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PubMed2004

Overview of the therapeutic management of insomnia with zolpidem.

Benzodiazepine hypnotic agents were the mainstream pharmacotherapy for insomnia from the 1960s to the 1980s, but their safety profile proved to be not quite as perfect as originally expected with regard to daytime performance and cognition, and above all the risk of dependence. These risks are substantially diminished in the non-benzodiazepine hypnotic agents developed and marketed during the past two decades, but the fears engendered by certain benzodiazepines still greatly influence the attitude of both physicians and the general public to the treatment of insomnia. For this reason, as well as in the interests of matching the pharmacotherapy of insomnia more closely to the often fluctuating nature of this disorder, the possibility of the discontinuous or 'as needed' use of hypnotic drugs has attracted increasing attention in recent years. Current recommendations strongly favour the use of hypnotic drugs for a limited period of time. However, some insomniac patients need sleep medication for longer periods in spite of a non-pharmacological approach, whereas other patients become dependent on drugs as a result of rebound insomnia, withdrawal symptoms, or the recurrence of insomnia. The pharmacological properties of zolpidem make it feasible for non-nightly use. A double-blind, randomized, parallel-group study of continuous treatment with either zolpidem or estazolam, followed by an observation of the discontinuation of drug treatments combined with the non-pharmacological management of primary insomnia, showed a carry-over benefit for zolpidem treatment.

Clinical Trials as Topic↗
PubMed1994

Insomnia and styles of parental authority in college students.

This study explored the hypothesis that styles of parental authority are related to insomnia in college students. To do this, I asked a large group of university students (N = 757) to respond to a questionnaire that included the items of Buri's Parental Authority Questionnaire and the Coren Insomnia Scale. Analysis suggested that more strict and uncompromising discipline engaged in by authoritarian parents was associated with higher insomnia in young adults, while the firm though flexible and warm discipline associated with the authoritative parents was associated with less insomnia. Further, as fathers' permissiveness increased, insomnia decreased, while mothers' permissiveness seemed to be unrelated to insomnia.

Adolescent↗
PubMed2004

MMPI-2 scores of patients with insomnia.

Although the MMPI-2 has been employed since 1989, to date no study has been reported on its use with patients with insomnia. The MMPI-2 was administered to 104 insomnia patients. The T scores of all the MMPI-2 scales fell below the cut-off score of T = 65. Although the group profile was within the normal range, the percentages of patients who had MMPI-2 scores above T = 65 for each scale indicated that a substantial portion of the insomnia patients obtained elevated scores, particularly in the Hs, D, Hy, and Pt scales. Thus, the results suggest that many of the insomnia patients exhibit psychological distress and would benefit from brief psychological interventions, such as sleep hygiene education and relaxation training. In view of the large number of insomnia patients who obtained abnormal MMPI-2 scores, a psychological measure such as the MMPI-2 remains an important assessment tool in identifying insomnia patients who may need extensive psychotherapeutic intervention.

Adolescent↗
PubMed2005

Socioeconomic impact of insomnia in working populations.

To determine whether insomnia impact the professional life of patients and have an economical weight, this review article focused on the socioeconomic impacts of sleep related problems in working populations. The goal is to summarise the work that has been accomplished in that field. Several occupational factors have an impact on insomnia: the work schedules (shift work and night work), the physical environment at work and the occupational stressors. Insomnia is also a common problem in daytime workers. The daytime functioning of insomniacs is a key point to understand the impact of insomnia on workers. Absenteeism is one major target in the evaluation of severe insomnia at the workplace. Most of the studies find a higher rate of work accidents in insomniacs. The economic impact is severe in term of direct and indirect costs. Insomnia is a common problem at the workplace. The negative impact is not only on individual but also at the societal levels. More epidemiological studies appear warranted to demonstrate a reciprocal link between work conditions and sleep disorders.

Absenteeism↗
PubMed2005

[The effects of foot reflexology on fatigue and insomnia in patients suffering from coal workers' pneumoconiosis].

