Pharmacologic and nonpharmacologic treatments of insomnia

Insomnia in its chronic form is present in high numbers of patients presenting to physicians. As older women who have medical problems have the highest rates of chronic insomnia, physicians must have a high index of suspicion and be prepared to explore various etiologic factors that might be operative. Treatment should focus on setting specific goals, with patients using strategies that combine lifestyle changes, behavioral interventions, and appropriate medications. OTC agents, sedating antidepressants at low dosages (trazodone, doxepin, amitriptyline, and others), and nonhypnotic benzodiazepines are insufficiently studied to provide evidence-based support for their use to treat chronic insomnia. Particularly in the elderly, close monitoring is needed to prevent falls, accidents, and cognitive impairment from these agents. FDA-labeled hypnotic agents are efficacious, but long-term studies have not been available until the recent release of eszopiclone in the United States. Recent work encourages the use of CBT even in patients who have used sleeping pills for several years, although the success of CBT has been less encouraging when applied to chronic insomnia sufferers who have concurrent psychiatric disorders and who have taken hypnotics for years.     

Non-pharmacological experimental treatments for spinal cord injury: a review

Introduction

Spinal cord injury is a complex result of primary mechanical damage and the secondary vascular compromise and inflammatory reactions. Depending on timing, different treatment modalities may have various effects.

Conclusions

We review the latest advances in terms of non-pharmacological experimental treatments.     

A review of behavioral treatments for insomnia

A variety of behavioral treatments for insomnia is reviewed. These are hypnosis, relaxation training, systematic desensitization, classical conditioning, biofeedback, electrosleep and the use of attribution techniques. While these procedures offer some promise in the management of insomnia, their effectiveness has not yet been fully evaluated.A number of psychological factors which may operate in the effective use of such treatment techniques are discussed. Particular consideration is given to the anxiety reduction associated with such processes as attention focusing, relaxation of the musculature, and the development of techniques for self-control. The roles of patient education and modification of expectations regarding insomnia are also discussed.     

The prevalence, morbidities, and treatments of insomnia

Insomnia is a common condition that often is co-morbid with other illnesses. It is associated with significant morbidities, including nighttime distress, impaired cognitive functioning, impaired daytime functioning, and increased risk of accidents. People with insomnia utilize healthcare services more often than those without insomnia, and they are at greater risk for the development of certain health problems; most notably psychiatric illness such as depression. It is now known that the significant impact of insomnia warrants diagnosis and treatment. Behavioral and psychopharmacological treatments have been available for some time. However, formerly common classes of therapeutics such as the barbiturates and benzodiazepines have been replaced by new allosteric modulators of the GABA(A) receptor and other therapeutics with novel mechanisms of action. This article presents existing approaches to insomnia treatment, and reviews new treatments, therapeutic targets, and treatment approaches to insomnia under development that may offer promise to practitioners and patients.     

Measuring outcomes in randomized clinical trials of insomnia treatments

Significant efforts have been made in the last decade to develop evidence-based guidelines for the treatment of insomnia and other sleep disorders. Despite such progress, there are still no standard assessment methods to document outcome and no accepted criteria to define what should be a successful outcome in the treatment of insomnia. This paper reviews methodological and conceptual issues related to the measurement of outcomes in clinical trials of insomnia. Selected studies of behavioral and pharmacological therapies of insomnia are summarized to illustrate the types of dependent variables and assessment instruments used to document treatment efficacy. Additional outcome variables and assessment methods of potential interest are discussed, and criteria for interpreting and reporting outcomes are summarized. As most studies have relied on fairly narrow criteria to define an effective treatment, the need to broaden the scope of outcome assessment is highlighted. For instance, it is essential to document treatment efficacy beyond the simple reduction of insomnia symptoms and to incorporate additional indicators of success. Given that insomnia is associated with significant morbidity, an effective treatment should not only improve sleep parameters, but it should also produce clinically meaningful changes in daytime functioning, fatigue, mood, and quality of life. The need to evaluate outcome from multiple perspectives and to develop a core-assessment battery that would consider efficacy, clinical significance, and cost-effectiveness are discussed.     

