Chronic insomnia, effects

Hartmann, E., Lindsley, J. G., and Spinweber, C., Chronic insomnia Effects of tryptophan, flurazepam, secobarbital, and placebo, Psychopharmacology, 80, 138, 1983. 

Patients with short-term or chronic insomnia should be evaluated after 1 week of therapy to assess for drug effectiveness, adverse events, and compliance with nonpharmacologic recommendations. Patients should be instructed to maintain a sleep diary, including a daily recording of awakenings, medications taken, naps, and an index of sleep quality. 

The development of tolerance is a major drawback to the use of benzodiazepines in the long-term treatment of insomnia. Whereas tolerance to the hypnotic effects of benzodiazepines permits them to be used without excessive sedation when treating anxiety disorders, this is counterproductive when attempting to treat insomnia. Patients often find themselves requiring higher doses to obtain the same sedative-hypnotic effect initially accomplished by lower doses. For this reason, careful consideration must be given before benzodiazepines are used to treat chronic insomnia. 

One principal difference between the medications is half-life, that is, the time required to metabolize 50% of the compound present in the body. Zolpidem has a half-life of 1.4-4.5 honrs, zaleplon has a half-life of 0.9-1.1 hours, and eszopiclone has a half-life of abont 6 honrs. The key is the markedly shorter half-lives that are displayed by many other sedative-hypnotics, as shown in Eigure 9.1. Only eszopiclone has been shown effective for the long-term (np to 6 months) treatment of chronic insomnia. 

Whichever sedative-hypnotic agent is selected, the following guidelines can help ensure a safe and effective treatment. Use the minimal therapeutic dose at first to decrease possible hangover effects. Consider using the medication on an as-needed basis if the insomnia is intermittent, and after 2-4 weeks attempt a trial off medication to see if it is still required. Many individuals with chronic insomnia will relapse after a 14-28 day trial of treatment, but this time frame also affords an opportunity to implement sleep hygiene improvements. 

Hypnotic Short-term treatment of insomnia, because barbiturates appear to lose their effectiveness in sleep induction and maintenance after 2 weeks. If insomnia persists, seek alternative therapy (including nondrug) for chronic insomnia. Preanesthetic Used as preanesthetic sedatives. 

Buysse DJ, Reynolds CF III, Kupfer DJ, et al. Effects of diagnosis on treatment recommendations in chronic insomnia-a report from the APA/NIMH DSM-IV field trial. Sieep 1997 20 542-552. 

In chronic insomnia, disorders of blood deficiency of the Heart and Liver and stagnation of the Qi and blood, as well as empty-heat, often exist in one syndrome. This small formula matches the pathological condition and can therefore bring an effective result in clinical practice. 

The question of insomnia effects on morbidity is more difficult. Since insomnia complaints are associated with depression, anxiety, neuroticism, and a wide variety of medical illnesses (44,49,54,55), it may be difficult to distinguish effects of insomnia from effects of the comorbid processes. In some cases, medications taken by insomniacs may be responsible for impairment. One attempt to assess disability related to insomnia found no association meeting Bonferroni criteria, after adjustment for age, gender, chronic disease, and major depression (56). It is possible that the trend for association would have been entirely eliminated had control been done for subthreshold depression, which was prevalent in the sample. Although sleep symptoms do predict future depression, they are less... 

Despite widespread use of standard hypnotics and sedating antidepressants for chronic insomnia, their role for this indication still needs to be defined by further research [8], In particular, clinicians must be cautious with antidepressants, which disturb sleep architecture and have various side effects [54, 55],... 

Whenever the use of hypnotics is considered appropriate, it is universally agreed that patients should be given the smallest effective dose for the shortest period of time necessary. This recommendation applies particularly to elderly patients. For transient and short-term insomnia there is no clear consensus, although in practice the use of a medium or short half-life hypnotic for a few days is sometimes recommended when sleep disturbance is associated with shift work or "jet-lag . For chronic insomnia, careful investigation of the underlying cause of the condition is essential before hypnotics are routinely prescribed. Should the insomnia be associated with a psychiatric condition or drug abuse, specific treatment of the core illness will often obviate the need for hypnotics. 

