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Couldn’t you link to this???? Kind of wordy…. – Hide quoted text — Show quoted text – This is a long, but a very good article. Enjoy Psychiatry Treatment Updates Clinical Frontiers in the Sleep/Psychiatry Interface CME Satellite Symposium of The 1999 American Psychiatric Association Annual Meeting Author: Karl Doghramji, MD Writer: Steffany Fredman Last updated: June 22, 1999 Introduction Sleep-related complaints such as insomnia and excessive daytime somnolence impair…..
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- Hide quoted text — Show quoted text – Couldn’t you link to this???? Kind of wordy…. This is a long, but a very good article. Enjoy Psychiatry Treatment Updates Clinical Frontiers in the Sleep/Psychiatry Interface CME Satellite Symposium of The 1999 American Psychiatric Association Annual Meeting Author: Karl Doghramji, MD Writer: Steffany Fredman Last updated: June 22, 1999 Introduction Sleep-related complaints such as insomnia and excessive daytime somnolence impair…..
Sorry..but this really bothered and offended me. I posted this since #1)You have to register with medscape to see their articles, and I thought I’d just save a little time for people and #2)Is their not something BETTER to complain about? Thats why this is a "support" group, not a "Why did you do this???" group. — James MacLachlan Co-Webmaster http://www.tomcochrane.ca "We live out here in the desert Where time stands still In the face of our foolish pride We trade our love for ambition And tell each other We’ll get it all back in time But time moves on like a river Soon leaves us all behind Like a summer rain It all gets washed away ..Don’t trade your love for ambition You’ll get washed away" Tom Cochrane "Washed Away"
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Hi, I’m very thankful that you posted this article…very helpful…THANKS! Yvonne
Couldn’t you link to this???? Kind of wordy…. This is a long, but a very good article. Enjoy Psychiatry Treatment Updates Clinical Frontiers in the Sleep/Psychiatry Interface CME Satellite Symposium of The 1999 American Psychiatric Association Annual Meeting Author: Karl Doghramji, MD Writer: Steffany Fredman Last updated: June 22, 1999 Introduction Sleep-related complaints such as insomnia and excessive daytime somnolence impair….. Sorry..but this really bothered and offended me. I posted this since #1)You have to register with medscape to see their articles, and I thought I’d just save a little time for people and #2)Is their not something BETTER to complain about? Thats why this is a "support" group, not a "Why did you do this???" group. — James MacLachlan Co-Webmaster http://www.tomcochrane.ca "We live out here in the desert Where time stands still In the face of our foolish pride We trade our love for ambition And tell each other We’ll get it all back in time But time moves on like a river Soon leaves us all behind Like a summer rain It all gets washed away ..Don’t trade your love for ambition You’ll get washed away" Tom Cochrane "Washed Away"
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This is a long, but a very good article. Enjoy Psychiatry Treatment Updates Clinical Frontiers in the Sleep/Psychiatry Interface CME Satellite Symposium of The 1999 American Psychiatric Association Annual Meeting Author: Karl Doghramji, MD Writer: Steffany Fredman Last updated: June 22, 1999 Introduction Sleep-related complaints such as insomnia and excessive daytime somnolence impair the lives of 20% to 50% of Americans,[1] and 60% of psychiatric outpatients complain of disturbed sleep.[2] Many of the major psychiatric syndromes, notably depression, posttraumatic stress disorder (PTSD), and chronic pain, feature sleep-related symptoms which often complicate treatment and exacerbate course of the primary disorder. For instance, it has been estimated that 80% of depressed patients complain of disturbed sleep, and that sleeplessness may be a risk factor for impaired mood. The most common complaint in PTSD is sleeplessness, and 50% to 70% of chronic pain patients report disturbed sleep. Excessive daytime somnolence, which may be a result of insomnia, is associated with increased morbidity and mortality. An estimated 200,000 automobile accidents each year are caused by excessive sleepiness on the part of drivers. This is perhaps not surprising given that 69% of all drivers feel drowsy while driving, and 20% of drivers indicate that they have fallen asleep behind the wheel. Excessive daytime sleepiness has been implicated in the cause of major catastrophes such as the Three Mile Island meltdown (1979), the erroneous launch of the Challenger (1986), and the grounding of the Exxon Valdez (1989). During the symposium entitled "Clinical Frontiers in the Sleep/Psychiatry Interface," held on May 16, 1999 at the Annual Meeting of the American Psychiatric Association, sleep experts provided a review of what is currently known about the genesis and treatment of insomnia and hypersomnolence, depression and sleep, sleep disturbances in PTSD, and pain and sleep. In the article that follows, I have summarized my own presentation at this symposium as well as the comments of my three fellow speakers. Insomnia and Hypersomnia: Old Problems With Newer Treatments Ten to twenty percent of Americans complain of chronic insomnia, and 40% to 50% report occasional insomnia. Thus, sleep difficulties and excessive daytime somnolence may well be considered public health problems. Sleep problems have been associated with decreased work productivity, increased healthcare utilization, more missed days of work, and an increased risk of serious accidents.[3,4] Studies have also shown that relative to normals, insomniacs have more problems with short-term memory and greater impairments with cognitive and motor performance.[5] Insomnia may have several etiologies and is, therefore, best diagnosed with a comprehensive medical examination. Disorders associated with insomnia include the following: adjustment sleep disorder psychophysiological insomnia inadequate sleep hygiene psychiatric conditions medical and neurological conditions drugs intrinsic sleep disorders such as sleep apnea syndrome and restless legs syndrome In restless legs syndrome (RLS), patients complain of "creepy," "crawling" sensations in the legs that are relieved by movement. RLS is generally idiopathic but may be secondary to uremia, anemia, and pregnancy. It often coexists with periodic limb movements in sleep (PLMS), and may be exacerbated by tricyclic antidepressants. Potential treatments for RLS/PLMS include dopaminergic agents such as carbidopa/levodopa, pergolide, and bromocriptine; benzodiazepines such as clonazepam, temazepam, and triazolam; opioids such as propoxyphene, codeine, oxycodone, hydrocodone, and methadone; anticonvulsants such as gabapentin, carbamazepine, and valproate; and vitamins and supplements including iron magnesium, folate, B12, and vitamins C and E.