Insomnia Use Research Articles

Sleep should not be this difficult: An interpretive descriptive study of older adults' perspectives on behaviour change elements in Sleepwell and experiences with benzodiazepine discontinuation

SummaryBenzodiazepine receptor agonists are often used for insomnia in older adults contrary to current evidence. The harms outweigh the benefits, which are limited. Cognitive behavioural therapy for insomnia is the first‐line recommended treatment. Sleepwell was created as a repository of evidence‐based resources to promote cognitive behavioural therapy for insomnia and limit benzodiazepine receptor agonist use. This qualitative study uses an interpretive description design and reflexive thematic analysis to explore older adults' perspectives on behavioural change techniques used in Sleepwell resources. It also explores challenges and opportunities towards benzodiazepine receptor agonist discontinuation and cognitive behavioural therapy for insomnia use. Participants were recruited from the Sleepwell arm of a randomized controlled trial. Data were collected from 15 older adults using semi‐structured interviews. Two main themes were developed: (1) sleep should not be this difficult; and (2) whether you know it, or learn it, drugs are bad. Two sub‐themes were created within the first theme: (1) justification of benzodiazepine receptor agonist use to achieve sleep goals; (2) efforts of committing to cognitive behavioural therapy for insomnia. Several behavioural change techniques (e.g. information about consequences, anticipated regret, salience of consequences) were enablers of benzodiazepine receptor agonist‐related behaviour change. For committing to cognitive behavioural therapy for insomnia, several behavioural change techniques (e.g. self‐monitoring of behaviour, distraction, stimulus substitution) were beneficial, but social support, which was perceived as useful, was absent. Older adults experienced tension with benzodiazepine receptor agonist use and deprescribing, despite knowing or learning the potential consequences of benzodiazepine receptor agonists. Cognitive behavioural therapy for insomnia implementation was challenging. Embedded behavioural change techniques in the Sleepwell booklets were identified as helpful, but more (e.g. social support) are needed to optimize cognitive behavioural therapy for insomnia use.

Workshop report: Workshop on psychiatric prescribing and psychology testing and intervention in children and adults with Duchenne muscular dystrophy

This workshop aimed at summarising knowledge and key issues in psychiatric prescribing and psychological testing in children and adults with Duchenne muscular dystrophy (DMD). It comprised clinicians and patient representatives from the UK and the Netherlands. The following topics were discussed: a model for capturing the range of non-motor problems in the domains of cognition, learning, emotion and behaviour; psychosocial screening tools for use with children and adults; assessing neurocognitive functioning in children and adults; parent and teacher perspectives on psychosocial needs; and psychopharmacological treatment for affective disorders, anxiety disorders, obsessive compulsive disorder, attention deficit hyperactivity disorder (ADHD) and insomnia. Some key considerations included: the need for tools used to assess behavioural and psychosocial functioning to consider motor aspects in DMD; to understand more about working memory performance; the need for early interventions for automatisation problems, which affect reading and arithmetic; appropriate selection of tests for neuropsychology assessments; in schools, acknowledging the range of psychosocial risks and gathering evidence of psychosocial needs; the suitability of selective serotonin reuptake inhibitors for mood and anxiety disorders; the use of stimulant medications for ADHD; melatonin use for insomnia; the cautious use of benzodiazepines; and the need for improving pathways for psychosocial care.

Reducing long-term use of benzodiazepine receptor agonists: In-depth interview study with primary care stakeholders.