Morin CM, Bastien, CH, Brink D, Brown TR. Adverse effects of temazepam in older adults with chronic insomnia. Hum Psychopharmacol Clin Exp 2003 18 75-82. 

In addition to showing statistically significant improvement on various parameters (for example, latency of sleep, onset of sleep, or total sleep time in transient insomnia or maintaining sleep and reducing wakefulness in chronic insomnia) the adverse effects caused by hypnotics are also measured. These include effects on residual sedation, rebound insomnia (referring to increase in wakefulness or anxiety), amnesia, and adverse cardiopulmonary effects. 

A multi-center, double-blind, randomized, placebo-controlled, parallel-group study compared the next-day residual effects, hypnotic efficacy, and sleep staging effects of fluraz-epam (30 mg) and zolpidem (10 and 20 mg) with those of placebo in patients with chronic insomnia. 

Some clinicians believe that sleep restriction is an effective form of treatment for chronic insomnia. Evidence from studies varies, and use of sleep restriction in many studies was part of combination therapy, and the specific contribution of sleep restriction toward sleep improvement was unclear. 

Few clinical trials have been done in insomnias that are not associated with circadian rhythm disorders. Large doses of melatonin may have a therapeutic effect in chronic insomnia. Insomnia that coincides with diminished melatonin secretion occurs in aging and following treatment with beta-adrenoceptor blockers. Trials of melatonin treatment for... 

The primary advantage of eszoplicone is that it has been shown to be effective in chronic insomnia (long-term treatment) in measures of sleep latency, total sleep time, and wake time after sleep onset without development of tolerance (38). Eszoplicone would appear to be most effectively used for patients who tend to awaken during the night rather than patients for whom the primary problem is initiating sleep (35). 

Efavirenz 3-5 h Chronic CNS effects confusion, disengagement, dizziness, hallucinations, insomnia, somnolence, vivid dreams. ... 

Insomnia is characterized as being primary where there is no obvious medical or psychiatric cause. It is a common clinical problan wherein 10-20% of people have chronic insomnia, characterized by trouble sleeping more than three nights a week. It has been directly linked to numerous impacts on individuals such as daytime fatigue, inattention, irritability, poor mood, and reduced energy levels. Consequently, they have reduced productivity, higher woik absenteeism, and an increased risk of depression or substance abuse. There is also a greater risk of traffic and woik-related accidents. Furthermore, studies have shown direct links between circadian rhythm disturbance and an increased risk in health problems, such as diabetes, metabolic disorders and depression. Insomnia is considered secondary if it is caused by external factors such as health conditions, for example, cancer, heart problems, depression, asthma, arthritis, or pain, or as a side effect of medication, or a substance, such as alcohol. 

Placebo-controlled studies In a 5-week, double-blind, randomized, placebo-controUed study, 270 patients aged 18-64 years with chronic insomnia were randomly assigned to ramelteon 8 or 16 mg/day or placebo [24. There was no rebound insomnia and no withdrawal effects. Headache (19%), fatigue (9.4%), and somnolence (7.9%) were the most common adverse events in those who took ramelteon. 

Mini L, Wang-Weigand S, Zhang J. Ramelteon 8 mg/d versus placebo in patients with chronic insomnia post hoc analysis of a 5-week trial using 50% or greater reduction in latency to persistent sleep as a measure of treatment effect. Clin Ther 2008 30(7) 1316-23. 

Zammit G, Wang-Weigand S, Rosenthal M, Peng X. Effect of ramelteon on middle of the night balance in older adults with chronic insomnia. J Clin Sleep Med 2009 5(1) 34-40. 

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