PURPOSE: The purpose of this study was to determine the effects of foot reflexology on fatigue and insomnia in patients suffering from coal workers' pneumoconiosis. METHOD: This study was a quasi-experimental study of pre-test and post-test design in a non-equivalent control group. The subjects of this study consisted of both the experimental group of twenty-nine and the control group of thirty coal workers' pneumoconiosis patients. Data was collected from December 10, 2002 to February 15, 2003. Foot reflexology was performed for 60 minutes twice a week through five weeks in the experimental group, but none in the control group. To evaluate the effects of foot reflexology, the scores of fatigue and insomnia were measured before and after the experiment in both groups. Fatigue was evaluated by Fatigue Symptoms Inventory. Insomnia was measured with the visual analogue scale (VAS). Data of this experiment was analyzed by Chi-square test, t-test, unpaired t-test and Repeated Measures ANOVA with the SAS Program. RESULTS: The scores of fatigue and insomnia decreased in the experimental group but not in the control group. There was a significant difference of fatigue and insomnia between the two groups. CONCLUSION: It is suggested that foot reflexology might have beneficial effects on reducing fatigue and insomnia in patients suffering from coal workers' pneumoconiosis, and can be recommended as a nursing intervention program for patients with coal workers' pneumoconiosis.

Aged↗
PubMed2000

Severity of insomnia correlates with cognitive impairment.

INTRODUCTION AND METHODS: Cognitive deficits in insomnia have been already reported (5), however, a correlation between cognitive impairment and severity of insomnia was not as yet studied. Sixteen not medicated patients with primary insomnia according to DSM-IV (4), 7 men an 9 women, of mean age 40.8 year, were compared to 16 controls, matched according to age, sex and education. Standard polysomnographic data (PSG) were recorded. The next day all the subjects completed Athens Insomnia Scale (AIS) (7), Hyperarousal Scale (HS) (6), Hamilton Depression Rating Scale (HAM-D), Beck Depression Inventory (BDI), Multiple Sleep Latency Test (MSLT) (3), Continuous Attention Test (CAT) with simple reaction time (RT) (8) and Selective Reminding Test (SRT) (2). RESULTS AND DISCUSSION: The psychophysiological differences between patients and controls are shown in Table I. HAM-D and BDI scores were elevated in patients, although none of the patients met clinical criteria of depression. Insomniacs did not differ in the immediate recall, but the number of repetitions necessary to learn all the items of SRT was greater in patients. Insomniacs usually complain of poor performance, however, learning impairment has not been documented in insomnia. Degree of the learning impairment correlated with insomnia score (Fig. 1). Cognitive deficit cannot be due to a daytime sleepiness because sleep latency in all MSLT sessions was not shorter in insomniacs. No correlations between results of SRT and standard PSG parameters were found, in accordance with the thesis that subjective feeling of nonrestorative sleep and other accompanying deficits are only symptoms of an underlying 24-hour disorder (1).

Adult↗
PubMed1995

Insomnia in the elderly: its prevalence and correlates in the general population.

OBJECTIVE: To estimate the prevalence of persistent insomnia and its correlates in samples of people living in the community and in institutional settings. METHODS: Respondents were interviewed in their place of residence by trained interviewers using the Canberra Interview for the Elderly, a structured psychiatric examination. RESULTS: Information about sleeping habits was obtained from 874 community and 59 institutional residents. Insomnia was persistent in 16% of the community-dwelling population and 12% of the institutional residents, with 15% and 40%, respectively, regularly taking a hypnotic. Of those without insomnia, 10% in the community but over a third in institutions were using a hypnotic. Insomnia was associated with depression, pain and poor physical health. CONCLUSIONS: Persistent insomnia in the elderly, as in other age groups, is strongly associated with depressed mood, as well as with physical disease. Because of this, insomnia should not be dismissed as a normal part of ageing, and therefore ignored as a significant symptom. Continued surveillance is needed in general practice, geriatric services and nursing homes of the routine use of hypnotics by the elderly.

Activities of Daily Living↗
PubMed1999

[Determinants of insomnia in relatively healthy elderly. A literature review].