To increase our understanding of which factors contribute to long-term benzodiazepine receptor agonist (BZRA) use for insomnia in primary care, from a patients', general practitioners' (GP) and pharmacists' perspective. Qualitative research following a grounded theory approach. Primary care in Belgium. Twenty-four participants were interviewed, including nine patients, six GPs and nine pharmacists. In-depth, semistructured interviews with iterative cycles of data collection and analysis. Transcripts were analysed using the framework method. Thematic findings were interpreted in the context of the Theoretical Domains Framework. A reflexive relation was identified between views about hypnotic use at the level of society, healthcare and patients. Behaviour change appeared to depend strongly on context and social influence, including a need for supporting relationships by all stakeholders. Six key messages captured factors that contribute to long-term BZRA use for insomnia in primary care: societal beliefs as a game changer, the opportunity of nonpharmacological treatment, collaborative primary care, patient-centred goals, informed consent and self-management. Long-term BZRA use for insomnia is a complex and multifaceted public health problem that is not adequately addressed in primary care at this time. Although primary care professionals in this study found discontinuation of long-term BZRA use relevant to the patient's health, many organisational and personal barriers were reported. Moreover, the current social and healthcare context is not empowering patients and professionals to reduce long-term BZRA use for insomnia. Specifically, for primary care, all stakeholders reported the need for a nonmedicalised relationship between the patient and GP to lower prescribing rates. The Flemish Patient Platform, a patient representative organisation, assisted with recruitment by launching a call for participants in their newsletter and volunteered to disseminate the results. The call for recruitment was also published online in social media groups regarding insomnia and via posters in public pharmacies. Patients or public were not involved in designing or conducting the interview study.

Cannabis Use Patterns among Patients with Early-Stage Breast Cancer in a Large Multicenter Cohort from a State with Legalized Adult Non-Medical Cannabis

Cannabis use among patients with cancer is an area of great interest given its widespread acceptance despite the lack of supporting clinical data. The absence of data limits the understanding of potential clinical benefits of cannabis and the ability of providers to deliver evidence-based recommendations for patient care. We explored cannabis use patterns in patients with early-stage breast cancer in a large multicenter cohort in a state with legalized adult non-medical cannabis. Initial questions about cannabis use history and frequency were introduced in Michigan Radiation Oncology Quality Consortium (MROQC) breast cancer patient surveys on 2/1/2020 for female patients receiving radiation after lumpectomy for non-metastatic breast cancer. Expanded questions were introduced on 6/28/2022 to assess mode of administration, active ingredient, and reason for use. Summary statistics were generated. A multivariable model using logistic regression identified patient characteristics associated with cannabis use. Among 3948 eligible patients, 2738 (69.35%) completed survey questions, and 2462/2738 (89.9%) completed the initial question on cannabis use. Among those, 364/2462 (14.8%) noted cannabis use in the last 30 days, 588 (23.9%) noted remote use (>30 days ago), 1462 (59.4%) reported never having used cannabis, 44 (1.8%) preferred not to answer cannabis use questions, and 4 (0.4%) did not provide use history. Younger age [age <50 vs 60-70, OR 2.5 (95% CI 1.65, 3.79) p<0.001)], Hispanic ethnicity [OR 2.20 (95% CI 1.06, 4.56) p = 0.03], history of smoking [OR 2.56 (95% CI 1.88, 3.48) p<0.001], current smoking [OR 4.70 (95% CI 3.22, 6.86) p<0.001)], and prior chemotherapy [OR 1.40 (95% CI 1.00, 1.96) p = 0.05] predicted recent cannabis use in a multivariable model. Of the 364 patients endorsing cannabis use in the last 30 days, 89 (24.5%), 72 (19.8%), 29 (8.0%), 66 (18.1%), 30 (8.2%), and 78 (21.4%) reported using cannabis 1-2 days, 3-5 days, 6-9 days, 10-19 days, 20-29 days, and all 30 days, respectively. The most common modes of administration among 76 individuals who responded to the expanded questionnaire to date were oral (39.4%), smoking (30.3%), and topical (10.5%). The products used contained tetrahydrocannabinol (THC; 26.3%), cannabidiol (CBD; 19.7%), balanced levels of THC and CBD (19.7%), or active ingredients that were unknown to the patient (34.2%). Patients frequently endorsed cannabis use for insomnia, anxiety, and pain. Many patients with early-stage breast cancer are using cannabis. Younger age, Hispanic ethnicity, smoking, and chemotherapy history are predictors of cannabis use. Patients are often unaware of the active ingredients in the products that they use, suggesting an important role for patient education and a need to equip providers to advise patients in their care.