[6] Combination Treatment with Pharmacologic/Behavioral Therapy Insomnia is commonly treated with a combination of pharmacologic agents and behavioral strategies. There are, however, pros and cons associated with each. Pharmacologic agents provide rapid relief of symptoms but are generally associated with only short-term benefit. Behavioral strategies, while associated with long-term benefit, often take a great deal of time to learn and implement. Therefore, a combined approach, incorporating both behavioral and pharmacological strategies, promises to provide optimal benefit. Sleep Hygiene Instruction in sleep hygiene, ie, good sleep habits, may be helpful in the treatment of insomnia for many patients. To achieve good sleep hygiene, one must[7]: maintain regular wake time avoid excessive time in bed avoids naps, except if shift worker use the bed only for sleeping and sex avoid nicotine, caffeine, and alcohol exercise regularly early in the day do something relaxing before bedtime don’t watch the clock eat a light snack before bed if hungry Breaking the Cycle of Psychophysiological Insomnia Stressors such as hospitalization, job loss, and rapid changes in work shift can precipitate self-limited insomnia, called adjustment sleep disorder. However, these may outlast the time course of the stressor and become chronic because of brooding oversleeplessness and conditioning factors, which result in an autonomous, entrenched, and persistent insomnia, referred to as psychophysiological insomnia. Therefore, staying in bed too long and worrying about falling asleep may lead to an obsession with sleeplessness and an escalation of the symptom. One strategy, which may break this obsessive cycle of sleep worry, is stimulus-control therapy. Patients are instructed to follow several steps related to good sleep hygiene. go to bed only when sleepy if unable to fall asleep within 15-20 minutes, move to another room return to bed only when sleepy adhere to a regular awakening time avoid napping Other behavioral methods in the treatment of these types of insomnia include relaxation training (biofeedback, progressive muscle relaxation) and psychotherapy. Pharmacotherapy — The Old and the New The first agents used to treat sleep disturbances included choral hydrate, barbiturates, and barbiturate-like compounds (Figure 1). These agents were associated with addiction, respiratory suppression, hepatic disease, and even unexpected deaths. The newer benzodiazepines and the imidazopyridine zolpidem have largely replaced these original agents because they are safer to use. In the near future, a new class of compounds, the pyrazolopyrimidines, will be introduced, and zaleplon is so far the sole agent in this class. Figure 1: Agents used to treat sleep disturbances. With the exception of temazepam, all the benzodiazepines and newer nonbenzodiazepine agents have a rapid onset of action. However, some of the benzodiazepines have a long duration of action, primarily because they have active metabolites which cause residual daytime sleepiness ("hangover"). These agents also increase the risk of impairment in daytime occupational performance and may enhance the risk of driving accidents or falls. In contrast, some of the benzodiazepines without active metabolites, such as triazolam, and the newer nonbenzodiazepines zolpidem and zaleplon, do not have active metabolites, have shorter durations of action, and are not likely to produce daytime residual effects. Zolpidem and Zaleplon — Different Clinical Niches? Zolpidem’s duration of sedative action is approximately 7 hours, whereas that of zaleplon is less than 4 hours[8] (Figure 2). The difference in duration of action may make zolpidem better-suited for disturbances that affect all portions of the night, while zaleplon may be useful for targeting certain portions of the night. For example, zaleplon can be administered at the beginning of the night for initiation insomnia and in the middle of the night for terminal sleep difficulties. The short duration of action of zaleplon allows the patient to take a sleep medication following middle-of-the-night awakening without experiencing hangover. Figure 2: Drowsiness following the administration of zolpidem and zaleplon. Disadvantages of Short Half-Life in Benzos? A possible disadvantage of the short half-life benzodiazepines such as triazolam is the increased risk for tolerance after repeated administration and rebound insomnia following rapid discontinuation. Data confirming this clinical observation are not extensive. This may not be as prominent a difficulty with the newer nonbenzodiazepine drugs, such as zolpidem and zaleplon. Controlled studies have shown the lack of tolerance and rebound following 6 weeks of zolpidem therapy and following 1 year of zaleplon therapy. Despite the improved safety profile of newer agents, patients using any hypnotics should be warned about the possibility of excessive daytime sedation, especially if they use higher-than-recommended doses. Zolpidem has also been associated with headache, nausea, and dizziness and, at higher-than-recommended doses, even the newer agents may produce memory impairment, motor imbalance, confusion, and nightmares. General Guidelines for Prescribing Hypnotics General guidelines for hypnotic use are as follows: individualize dose for each patient prescribe lowest effective dose lower dose of hypnotic drug if used with a CNS depressant or alcohol lower dose in the elderly and in patients with hepatic disease avoid nightly use limit duration of use taper during withdrawal Certain insomniacs may require hypnotic management for longer than the recommended 2-week period. In such cases, administration of medication on a 5-night/week basis may diminish the possibility of tolerance. Other Agents — Melatonin, Antidepressants, and Anticholinergics Melatonin is a promising new agent. Trials are under way to investigate the utility of melatonin analogs that selectively act at the melatonin receptor sites. Melatonin has been … read more »
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