A review is presented based on the findings resulting from interview and questionnaire research concerning factors that determine insomnia in relatively healthy elderly. The investigated factors include modes of living, sleep wishes and personality aspects. During the period 1988-1997 18 published reports were found. Based on the findings it is difficult to claim that elderly persons with insomnia are characterized by inappropriate modes of living. There were, however, some (inconsistent) indications that tea consumption, smoking and lack of exercise predicted insomnia. There were also scarce indications for less realistic sleep expectations in bad than in good sleepers. More bad sleepers perceived their sleep as uncontrollable and unpredictable than than good sleepers. Bad sleepers had significantly higher scores for anxiety, neuroticism and depression than good sleepers. Anxiety as well as depression correlated positively with insomnia and negatively with sleep duration. Depression, anxiety or neuroticism often were better predictors of insomnia than health indicators such as perceived health and number of prescribed drugs. The findings suggest that insomnia in relatively healthy elderly is more tightly associated with psychological factors than with modes of living or health indicators. This has some consequences for therapy. In addition to advice concerning modes of living and sleep hygiene, one has to be alert for the possible presence of depression or anxiety. In that case depression or anxiety has to be treated, pharmacologically or nonpharmacologically.

Aged↗
PubMed1999

Antidepressant treatment of the depressed patient with insomnia.

Sleep disturbances are an integral part of depressive disorder. As such, they are a part of all contemporary sets of diagnostic criteria for major depression and of all major symptom-based rating scales for depression. Insomnia is a particularly frequent complaint, and it is reported by more than 90% of depressed patients. Although the "kindling" or "illness transduction" model of depression remains hypothetical, there is evidence that people with recurrent depression have more pronounced abnormalities of sleep neurophysiology than those experiencing a single or initial episode. Therefore, early relief of insomnia in a depressed patient, in addition to alleviating other symptoms, may increase adherence to treatment and increase daytime performance and overall functioning, while complete relief of insomnia may improve prognosis. Stimulation of serotonin-2 (5-HT2) receptors is thought to underlie insomnia and changes in sleep architecture seen with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This is the reason why hypnotics or low-dose trazodone are commonly coprescribed at the initiation of the treatment with either the SSRIs or SNRIs. On the other hand, antidepressant drugs with 5-HT2 blocking properties, such as mirtazapine or nefazodone, alleviate insomnia and improve sleep architecture. In depressed patients, mirtazapine produces a significant shortening of sleep-onset latency, increases a total sleep time, and leads to a marked improvement in sleep efficiency. Antidepressants with preferential 5-HT2 blocking properties are therefore a good treatment option for depressed patients with marked insomnia.

Antidepressive Agents, Tricyclic↗
PubMed2000

The diagnosis and management of insomnia in clinical practice: a practical evidence-based approach.

Insomnia, or the dissatisfaction with the quantity, quality or timing of sleep, is a common complaint. Because the definition of "normal" sleep is not well established, the estimates of the prevalence and severity of insomnia vary widely. Insomnia is often secondary to underlying psychiatric and medical conditions, and these should be evaluated and treated as a first measure. Nonpharmacological interventions for insomnia including sleep hygiene manoeuvres and exercise are recommended, although the success of these interventions has not been well documented. Benzodiazepines have been the pharmacologic agents of choice for the treatment of insomnia, but there is reason to exercise caution with their use; their overall benefit compared with placebo appears to be minor, and they are often associated with adverse cognitive effects. Unfortunately, no other class of drugs has proven to be superior to the benzodiazepines in terms of benefit:risk ratio. Given the importance of sleep for health and normal daily functioning the diagnosis, prognosis and treatment of insomnia should be a research priority.

Benzodiazepines↗
PubMed2000

Insomnia in the elderly: a review for the primary care practitioner.

The elderly are known to have a high prevalence of insomnia. Causes of insomnia include: medical, psychiatric, and drug issues; circadian rhythm changes; sleep disorders; and psychosocial factors. The elderly frequently use sleeping aids. Risks associated with elderly patients' use of hypnotic drugs are attributable to concomitant comorbid conditions, use of multiple medications, altered pharmacokinetics, and increased central nervous system sensitivity to these drugs. Treatment options for insomnia include behavior modification and pharmacotherapy. The choice of hypnotics is based on matching the nature of the insomnia to the hypnotic agent. Benzodiazepine receptor agonists are common hypnotics prescribed for insomnia in the elderly. The ideal agent has rapid onset, duration of action that lasts through the night but no residual daytime effects, and no adverse effects. The longer-acting agents have been shown to result in a higher risk of falls and hip fractures in the elderly. This relationship is not apparent with short-acting agents. Zaleplon, the newest benzodiazepine receptor agonist, has the shortest half-life of available agents. Studies have demonstrated that zaleplon is effective in improving sleep latency, duration, and sleep quality in the elderly. Zaleplon does not appear to cause rebound insomnia, residual sedation, or adversely affect psychomotor function. The key for the healthcare professional is finding the appropriate treatment or treatment combination, including behavioral modification and pharmacotherapy. When hypnotics are indicated, the most appropriate short-acting agent should be considered.