0720 Depression and pain are barriers to benzodiazepine and z-drug deprescribing

Abstract Introduction Clinical guidelines recommend avoiding benzodiazepines and z-drugs (BZRAs) in older adults due to an increased risk of adverse outcomes (e.g., falls) in this population. Efforts to reduce BZRA use among older adults are growing, yet long-term BZRA deprescribing among patients with insomnia is challenging. We examined whether clinical conditions commonly comorbid with insomnia (i.e., depression, pain, nightmares, and anxiety) are barriers to BZRA deprescribing. Methods In an ongoing multi-site trial comparing two BZRA deprescribing programs (both include cognitive behavioral treatments for insomnia), participants aged &amp;gt;=55 years with chronic BZRA use for insomnia (N=165, mean age 68.7, sd 7.9) completed baseline Patient Health Questionnaire-9 (PHQ9), Brief Pain Inventory (BPI), Disturbing Dreams and Nightmare Severity Index (DDNSI), and Generalized Anxiety Disorder-7 (GAD-7). Deprescribing outcomes (discontinuation, dose, and frequency of use over 7-days) were assessed 1 week and 6 months after completing the deprescribing program. Using logistic and linear regression models, we assessed whether depression, pain severity, nightmare severity, and anxiety were predictors of BZRA deprescribing outcomes, controlling for site, gender, and age. Results Among participants assessed 1 week (n=133) and 6 months (n=106) after intervention, 77% and 66% discontinued their BZRA use, respectively. Worse PHQ-9 was associated with reduced odds of discontinuation (OR 0.88, 95% CI 0.79-0.99, p=.027) at 6 months, but not frequency of use or dose at follow up. Pain severity predicted more frequent use (b=0.26, p=.02) and higher dose (b=0.94, p=.016) but not discontinuation at 6 months. DDNSI (p values &amp;gt;=.068) and GAD-7 (p values &amp;gt;= 0.15) were not significant predictors of discontinuation, frequency, or dose at follow-up. Conclusion More severe depression at baseline is a predictor of BZRA deprescribing failure long-term. Pain is also a barrier to BZRA reduction efforts. Programs aimed at reducing and discontinuing BZRAs used for insomnia should consider interventions that not only address underlying insomnia, but also depression and pain. Support (if any) NIA R01AG057929; VA IIR 17-234

“At the time I only wanted to relieve stress”: Exploring motivation for behaviour change in long-term hypnotic users

BackgroundMotivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. AimExploring primary care patients’ views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and settingA qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. MethodEighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. ResultsThe success of discontinuation interventions does not solely rely on patients’ spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. ConclusionMotivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Implementing Blended Care to Discontinue Benzodiazepine Receptor Agonist Use for Insomnia: Process Evaluation of a Pragmatic Cluster Randomized Controlled Trial.

Long-term use of benzodiazepine receptor agonists (BZRAs) remains common despite European guidelines advising that these drugs be used in the lowest possible dose and for the shortest possible duration. Half of all BZRAs are prescribed in family practice. This creates a window of opportunity for discontinuation in primary care. Therefore, the effectiveness of blended care for the discontinuation of long-term BZRA use in adult primary care patients with chronic insomnia disorder was tested in a multicenter, pragmatic, and cluster randomized controlled superiority trial in Belgium. In the literature, information on implementing blended care in a primary care setting is scarce. The study aimed to contribute to a framework for the successful implementation of blended care in a primary care setting by increasing our understanding of this complex intervention through an evaluation of e-tool use and views and ideas of participants in a BZRA discontinuation trial. Based on a theoretical framework, this study evaluated the processes of recruitment, delivery, and response using 4 components: a survey on recruitment (n=76), semistructured in-depth interviews with patients (n=18), web-based asynchronous focus groups with general practitioners (GPs; n=19), and usage data of the web-based tool. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. For recruitment, the most common barriers were refusal by the patient and the lack of digital literacy, while facilitators were starting the conversation and the curiosity of patients. The delivery of the intervention to the patients was diverse, ranging from GPs who never informed the patient about their access to the e-tool to GPs consulting the e-tool in between consultations to have discussion points when the patient visited. Concerning response, patients' and GPs' narratives also showed much variety. For some GPs, daily practice changed because they received more positive reactions than expected and felt empowered to talk more often about BZRA discontinuation. Conversely, some GPs reported no changes in practice or among patients. In general, patients found follow-up by an expert to be the most important component in blended care, whereas GPs deemed the intrinsic motivation of patients to be the key element of success. An important barrier to implementation by the GP was time. Overall, the participants who had used the e-tool were positive about its structure and content. Nevertheless, many patients desired a more tailored application with feedback from an expert and personal tapering schedules. Strict pragmatic implementation of blended care seems to only reach GPs with an interest in digitalization. Although not superior to usual care, blended care could be a complementary tool that allows tailoring the discontinuation process to the personal style of the GP and the needs of the patient. ClinicalTrials.gov NCT03937180; https://clinicaltrials.gov/ct2/show/NCT03937180.

