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Pharmacological Treatment 183 the 3 weeks of treatment, in 63% of patients the weekly number of tablets used was reduced in contrast to baseline without any significant impact on the treatment efficacy. Efficacy of treatment was rated as very good or good in 93% by the investigators. Adverse events were observed only in 1.2% of patients and were generally of mild nature. No serious adverse event occurred (49). In conclusion, the non-benzodiazepine hypnotics (zolpidem, zoplicone, and zaleplon) are safe and effective hypnotics with minimal adverse effects and no dependence, withdrawal, tolerance, or rebound insomnia over long-term use (43,45,46,50) Of course given the relatively small number of studies further research is warranted to assess both the efficacy and the safety of long-term use. SECONDARY INSOMNIAS REQUIRING SPECIFIC PHARMACOLOGICAL TREATMENTS Restless Legs Syndrome RLS and the resulting insomnia respond only to medication. Behavioral therapies have no role in the treatment of RLS. Sometimes, antidepressants and other medications aggravate RLS. Cessation of these medications helps alleviate the symptoms. In those patients who have low serum ferritin, iron replacement, may be helpful. Most patients, however, require medication. The most effective medications for treating RLS symptoms belong to three distinct classes: (1) the dopaminergics agents, e.g., pramipexole (51,52), ropinirole hydrochloride (53,54), pergolide mesylate (55) bromocriptine mesylate (55), and levodopa (56); (2) the opiates (57); and (3) the benzodiazepines, especially clonazepam (58). Studies have shown that the newer anticonvulsants gabapentin (59,60) and clonidine (especially in patients who do not have a large amount of PLMs) (61) are also effective in controlling RLS. The doses of the above medication used in the treatment of RLS are usually much lower than the doses utilized in the treatment of other conditions such as Parkinson’s disease, pain, anxiety, seizures, and other medical conditions for which the above medications are effective. In rare instances, higher doses are reached by titrating to the patients’ symptoms. Menopause-Related <strong>Insomnia</strong> In menopause-related insomnia, estrogen replacement therapy (ERT) may control insomnia along with other menopause-related symptoms (62,63). The recent medical problems reported with ERT have led to a search for other alternatives. One herbal alternative, Black Cohosh, has been studied but there is no conclusive evidence as to its efficacy in menopausal insomnia (64). REFERENCES 1. NIH Consensus Development Conference Summary. (1984) Drugs and insomnia: the use of medication to promote sleep. JAMA 251(18), 2410–2414. 2. Gauillard, J. Cheref, S., Vacherontrystram, M. N., and Martin, J. C. (2002) [Chloral hydrate: a hypnotic best forgotten?]. Encephale 28(3 Pt 1), 200–204.
184 Attarian 3. Wyatt, R. J., Engelman, K., Kupfer, O. J., Fram, D. H., Sjverdsma, A., Snyder, F. (1970) Effects of L-tryptophan (a natural sedative) on human sleep. Lancet 2(7678), 842–846. 4. Glickstein, S. L., Gertner, E., Smith, S. A., et al. (1990) Eosinophilia-myalgia syndrome associated with L-tryptophan use. J. Rheumatol. 17(11), 1534–1543. 5. Marks, D. R. (1990) A case of L-tryptophan-induced eosinophilia-myalgia resulting in death. Conn. Med. 54(10), 552–554. 6. Zollner, N., Sorg, M., and Kruger, K. (1990) [Eosinophilia myalgia syndrome in administration of L-tryptophan]. Klin. Wochenschr. 68(14), 739–742. 7. Roehrs, T., Hollebeek, E., Drake, C., and Roth, T. (2002) Substance use for insomnia in Metropolitan Detroit. J. Psychosom. Res. 53(1), 571–576. 8. Weiler, J. M., Bloomfield, J. R., Woodsworth, G. G., et al. (2000) Effects of fexofenadine, diphenhydramine, and alcohol on driving performance. A randomized, placebo-controlled trial in the Iowa driving simulator. Ann. Intern. Med. 132(5), 354–363. 9. Basu, R., Dodge, H., Stoehr, G. P., Ganguli, M. (2003) Sedative-hypnotic use of diphenhydramine in a rural, older adult, community-based cohort: effects on cognition. Am. J. Geriatr. Psychiatry 11(2), 205–213. 