Psychophysiological insomnia: combined effects of pharmacotherapy and relaxation-based treatments

Objective: To compare treatment outcomes associated with combined pharmacologic and non-pharmacologic treatments for psychophysiological insomnia.Background: Treatments for insomnia have included a variety of pharmacotherapy and cognitive–behavioral interventions, although few studies have investigated the combined efficacy of drug and non-drug therapy.Methods: Forty-one patients with primary insomnia were randomly assigned to one of three treatment groups: (i) estazolam + muscle relaxation, (ii) estazolam + guided imagery, and (iii) estazolam + sleep education. After 4 weeks of active treatment, subjects were withdrawn from medication and followed for an additional 6 months.Results: Significant improvements were observed in self-report measures of total sleep time, sleep efficiency, and wakefulness after sleep onset in the combined drug and relaxation groups, compared to a significant improvement in total sleep time only in the educational control group. At follow-up, all three groups showed significant improvements across the major sleep measures. Positive changes were also observed in quality of life measures, including mood state and self- ratings of daytime arousal.Conclusions: These findings provide support for the value of combined pharmacotherapy and relaxation training in the treatment of psychophysiological insomnia.     

Non-pharmacological treatment of depression

Neurological Sciences - Depression is a serious mental disorder, which can affect people with multiple sclerosis (MS) and have a significant influence on their quality of life. Studies have...     

An actigraphic comparison of sleep restriction and sleep hygiene treatments for insomnia in older adults

We compared the efficacy of sleep restriction therapy combined with sleep hygiene, nap modification of sleep restriction therapy combined with sleep hygiene, and sleep hygiene alone as treatments for insomnia in 39 community-dwelling men and women 55 years and older. We used the wrist actigraph as an objective outcome measure for all subjects at baseline, end of treatment, and 3-month follow-up; polysomnography (PSG) was conducted in a subgroup of subjects. Although subjects appeared to follow restriction instructions through follow-up, we found few between-group differences in treatment efficacy. Lack of treatment effect might be explained by the efficacy of HYG as a treatment in itself and the relatively low symptom level in these healthy older poor sleepers. At baseline, actigraphic results were found to correlate more highly than sleep log data with PSG in our sample. Actigraphic total sleep time, in particular, was highly correlated with PSG.     

Non-pharmacological management of migraine during pregnancy

Migrainous women note a significant improvement in their headaches during pregnancy. However, persistent or residual attacks need to be treated, keeping in mind that many drugs have potential dangerous effects on embryo and foetus. It is evident, therefore, that hygiene and behaviour measures capable of ensuring the best possible well-being (regular meals and balanced diet, restriction of alcohol and smoking, regular sleeping pattern, moderate physical exercise and relaxation) are advisable during pregnancy. Among non-pharmacological migraine prophylaxis only relaxation techniques, in particular biofeedback, and acupuncture have accumulated sufficient evidence in support of their efficacy and safety. Some vitamins and dietary supplements have been proposed: the prophylactic properties of magnesium, riboflavin and coenzyme Q10 are probably low, but their lack of severe adverse effects makes them good treatment options.     

Non-pharmacological Approaches for Management of Insomnia

Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13311-021-01029-2.Key Words: Sleep, Insomnia, Treatment, Non-pharmacological, Cognitive behavioral therapy, Comorbidity     

Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors

BACKGROUND AND PURPOSE: To estimate the prevalence of insomnia symptoms and syndrome in the general population, describe the types of self-help treatments and consultations initiated for insomnia, and examine help-seeking determinants. PATIENTS AND METHODS: A randomly selected sample of 2001 French-speaking adults from the province of Quebec (Canada) responded to a telephone survey about sleep, insomnia, and its treatments. RESULTS: Of the total sample, 25.3% were dissatisfied with their sleep, 29.9% reported insomnia symptoms, and 9.5% met criteria for an insomnia syndrome. Thirteen percent of the respondents had consulted a healthcare provider specifically for insomnia in their lifetime, with general practitioners being the most frequently consulted. Daytime fatigue (48%), psychological distress (40%), and physical discomfort (22%) were the main determinants prompting individuals with insomnia to seek treatment. Of the total sample, 15% had used at least once herbal/dietary products to facilitate sleep and 11% had used prescribed sleep medications in the year preceding the survey. Other self-help strategies employed to facilitate sleep included reading, listening to music, and relaxation. CONCLUSIONS: These findings confirm the high prevalence of insomnia in the general population. While few insomnia sufferers seek professional consultations, many individuals initiate self-help treatments, particularly when daytime impairments such as fatigue become more noticeable. Improved knowledge of the determinants of help-seeking behaviors could guide the development of effective public health prevention and intervention programs to promote healthy sleep.     

Non-pharmacological neuroprotection: role of emergency stroke management

Acute stroke should be considered a medical emergency, where actions taken in the first hours are fundamental for achieving recovery of the damaged cerebral tissue and a better prognosis for the patient. Recanalization and neuroprotective treatment has been used with mixed results. The effectiveness observed in the first hours with thrombolytic drug treatment is only applicable to a small percentage of patients, and attempts to widen this treatment window have not yet proved fruitful. Pharmacological neuroprotective treatment has not yet demonstrated the clinical effectiveness observed in experimental models. The concept of neuroprotection in cerebral ischemia also involves a series of mechanisms that take place at the cerebral level following vascular occlusion. In this context, it should be borne in mind that a series of physiological functions usually involved in the cerebral metabolism (control of blood pressure, of temperature, of glycemia and of arterial oxygen saturation) play a key role in modulation of the ischemic process. Changes in the control of these mechanisms may aggravate the process of cerebral damage in the first hours of ischemic stroke. In this work we review the prognostic importance of the main mechanisms that may influence the acute phase of cerebral ischemic stroke, as well as their therapeutic management and control in the clinical situation.     

Non-pharmacological factors in drug treatment of anxiety states.

Forty-six outpatients with anxiety tension states took part in a study on the effects of anxiolytic drugs. After the first interview the subjects also filled in a questionnaire as to their expectations of treatment outcome (n=41) and their experience of the first consultation (n=42), and the doctors made a prognostic evaluation (n=46). The relations between these three factors and background variables as well as initial ratings and outcome as rated by the doctors at follow-up examinations after 2, 4, and 8 weeks were investigated. Expectations, experience, and prognosis were not related to each other. Less hopeful patients more often considered conflicts to be the exclusive cause of their disorder and they were rated higher on signs and on the variable difficulties in being with people. Patients with less favourable experience more often considered practical and economic difficulties to be a cause of their disorder. Single or divorced patients were more often judged to have a less favourable prognosis. More positive expectations and a favourable prognosis. More positive expectations and a favourable prognosis were to some extent related to a better outcome after 2 and 4 weeks and a favourable experience was to some extent related to a better outcome after 4 and 8 weeks.     

Non-pharmacological approaches in migraine prophylaxis: behavioral medicine

The high prevalence of headache in young age has a significant impact on patients and their families. Migraine and tension-type headache are the most common forms of headache for which young patients see a physician. Recent studies confirm the increasing incidence of migraine and also chronic migraine in the pediatric population. The article reviews the most important diagnostic categories of headache in young age and the limitations of the classification criteria for this group of patients.     

Non-pharmacological management of psychiatric disturbances after traumatic brain injury

Persons who suffer traumatic brain injury (TBI) often demonstrate a variety of psychiatric and neuropsychiatric disturbances. Some of those disturbances may be managed by non-pharmacological methods. The methods draw heavily on established principles of psychotherapy and behavioral modification. However, the unique problems imposed by neurocognitive deficits must be factored into any form of non-pharmacological intervention with this patient group. A simple model consolidates information about the important ingredients in the non-pharmacological management of psychiatric disturbances in TBI patients.