Updates in the use of cannabis for insomnia.

This review aims to summarize recent updates in the area of cannabis use for insomnia. Cannabis products have continued to become more potent, particularly in regard to delta-9- tetrahydrocannabinol (THC) concentration. Additionally, the use of cannabis has continued to become more accepted with less legal restrictions. The reported use of cannabis for relief of symptoms in sleep disorders appears to be increasing, however the specific effects of cannabinoids on sleep varies with cannabinoid type and concentration. Some evidence supports claims of efficacy of cannabinoids in sleep disorders such as insomnia, while other evidence is either lacking or in some cases contradictory. Regular cannabis use has been associated with withdrawal which can profoundly alter sleep. Also, clinicians should be aware of the potential effects of cannabis on the metabolism of other medications as well as the fact that cannabis use has been reported in a significant number of women in the periods before, during, and after pregnancy. Cannabis use has been becoming more and more prevalent in the setting of relaxed restrictions and easier consumer level access to cannabis and cannabis products. A relative paucity of high quality evidence regarding the effects of cannabis on sleep and the treatment of insomnia symptoms remains. The optimal type, concentration, ratio, and dosage form of cannabinoids in the treatment of insomnia symptoms needs further clarification. As the trend of acceptance and use of cannabis continues, more high quality evidence to help guide clinicians in their recommendations will hopefully become available.

0686 Cognitive Behavioral Therapy for Insomnia to Reduce Cannabis Use: Results from a Pilot Randomized Controlled Trial

Abstract Introduction Cannabis use, including use for insomnia, has increased significantly in the United States over the past decade. Cannabis use disorders and/or heavy cannabis use have been linked to numerous negative outcomes, including poor work performance, other substance use, increased risk of psychosis, and neurocognitive deficits. In a pilot randomized controlled trial, we compared telemedicine-delivered CBT for insomnia tailored to individuals regularly using cannabis for sleep (CBT-CB-TM) to sleep hygiene education (SHE-TM) for improving sleep and daytime functioning and for reducing cannabis use. Methods Adults with chronic insomnia who reported using cannabis for sleep at least three times weekly were recruited through advertisements and at local cannabis dispensaries and screened for disqualifying sleep, medical, and mental health disorders. Fifty-seven eligible participants (43 women, mean age 37.6 ± 12.8 years) were randomized to 6 sessions of CBT-CB-TM (n=30) or SHE-TM (n=27). Participants completed self-reported measures of insomnia (Insomnia Severity Index, primary outcome), daytime functioning (sleep beliefs, depression, and overall functioning) and cannabis use before and after treatment and at 8-week follow-up. Results Mixed models showed that scores improved more on the Insomnia Severity Index (β=-2.83, se=0.62, p&amp;lt;.001) and Dysfunctional Beliefs and Attitudes about Sleep scale (β=-0.73, se=0.25, 9&amp;lt;.006) in the CBT-CB-TM compared to SHE-TM condition. Small pre- to post-treatment reductions in the daily frequency of cannabis use were evident for CBT-CB-TM compared to SHE-TM participants (pre-post change: 0.60 ± 0.94 vs. -0.04 ± 0.35, p&amp;lt;.007). Depression symptoms (PHQ-8: CBT-CB-TM 8.5 ± 0.7 to 6.8 ± 1.0 vs. SHE-TM 9.1 ± 0.7 to 7.0 ± 0.9, p&amp;lt;.004), and overall functioning (SF-12 MCS: CBT-CB-TM 43.3 ± 1.9 to 50.8 ± 2.9 vs. SHE-TM 39.8 ± 2.0 to 51.6 ± 2.5, p&amp;lt;.0005) improved in both conditions from pre-treatment through follow-up. Conclusion Telemedicine-delivered CBT for insomnia improved sleep and reduced cannabis use more than a matched behavioral placebo control in this pilot trial of adults using cannabis regularly for insomnia. These preliminary findings support the need for adequately-powered randomized controlled trials with longer follow-up periods to evaluate the efficacy of targeting insomnia to reduce problematic cannabis use. Support (If Any) R34 DA047466 (MPI: MA Ilgen, JT Arnedt)