Age Factors↗
PubMed2000

Insomnia, fatigue, anxiety, depression, and quality of life of cancer patients undergoing chemotherapy.

The purposes of this study were to examine: (a) the relationships between the symptoms of insomnia and fatigue and the psychological factors of anxiety and depression, and; (b) the relationships between these psychological and symptom variables and quality of life in cancer patients who were receiving chemotherapy. The Theory of Unpleasant Symptoms was the framework for the study. A descriptive correlational design was used in a secondary analysis of data obtained from a sample of 263 cancer patients who were undergoing chemotherapy. Insomnia, fatigue, depression, and anxiety were positively correlated with one another (r = .26 to r = .69, p < .001) and negatively correlated with quality of life (r = -.28 to r = -.63, p < .001). Women had more anxiety and fatigue and poorer quality of life than did men. Older age was associated with better quality of life and less insomnia, fatigue, anxiety, and depression. Multiple regression analysis revealed that the symptoms and psychological variables explained 47% of the variance in quality of life, with the largest proportion of the variance explained by depression. Fatigue and insomnia explained only 4% of the variance in quality of life in excess of that contributed by the psychological factors. Although overall depression levels were low in this sample, these findings suggest that insomnia and fatigue are related to depression and that depression is more closely associated with quality of life than are insomnia and fatigue.

Adult↗
PubMed2001

Neuroendocrine dysregulation in primary insomnia.

Recent research has pointed to a functional link between stress, disturbed sleep, psychiatric disorders, ageing, and neuroendocrine dysfunctions. In particular, increased activation of the hypothalamic-pituitary-adrenal (HPA) axis--expressed as elevated plasma cortisol levels--was shown in physiological ageing and patients with psychiatric disorders. We found increased evening and nocturnal plasma cortisol concentrations in patients with primary insomnia. Considering that both ageing and psychiatric disorders are commonly associated with sleep disturbances, our results implicate that elevated cortisol concentrations are a rather unspecific feature of disturbed sleep. Furthermore, our data revealed a strong positive correlation between evening cortisol secretion and the number of nocturnal awakenings in both insomniac patients and controls. Since nocturnal exposure to increased HPA activity promotes sleep fragmentation even in healthy controls, increased evening cortisol levels may be a crucial factor in inducing and maintaining sleep disturbances. We therefore propose a model of HPA dysregulation in insomnia. This model is based on the arousal theory of insomnia and the strong correlation between evening cortisol secretion and sleep fragmentation as a pathophysiological mechanism of a vicious cycle of insomnia. In patients with long-lasting insomniac complaints we found decreased nocturnal plasma melatonin levels thereby indicating a labilisation of circadian rhythm functions. Taken together, the neuroendocrine dysregulation seems to be more expressed in chronic insomnia than in acute insomnia and may be a contributing factor in maintaining disturbed sleep.

Arousal↗
PubMed2002

Medical and socio-professional impact of insomnia.

STUDY OBJECTIVES: Insomnia, a highly prevalent disorder with direct and indirect economic and professional consequences, affects daytime functioning, behavior, and quality of life. Several studies have shown that insomnia affects the workforce and is associated with an increased risk of accidents. Insomnia may also play a role in other disorders. Our study attempted to evaluate the socio-professional correlates of insomnia by comparing a group of insomniacs to a group of good sleepers. DESIGN: With a questionnaire focused on the socio-professional and medical consequences of insomnia, we surveyed a group of severe insomniacs and a group of good sleepers. Persons with psychiatric disorders according to the DSM-IV minimum criteria for anxiety and depression were eliminated from each group. After screening, 240 insomniacs and 391 good sleepers remained and were then compared. MEASUREMENTS AND RESULTS: Compared to good sleepers, severe insomniacs reported more medical problems, had more physician-office visits, were hospitalized twice as often, and used more medication. Severe insomniacs had a higher rate of absenteeism, missing work twice as often as did good sleepers. They also had more problems at work (including decreased concentration, difficulty performing duties, and more work-related accidents). CONCLUSIONS: Our study showed that insomnia has socio-professional consequences and is correlated with lower medical status.

