Primary insomnia

Primary Insomnia. Primary insomnia is a sleep disturbance lasting at least a month with no clear cause. However, many well-recognized psychological and physical factors contribute to prolonging the insomnia. For this reason, some call this condition psychophysiological insomnia. 

Neubauer DN New directions in the pharmacologic treatment of insomnia. Primary Psychiatry 2006 13 51. 

Insomnia complaints are common in the general population and can be dichotomized into problems of delayed sleep onset and those related to sleep maintenance. Increasing attention is being focused on the adverse daytime effects of insomnia. Sleep disturbances become more common with increased age and are more prevalent in women. Sleep complaints arise from very diverse etiologies which prominently include concomitant primary... 

Notify the primary health care provider immediately if any of the following signs of theophylline toxicity develop anorexia, nausea, vomiting, diarrhea, confusion, abdominal cramping, headache, restlessness insomnia, tachycardia, arrhythmias or seizures... 

These dragp may cause nervousness, insomnia, and restlessness (especially the sympathomimetics). Contact the primary health care provider if the symptoms become severe. 

Side effects. The primary side effects reported with bupropion administration in cigarette smokers are headache, dry mouth, nausea and vomiting, insomnia, and activation. Although most of these adverse effects occur during the first week of treatment, insomnia can persist. Seizures are of exceedingly low occurrence (<0.5%) at doses of 300 mg daily or less, but a prior history of seizures or a seizure disorder contraindicate its use. 

Lamotrigine Modulate sodium channels Loading dose Not recommended due to increased risk of rash Maintenance dose 1 50-800 mg/day in 2-3 divided doses. Doses should be initiated and titrated according to the manufacturer s recommendations to reduce the risk of rash Half-life Not established Monotherapy 24 hours Concurrent enzyme inducers 12-15 hours Concurrent enzyme inhibitors 55-60 hours Apparent volume of distribution 1.1 L/kg Protein binding 55% Primary elimination route Hepatic Ataxia, drowsiness, headache, insomnia, sedation Rash... 

O Insomnia is most frequently a symptom or manifestation of an underlying disorder (secondary insomnia) but may occur in the absence of contributing factors (primary insomnia). Early treatment of insomnia may prevent the development of psychopathologic complications. 

Monti, J. M. (2004). Primary and secondary insomnia prevalence, causes and current therapeutics. Cum Med. Chem. Central Nerv. Syst. Agents, 4, 119-37. 

The SSRIs produce fewer sedative, anticholinergic, and cardiovascular adverse effects than the TCAs and are less likely to cause weight gain than the TCAs. The primary adverse effects include nausea, vomiting, diarrhea, headache, insomnia, fatigue, and sexual dysfunction. A few patients have anxiety symptoms early in treatment. 

A phase II study of EVT-201, a partial positive modulator of GABAa receptor, has recently been initiated in the US in elderly patients with chronic insomnia with the maintenance as primary endpoint (no structure disclosed). 

NG2-73 is a GABAa receptor partial agonist that, according to the information given by the company, modulates preferentially the a3 subunit - a subunit that is hypothesized to be associated with sleep induction - and is undergoing phase II trials for chronic insomnia with primary endpoints measuring sleep onset as well as maintenance (no structure disclosed) [25]. 

Takeda s melatonin (MT1/MT2) receptor agonist ramelteon (11) was approved and launched in 2005 in the U.S., indicated for the treatment of primary insomnia characterized by difficulty with sleep onset. It is the first prescription medication for insomnia with a novel mechanism of action to reach the US market in 35 years. It is also the first and only prescription sleep medication that has not exhibited potential for abuse and dependence, and as such is not designated as a scheduled substance by the DEA. Moreover, ramelteon was also filed in late March 2007 in E.U. for primary insomnia. 

In controlled clinical trials in patients with primary insomnia, ramelteon 4-32 mg demonstrated significant reduction in latency to persistent sleep (LPS) compared with placebo. In elderly patients, objective and subjective LPS were also reduced at doses of 4 and 8 mg. Data on total sleep time are more variable,... 

HY-10275 (no structure reported), having such a dual mechanism, has been recently reported to meet the primary and secondary endpoints in the initial phase II trial at doses of 1 and 3 mg in adults with transient insomnia [93]. 

Patients with depression usually do not present initially to mental health professionals. Most visit their primary care physicians, complaining not of depressed mood but of other symptoms of depression. Fatigue, insomnia, loss of appetite, loss of interest in sex, muscle tension, body aches, and poor concentration are all commonly reported. These so-called masked presentations of depression may in part explain the documented failure of primary care physicians to diagnose depression reliably. This underscores the importance of considering depression in the differential diagnosis of physical complaints that appear vague or exaggerated. 

In contrast to panic disorder, the somewhat more subtle and persistent symptoms of GAD do not always command immediate attention. Although patients with GAD may present with a primary complaint of anxiety, they are more likely to complain of a physical ailment or another psychiatric condition or symptoms, for example, depression or insomnia. As such, many patients with GAD will seek treatment from a primary care physician long before recognizing the need for mental health care despite readily acknowledging that they have been anxious virtually all of their lives. 

Although we are focusing on the primary sleep disorders, sleep disturbance quite often occurs as a symptom of another illness. Depression, anxiety, and substance abuse can impair the quality of sleep, though in the setting of chronic insomnia, other psychiatric disorders account for less than 50% of cases. Nightmares are a frequent complication of post-traumatic stress disorder (PTSD), and pain, endocrine conditions, and a host of medical illnesses can produce sleep problems. Thus, when discussing insomnia or hypersomnia, we are well advised to remember that these can be either a symptom of a psychiatric syndrome, a medical illness, or a sleep disorder. 

A variety of factors can trigger insomnia. Medications, medical illness, pain, stress, schedule changes, depression, anxiety, and nighttime breathing problems all can produce insomnia. When insomnia has no clear cause, that is, it is not secondary to another condition, it is termed primary insomnia. The diagnostic criteria for primary insomnia are shown in Table 9.1. 

Gatchel RJ, Oordt MS. Insomnia. In Clinical Health Psychology and Primary Care Practical Advice and Clinical Guidance for Successful Collaboration. Washington DC American Psychological Association, 2003, pp 135-148. 

Ringdahl EN, Pereira SL, Delzell JE. Treatment of primary insomnia. J Am Board Earn Bract 2004 17 212-219. 

Duration of therapy Because sleep disturbances may be the presenting manifestation of a physical or psychiatric disorder, initiate symptomatic treatment of insomnia only after careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the need for evaluation of a primary psychiatric or medical illness. Do not prescribe zaleplon in quantities exceeding a 1-month supply. 

The first step is the recognition that a depressed mood is not synonymous with a depressive episode. Conversely, an episode of depression may not present with a mood complaint, but rather with associated symptoms such as insomnia or other somatic complaints. This is particularly true for the elderly and for those seen in primary care settings. Even when a mood complaint is prominent, it may not be described as depressed, but instead as irritable or anxious. Thus, patients with MDD may have a variety of complaints other than depressed mood, including the following ... 

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