0475 Prevalence and Potential Benefits of Cannabis Use in Patients with Insomnia

Abstract Introduction Insomnia is highly prevalent amongst patients presenting to sleep centers and it can be challenging to treat. Current treatment modalities include pharmacological intervention and cognitive behavioral therapy. Cannabis use is widely prevalent and has been approved in most states in the United States for medical use. Insomnia has been approved in some states as a qualifying condition for prescribing medical marijuana. Although the sedative effects of cannabis are well known, there are no established clinical guidelines with regards to its use for the treatment of insomnia. Methods We conducted a retrospective chart review to determine the use and potential benefits of cannabis in patients with insomnia over a three-year period at a tertiary care academic center. All patients with cannabis/marijuana and insomnia use listed in their electronic health record were included. Results Our cohort included 159 patients (67 males, 91 females; mean age= 48.4 years) who had a diagnosis of insomnia and used cannabis. 62 out of 159 (39%) patients reported improvement in sleep symptoms, whereas 18 (11.3%) patients denied any improvement. The status of remaining 79 patients (49.7%) was undetermined. 40 patients were African American, 103 were white, 4 were Hispanic; the remaining were of other or unknown ethnicities. 80 (50.3%) patients were using medically prescribed marijuana for various disorders; 50 (31.4%) were using non prescribed cannabis and prescription status was undetermined in 29 (18.2%) patients. Average use of cannabis was 4.9 days per week as reported by 47 patients who used cannabis regularly.50 out of the 62 patients with diagnoses of insomnia and cannabis use who reported improvement in symptoms had a history of comorbid anxiety, whereas 37 of 62 (59.6%) patients had comorbid depression. 29 out of 62 (46.7%) patients were using selective serotonin receptor uptake inhibitors (SSRI) and 24 of 62 (38.7%) were using benzodiazepines. Conclusion Cannabis use is highly prevalent among patients with a diagnosis of insomnia. Patient with cannabis use may have comorbid mood and anxiety disorders and may be taking SSRIs or benzodiazepines. Sleep physicians need to be aware of cannabis use and its impact on sleep symptoms in patients with insomnia. Support (If Any)

Lemborexant, an orexin receptor antagonist sedative-hypnotic: Is it useful for insomnia in psychiatric disorders?

Lemborexant, an orexin receptor antagonist similar to suvorexant, has been approved for the treatment of sleep onset and/or maintenance insomnia. Lemborexant is reviewed and compare to suvorexant from a psychiatric perspective. Rapidly absorbed (peak 1-3h), lemborexant has a half-life of 17-19h (suvorexant half-life 12h). It is metabolized by CYP3A4/5, with no significant effects of age, sex or weight. Trials for insomnia indicate sustained efficacy beyond 6months. Lemborexant has not been trialled in major psychiatric disorders. Commenced at 5mg, lemborexant can then be increased to 10mg, taken at least 7h before planned awakening. Adverse effects are higher at 10mg: somnolence occurs in about 10% while headache and nightmares affect 2-5%, approximately similar to 40mg suvorexant (recommended suvorexant dose 20mg). Sleep paralysis, hypnagogic/hypnopompic hallucinations, and cataplexy-like symptoms, complex sleep behaviours and emergence of depression/suicidal ideation can occur. Neither tolerance to sedation nor withdrawal effects on discontinuation have been observed. Whether the differences between lemborexant and suvorexant are clinically relevant is unclear. Like suvorexant, lemborexant appears to be effective in longer-term use for insomnia, but until efficacy and safety are adequately investigated in major mental disorders, clinicians need to monitor patient experience closely.