Accidents, Occupational↗
PubMed2004

The changing perspective on chronic insomnia management.

A particular challenge in the treatment of insomnia is management of chronic insomnia, which occurs in a substantial portion of the population. A number of factors suggest the importance of identifying this condition as distinct from short-term insomnia in clinical practice and treating these 2 entities differently. Yet, there is no consensus about how to make this distinction or how to manage patients beyond the short term. Clinicians have been without guidance as to how to address the significant challenges associated with treating patients long term with any of the currently available treatments. In recent years, however, new studies have suggested the emergence of a changing perspective on the management of chronic insomnia. These studies have begun to provide an empirical basis for making decisions in the treatment of patients with chronic insomnia. They suggest that clinical practice is evolving toward an improved capacity to treat insomnia, with treatments that can safely lead to sustained efficacy.

Antidepressive Agents↗
PubMed2003

[Cognitive-behavioral treatment of insomnia and its use during withdrawal of hypnotic medication].

Insomnia is a widespread health problem that often leads to the use of hypnotic medication. Among the available pharmacological agents to treat insomnia, benzodiazepines (BZD) present some undesirable effects, entailing risks of tolerance and dependence, and increased risk of automobile accidents, falls and fractures in the elderly. Cognitive-behavioral treatment (CBT) of insomnia, which focuses on psychological and behavioral factors that play a role in maintaining sleep-related problems, is efficient to improve sleep in the elderly who suffer from primary insomnia. This treatment may represent an alternative to pharmacotherapy or again be complementary during discontinuation of hypnotic medication. The CBT of insomnia may include different components such as stimulus control, sleep restriction, relaxation, cognitive restructuring and sleep hygiene. For people who are dependent to BZD or other hypnotic medication, a supervised tapering based on attaining successive objectives is generally added to the CBT of insomnia.

English Abstract↗
PubMed2004

Cognitive-behavioral approaches to the treatment of insomnia.

Insomnia is a pervasive condition with various causes, manifestations, and health consequences. Regardless of the initial cause or event that precipitates insomnia, it is perpetuated into a chronic condition through learned behaviors and cognitions that foster sleeplessness. This article reviews the rationale and objectives of cognitive-behavioral therapy (CBT), a safe and effective treatment for insomnia that may be used to augment hypnotic drugs or as a monotherapy. Cognitive-behavioral management of insomnia includes 3 components--behavioral, cognitive, and educational modules--and is usually presented in a group or individual therapy setting. Each treatment procedure is detailed herein, and recommendations for implementation are given. The evidence supporting this behavioral approach shows that CBT is effective for 70% to 80% of patients and that it can significantly reduce several measures of insomnia, including sleep-onset latency and wake-after-sleep onset. Aside from the clinically measurable changes, this therapy system enables many patients to regain a feeling of control over their sleep, thereby reducing the emotional distress that sleep disturbances cause. Some clinical and practical issues that often arise when implementing this therapeutic approach for insomnia are also discussed.

Clinical Trials as Topic↗
PubMed2005

Insomnia: a primary care perspective.

Primary care physicians once considered insomnia a nuisance diagnosis with which they had little concern. A complaint of insomnia is often brought to a physician's attention as a last-minute secondary complaint, which may be dismissed as unimportant by the physician. However, chronic insomnia is prevalent, associated with a decrease in quality of life, and can be an exacerbating factor in other psychiatric and medical conditions. Primary care physicians therefore should be aware of the signs of insomnia and include the detection of it in the evaluation of patients who present with other complaints or as part of annual physical examinations. Physicians can assess insomnia with tools they already use, such as a patient's initial history. If insomnia is detected, primary care physicians should work with patients to educate them. Management necessitates the inclusion of education and patient counseling about sleep hygiene and correction of dysfunctional beliefs and behaviors. It may also include pharmacologic treatment, nonpharmacologic treatment, or a combination of both.

Attitude of Health Personnel↗