10. Gilhooly, T. C., Webster, M. G., Poole, N. W., Ross, S. (1998) What happens when doctors stop prescribing temazepam? Use of alternative therapies. Br. J. Gen. Pract. 48(434), 1601–1602. 11. Sproule, B. A., Busto, U. E., Buckle, C., Herrmann, N., and Bowles, S. (1999) The use of nonprescription sleep products in the elderly. Int. J. Geriatr. Psychiatry 14(10), 851–857. 12. Zhdanova, I. V., Wurtman, R. J., Regan, M. M., Taylor, J. A., Shi, J. P., Leclair, O. U. (2001) Melatonin treatment for age-related insomnia. J. Clin. Endocrinol. Metab. 86(10), 4727–4730. 13. Smits, M. G., Nagtegaal, E. E., van der heijden, j., Coenen, A. M. and Kerkhof, G. A. (2001) Melatonin for chronic sleep onset insomnia in children: a randomized placebo-controlled trial. J. Child. Neurol. 16(2), 86–92. 14. Shamir, E., Landon, M., Barak, Y., et al. (2000) Melatonin improves sleep quality of patients with chronic schizophrenia. J. Clin. Psychiatry 61(5), 373–377. 15. Sack, R. L., Lewy, A. J. and Hughes, R. J. (1998) Use of melatonin for sleep and circadian rhythm disorders. Ann. Med. 30(1), 115–121. 16. Arendt, J. (1998) Complex effects of melatonin. Therapie 53(5), 479–488. 17. Olde Rikkert, M. G. and Rigaud, A. S. (2001) Melatonin in elderly patients with insomnia. A systematic review. Z. Gerontol. Geriatr. 34(6), 491–497. 18. Stone, B. M., Turner, C., Mills, S. L, and Nicholson, A. N. (2000) Hypnotic activity of melatonin. Sleep 23(5), 663–669. 19. Dominguez, R. A., Bravo-Valverde, R. L., Kaplowitz, B. C., and Cott, J. M. (2000) Valerian as a hypnotic for Hispanic patients. Cultur. Divers. Ethnic Minor. Psychol. 6(1), 84–92. 20. Donath, F., Quispe, S., Diefenbach, K., Maurer, A., Fietze, I., and Roots, I. (2000) Critical evaluation of the effect of valerian extract on sleep structure and sleep quality. Pharmacopsychiatry 33(2), 47–53. 21. Fussel, A., Wolf, A., and Brattstrom, A. (2000) Effect of a fixed valerian-Hop extract combination (Ze 91019) on sleep polygraphy in patients with non-organic insomnia: a pilot study. Eur. J. Med. Res. 5(9), 385–390. 22. Dorn, M. (2000) [Efficacy and tolerability of Baldrian versus oxazepam in non-organic and nonpsychiatric insomniacs: a randomised, double-blind, clinical, comparative study]. Forsch. Komplementarmed. Klass. Naturheilkd. 7(2), 79–84. 23. Ziegler, G., Ploch, M., Miettinern-Baumann, A., Collet, W. (2002) Efficacy and tolerability of valerian extract LI 156 compared with oxazepam in the treatment of non-organic insomnia: a randomized, double-blind, comparative clinical study. Eur. J. Med. Res. 7(11), 480–486. 24. Carvalho-Freitas, M. I. and Costa, M. (2002) Anxiolytic and Sedative Effects of Extracts and Essential Oil from Citrus aurantium L. Biol. Pharm. Bull. 25(12), 1629–1633. 25. Chung, K. F. and Lee, C. K. (2002) Over-the-counter sleeping pills: a survey of use in Hong Kong and a review of their constituents. Gen. Hosp. Psychiatry 24(6), 430–435.
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Clinical Handbook of Insomnia Edite
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C URRENT CLINICAL NEUROLOGY Daniel
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© 2004 Humana Press Inc. 999 River
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Series Editor’s Introduction The
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x Foreword nervous system hypersomn
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Contents Series Editor’s Introduc
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Contributors HRAYR P. ATTARIAN, MD
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2 Attarian et al.
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4 Attarian et al. until the 1970s t
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6 Attarian et al. Table 2 Diagnosti
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8 Attarian et al. Duration of Illne
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10 Attarian et al. REFERENCES 1. Ma
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12 Attarian Another study in Austri
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14 Attarian even less well studied.