An investigation of cannabis use for insomnia in depression and anxiety in a naturalistic sample

BackgroundLittle is known about cannabis use for insomnia in individuals with depression, anxiety, and comorbid depression and anxiety. To develop a better understanding of distinct profiles of cannabis use for insomnia management, a retrospective cohort study was conducted on a large naturalistic sample.MethodsData were collected using the medicinal cannabis tracking app, Strainprint®, which allows users to monitor and track cannabis use for therapeutic purposes. The current study examined users managing insomnia symptoms in depression (n = 100), anxiety (n = 463), and comorbid depression and anxiety (n = 114), for a total of 8476 recorded sessions. Inferential analyses used linear mixed effects modeling to examine self-perceived improvement across demographic variables and cannabis product variables.ResultsOverall, cannabis was perceived to be efficacious across all groups, regardless of age and gender. Dried flower and oral oil were reported as the most used and most efficacious product forms. In the depression group, all strains were perceived to be efficacious and comparisons between strains revealed indica-dominant (Mdiff = 1.81, 95% CI 1.26–2.36, Padj < .001), indica hybrid (Mdiff = 1.34, 95% CI 0.46–2.22, Padj = .045), and sativa-dominant (Mdiff = 1.83, 95% CI 0.68–2.99, Padj = .028) strains were significantly more efficacious than CBD-dominant strains. In anxiety and comorbid conditions, all strain categories were perceived to be efficacious with no significant differences between strains.ConclusionsIn terms of perceptions, individuals with depression, anxiety, and both conditions who use cannabis for insomnia report significant improvements in symptom severity after cannabis use. The current study highlights the need for placebo-controlled trials investigating symptom improvement and the safety of cannabinoids for sleep in individuals with mood and anxiety disorders.

Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders.

Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.

Trazodone effects on developing brain

Trazodone (TRZ) is a commonly prescribed antidepressant with significant off-label use for insomnia. A recent drug screening revealed that TRZ interferes with sterol biosynthesis, causing elevated levels of sterol precursor 7-dehydrocholesterol (7-DHC). Recognizing the well-documented, disruptive effect of 7-DHC on brain development, we designed a study to analyze TRZ effects during pregnancy. Utilizing an in vivo model and human biomaterial, our studies were designed to also account for drug interactions with maternal or offspring Dhcr7 genotype. In a maternal exposure model, we found that TRZ treatment increased 7-DHC and decreased desmosterol levels in brain tissue in newborn pups. We also observed interactions between Dhcr7 mutations and maternal TRZ exposure, giving rise to the most elevated toxic oxysterols in brains of Dhcr7+/− pups with maternal TRZ exposure, independently of the maternal Dhcr7 genotype. Therefore, TRZ use during pregnancy might be a risk factor for in utero development of a neurodevelopmental disorder, especially when the unborn child is of DHCR7+/− genotype. The effects of TRZ on 7-DHC was corroborated in human serum samples. We analyzed sterols and TRZ levels in individuals with TRZ prescriptions and found that circulating TRZ levels correlated highly with 7-DHC. The abundance of off-label use and high prescription rates of TRZ might represent a risk for the development of DHCR7 heterozygous fetuses. Thus, TRZ use during pregnancy is potentially a serious public health concern.

Trends in Dispensing of Zolpidem and Low-Dose Trazodone Among Commercially Insured Adults in the United States, 2011-2018

This study uses IBM MarketScan database data to describe trends in zolpidem and low-dose trazodone dispensing among adults with employer-sponsored insurance or Medicare supplemental plans between 2011 and 2018, before and after a 2017 clinical practice guideline discouraged trazodone use for insomnia.

