-label antidepressant prescriptions for insomnia

Background:The primary objective of our study was to investigate the prevalence of off-label antidepressant drug use in insomnia. The secondary objective was to compare prescribing patterns between off-label antidepressants vs hypnotics approved by the US Food and Drug Administration for insomnia, with particular emphasis on socioeconomic characteristics of patients and physicians.Methods:We undertook a secondary data analysis using the national longitudinal database from the 2006 National Ambulatory Medical Care Survey. Subjects were identified from outpatient visits in which at least one insomnia drug was prescribed. A series of weighted Chi-squared statistics was used to compare drug use for insomnia across various patient and physician characteristics. Multivariate logistic regression was conducted to identify factors associated with off-label antidepressant drug use.Results:Among 901.95 million outpatient visits that took place in the US in 2006, an estimated 30.43 million visits included at least one drug prescription for insomnia. Off-label antidepressants were prescribed significantly more frequently (45.1%) than nonbenzodiazepine z-hypnotics (43.2%) and benzodiazepines (11.7%). Insomnia prescribing patterns were significantly influenced by physician specialty and physician office settings. Pediatricians (odds ratio [OR]: 65.892; 95% confidence interval [CI]: 5.536–810.564) and neurologists (OR: 4.784; 95% CI: 2.044–11.201) were more likely to prescribe off-label antidepressants than psychiatrists. Self-paying patients were more likely to receive off-label antidepressants as treatment for insomnia than patients with private insurance (OR 2.594; 95% CI: 1.128–5.967).Conclusion:Our findings indicate significant socioeconomic disparities in the use of off-label antidepressants. Future studies might explore interventional and educational strategies to ensure well informed clinical decisions that can withstand pharmaceutical marketing strategies and diagnostic uncertainties regarding the treatment of insomnia.

Eszopiclone: An update on its use in insomnia

Eszopiclone is the single (S)-enantiomer of the cyclopyrrolone hypnotic zopiclone. It was marketed in the U.S. in December 2004. Its kinetics and possible mode of action, pivotal regulatory trials and its use in insomnia comorbid with other conditions are reviewed, together with trials in patients with obstructive sleep apnea syndromes. Safety and tolerability aspects are discussed, including its dysgeusic profile and effects on memory, cognitive and psychomotor function. U.S.-based pharmacoeconomic data are included together with the design features of key regulatory studies submitted for regulatory approval in Japan.