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16 Attarian communities. A structur
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18 Attarian 5. Sutton, D. A., Moldo
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20 Attarian 53. Kageyama, T., Kabut
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22 Attarian
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24 Bonnet and Arand Table 1 Reporte
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26 Bonnet and Arand On the day spen
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28 Bonnet and Arand SUMMARY These m
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30 Bonnet and Arand chronic caffein
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32 Bonnet and Arand response that a
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34 Bonnet and Arand The Development
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36 Bonnet and Arand ACKNOWLEDGMENT
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38 Bonnet and Arand 45. Bonnet, M.
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40 Attarian Table 1 Types of Insomn
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42 Attarian 15 to 40 seconds. PLMs
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44 Fig. 1. Example of a 1-week slee
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46 Fig. 3. One-week printout of an
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48 Attarian Fig. 4. Algorithm. (Use
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50 Attarian 27. Polo-Kantola, P., E
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52 Garcia
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54 Garcia association is known as s
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56 Fig. 1. A sleep log used in chil
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58 Garcia the reality that the tend
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60 Fig. 2. Actigraph recording in a
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62 Garcia neurodevelopmental disabi
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64 Garcia 35. Czeisler, C., kronaue
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66 Garcia
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68 Attarian showed similar degrees
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70 Attarian agitation and hence the
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72 Attarian Affective disorder is s
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74 Attarian and Drug Administration
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76 Fig. 2. Sleep log after treatmen
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78 Attarian 18. Bonnet, M. H. and A
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80 Attarian 65. Perlis, M., Aloia,
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82 Attarian was confirmed by resear
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84 Attarian times worrying about th
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86 Attarian insomnia or for other s
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88 Attarian
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90 Duntley tion systems found that
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92 Duntley Case 1 A 36-year-old fem
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94 Fig. 2. The objective amount of
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96 Duntley PROGNOSIS AND COMPLICATI
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98 Duntley
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100 Attarian EPIDEMIOLOGY There are
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102 Attarian CLINICAL MANIFESTATION
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104 Attarian DIAGNOSTIC WORKUP The
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106 Attarian 13. Hauri, P. J. (1998
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108 Plotkin
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110 Plotkin quality of sleep. Ultim
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112 Plotkin of the therapeutic effi
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114 Plotkin months or years. The ef
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116 Plotkin associated somatic disc
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118 Plotkin Table 1 Causes of Secon
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120 Plotkin Table 1 (continued) Lew
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122 Plotkin REFERENCES 1. Foley, D.
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124 Plotkin 48. Marchetti, F., Rome
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126 Plotkin
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128 Karaz Table 1 DSM-IV Diagnoses
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130 Karaz poor. Focusing only on th
Page 149 and 150: 132 Karaz He felt hopeless that his
Page 151 and 152: 134 Karaz Table 4 Diagnostic Criter
Page 153 and 154: 136 Karaz complained of feeling anx
Page 155 and 156: 138 Karaz other physicians avoided
Page 157 and 158: 140 Karaz 17. Attarian, H. P. (2000
Page 159 and 160: 142 Duntley disorders has been conf
Page 161 and 162: 144 Duntley itance. A recent study
Page 163 and 164: 146 Duntley The patient’s primary
Page 165 and 166: 148 Duntley return to sleep. He tos
Page 167 and 168: 150 Duntley Treatment of RLS should
Page 169 and 170: 152 Duntley 34. Cartwright, R. (197
Page 171 and 172: 154 Perlis et al.
Page 173 and 174: 156 Perlis et al. Fig. 1. A schemat
Page 175 and 176: 158 Perlis et al. ditioned arousal
Page 177 and 178: 160 Perlis et al. subjected to empi
Page 179 and 180: 162 Perlis et al. effect), (3) may
Page 181 and 182: 164 Perlis et al. Cognitive Therapy
Page 183 and 184: 166 Perlis et al. Table 2 Cognitive
Page 185 and 186: 168 Perlis et al. Perhaps more impo
Page 187 and 188: 170 Perlis et al. 28. Carskadon, M.
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Page 191 and 192: 174 Attarian Secondary Insomnias Re
Page 193 and 194: 176 Attarian 50 years of age who sl
Page 195 and 196: 178 Attarian Antidepressants Becaus
Page 197 and 198: 180 Attarian The use of benzodiazep
Page 199: 182 Attarian to placebo. Zaleplon a
Page 203 and 204: 186 Attarian residual sedation foll
Page 205 and 206: 188 Index Clonidine, 183 CNS arousa
Page 207 and 208: 190 Index Proton pump inhibitors, 1
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