Melatonin Increasingly Used in Hospitalized Patients

The frequency of melatonin use for insomnia in hospitalized patients is unknown. This study assessed temporal trends of melatonin use in the hospital and compared them with those of use of zopiclone and lorazepam. We performed a retrospective observational study over 6 years from January 2013 to December 2018 at two academic urban hospitals in Toronto, Canada. We abstracted pharmacy dispensing data and standardized rates of medication use by inpatient days. Melatonin use increased from almost none to more than 70 doses per 1,000 inpatient days during 2013-2018, while zopiclone use decreased by 20 doses per 1,000 inpatient days. Melatonin use was twice as high at one hospital and was higher on internal medicine and critical care. Overall use of the three medications increased by 25.7%, which mainly reflects a marked increase in melatonin use. Melatonin is likely being used in a proportion of patients who would not otherwise have received a sleep medication.

Genome-wide association analysis of insomnia using data from Partners Biobank

Insomnia is one of the most prevalent and burdensome mental disorders worldwide, affecting between 10–20% of adults and up to 48% of the geriatric population. It is further associated with substance usage and dependence, as well other psychiatric disorders. In this study, we combined electronic health record (EHR) derived phenotypes and genotype information to conduct a genome wide analysis of insomnia in a 18,055 patient cohort. Diagnostic codes were used to identify 3,135 patients with insomnia. Our genome-wide association study (GWAS) identified one novel genomic risk locus on chromosome 8 (lead SNP rs17052966, p = 4.53 × 10−9, odds ratio = 1.28, se = 0.04). The heritability analysis indicated that common SNPs accounts for 7% (se = 0.02, p = 0.015) of phenotypic variation. We further conducted a large-scale meta-analysis of our results and summary statistics of two recent insomnia GWAS and 13 significant loci were identified. The genetic correlation analysis yielded a strong positive genetic correlation between insomnia and alcohol use (rG = 0.56, se = 0.14, p < 0.001), nicotine use (rG = 0.50, se = 0.12, p < 0.001) and opioid use (rG = 0.43, se = 0.18, p = 0.02) disorders, suggesting a significant common genetic risk factors between insomnia and substance use.

From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

1030 Melatonin use for insomnia in post-traumatic spinal cord injury.

1030 Melatonin use for insomnia in post-traumatic spinal cord injury.

Sleepless Nights: Trazodone Use and Insomnia Evaluation in the Palliative Care Clinic (QI728)

1.Discuss the evaluation of insomnia in the palliative care clinic of a large academic medical center.2.Discuss the use of trazodone in the palliative care population and discuss the concerns regarding the use of trazodone. Insomnia is a common symptom in the Palliative Care patient population with some estimates showing up to 70% of patients having symptoms of Insomnia. However, patients continue to depend on pharmaceutical agents owing in part due to lack of access to Cognitive Behavioral Therapy and longtime use of medications to treat insomnia. Although trazodone has limited efficacy for insomnia, it is used roughly by 1% of the U.S. adult population. We sought to better define within our clinic population the likelihood patients were using trazodone and also the likelihood of recognition of its use for insomnia. evaluate the use and documentation of Insomnia and trazodone use in the outpatient clinic in the palliative care clinic of a large academic medical center. This is a retrospective chart review assessing patients seen in the Palliative Care Clinic at a large academic center from June 2017 to November 2017. Data includes demographics, presence of trazodone in their medication list, and documentation of ESAS (date documented, and drowsiness score). Charts were manually reviewed for any documented discussion of insomnia either in the problem list, discussion, or history. Descriptive statistics were used during analysis. Fifteen (9.2%) of 163 patients had trazodone in their medication list during the review period; 6(40%) were female with mean age of 63.5. Discussion of insomnia was documented for only 4(26.6%) patients. The mean ESAS drowsiness score was 5.03. The most common prescribed dose of trazodone was 50 mg (47%). We were unable to identify thorough assessment or alternative non-pharmacologic strategies within any of these charts. Discussion with patients regarding the effectiveness of interventions to help treat insomnia are rare in palliative care patients receiving trazodone. Future interventions will focus on implementing better screening methods, patient education, and documentation regarding insomnia and its management.