Insomnia long-term

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). 

An abstinence syndrome after long-term, low-dose treatment has also been described (Busto et al. 1986a Covi et al. 1973 Petursson and Lader 1981b Tyrer et al. 1981). Reported symptoms include muscle twitching, abnormal perception of movement, depersonalization or derealization, anxiety, headache, insomnia, diaphoresis, difficulty concentrating, tremor, fear, fatigue, lowered threshold to perception of sensory stimuh, and dysphoria. 

Antidepressants are commonly used to treat both acute withdrawal and persistent anxiety or insomnia. There is evidence to suggest that they are effective in relieving some acute abstinence symptoms, but it has been more difficult to establish their effectiveness in long-term discontinuation. Antidepressants with sedative and antianxiety effects are the preferred drugs. 

Side effects may be as mild and rare as headache, nausea, and stomach upset for saw palmetto [23,24], However, some supplements may have serious side effects. Hypertension, euphoria, restlessness, nervousness, insomnia, skin eruptions, edema, and diarrhea were reported in 22 patients following long-term ginseng use at an average dose of 3 g of ginseng root daily [38]. Side effects reported with valerian use include headaches, hangover, excitability, insomnia, uneasiness, and cardiac disturbances. Valerian toxicity including ataxia, decreased sensibility, hypothermia, hallucinations, and increased muscle relaxation have been reported [39]. 

The side effects of amphetamine are related to its stimulant effects, especially at high doses and with long-term use. Side effects include irritability, insomnia, confusion, anxiety, paranoia, hallucinations, seizures, and aggressiveness. Amphetamines cause irreversible destruction of blood vessels in the brain, which can cause stroke—even in young people. These drugs also cause the potentially lethal side effects of increased heart rate, irregular heartbeat, and increased blood pressure. 

Long-term amphetamine abuse results in many damaging effects, not least of which is addiction. Chronic abusers exhibit symptoms that can include violent behavior, anxiety, confusion, and insomnia. They also can display a number of psychotic features, including paranoia, auditory hallucinations, mood disturbances, and delusions (for example, the sensation of insects creeping on the skin). The paranoia can result in homicidal as well as suicidal thoughts. 

High-potency benzodiazepines (e.g., clonazepam and lorazepam) are common alternatives to or in combination with antipsychotics for acute mania, agitation, anxiety, panic, and insomnia or in those who cannot take mood stabilizers. Lorazepam IM may be used for acute agitation. A relative contraindication for long-term benzodiazepines is a history of drug or alcohol abuse or dependency. 

The use of benzodiazepines should be avoided. There are other safer pharmacological alternatives. Benzodiazepine withdrawal may play a role in the occurrence of delirium in the elderly. Other withdrawal symptoms include tremor, agitation, insomnia and seizures (Turnheim 2003). Thus, when there is long-term use of benzodiazepines abrupt discontinuation might be difficult. Discontinuation should however not be withheld but done slowly and step-wise. If benzodiazepines are used in the elderly, short-acting benzodiazepines such as oxazepam are preferred, because they do not accumulate in the elderly to the same extent (Kompoliti and Goetz 1998). If short-acting benzodiazepines are used they should be prescribed with caution, at low doses, and for short periods. As with all pharmacotherapy the effects should be evaluated. Benzodiazepines are sometimes used as a behavioural control. One should always ask if this use is for the benefit of staff or the benefit of the patient. The presence of staff may be sufficient for behavioural control. 

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. 

With long-term use, the most problematic side effect is weight gain. However, many antihistamines including diphenhydramine also possess potent anticholinergic effects. This can cause dry mouth, blurred vision, constipation, confusion, and urinary retention. Because anticholinergic effects are especially problematic for the elderly, we advise against the routine use of antihistamines to treat elderly patients with 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. 

Long-Term Treatment. When sleep medications are used on a long-term basis, they are potentially not helping the problem but contributing to it. Unfortunately, this all too commonly results when a hypnotic medication is started without giving any thought to changing the behaviors that sustain the insomnia. 

Eszopiclone has been approved for the treatment of patients who experience difficulty falling asleep, poor sleep maintenance, and for long-term treatment of insomnia. Clinical trials have shown that eszopiclone improved sleep onset, sleep maintenance, total sleep time, sleep quality, and daytime functioning compared with placebo. Improved wake time alertness, concentration, and sense of well-being were reported. Eszopiclone was well tolerated, with only mild adverse events reported. There was no evidence of dmg-drug interactions, tolerance, residual drowsiness or treatment-related rebound insomnia. The recommended dose to improve sleep onset and maintenance is generally between 1 and 3 mg. 

Long-term use can result in a withdrawal symptoms such as insomnia, anxiety, tinnitus, tremor, perceptual disturbances and loss of appetite. 

Abrupt or too-rapid withdrawal after long-term use may result in pronounced restlessness and irritability, insomnia, hand tremors, abdominal or muscle cramps, vomiting, diaphoresis, and seizures. 

CNS Bowel Dysfunction Bladder Dysfunction Falls Other Withdrawal symptoms after long-term use, rebound insomnia... 

Insomnia, decreased appetite, weight loss, dysphoria Possible reduction In growth velocity during long-term use Withdrawal and rebound hyperactivity Unmasking or induction of tics... 

GAD differs from other types of anxiety disorders because, although the anxiety is present most of the time, GAD patients do not fear specific events such as social situations or having a panic attack (as in social anxiety or panic disorder). GAD is distinguished from normal worry or anxiety because of its long-term duration. GAD is frequently the underlying cause of many symptoms, including irritability, insomnia, headache, and muscle tension. This can often make it very hard to diagnose. A person with GAD will often go to his or her family physician and complain of nerves. ... 

Mild nausea, loose bowel movements, anxiety, headache, insomnia, and increased sweating are frequent initial side effects of SSRIs. They are usually dose related and may be minimized with low initial dosing and gradual titration. These early adverse effects almost always attenuate after the first few weeks of treatment. Sexual dysfunction (see Sexual Dysfunction subsection later in this section) is the most common long-term side effect of SSRIs. 

Like almost all relevant authors, Lader and Petursson (1983) also advise against the long-term use of anxiolytics and they emphasize that most anxiety states and phases of insomnia generally last for only a limited period of time either the acute stress fades or the patient becomes used to the situation (or copes with it successfully), or a spontaneous remission occurs. In many cases the patient can be managed with advice and reassurance, and thus without medicaments. 

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