Insomnia Is Chronic in the Majority of 2006 Insomniacs (%) 11.5% Hsu SC et al (unpublished) 10% 13.4% N=4011 n=4, % of 14,915 Tel. Survey

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1 What Is Insomnia? Tel: ext.2479 ICSD 2, 2005 Diagnosis Criteria for Insomnia Disorder Sleep-related complaints Difficulty initiating sleep Difficulty maintaining sleep Waking up to early Sleep that is chronically nonrestorative or poor in quality Despite adequate opportunity and circumstance for sleep Sleep insufficiency Insomnia Diagnosis Criteria for Insomnia Disorder (cont d) At least one of the following forms of daytime impairment: Fatigue/malaise Attention, concentration, or memory impairment Social/vocational dysfunction or poor school performance Mood/disturbance/irritability Daytime sleepiness Motivation/energy/initiative reduction Proneness for errors/accidents at work or while driving Tension headache and/or GI symptoms in response to sleep loss Concerns or worries about sleep ICSD 2, Hsu SC et al (unpublished) N= ~59 30

2 Insomnia Is Chronic in the Majority of 2006 Insomniacs (%) 11.5% Hsu SC et al (unpublished) 10% 13.4% N=4011 n=4, % of 14,915 Tel. Survey Respondents Reported Insomnia patients with insomnia at psychiatric sleep clinic 2 Percent of Insomniacs Duration of Insomniacs 1 Ohayon MM, Roth T. J Psychiatr Res Hsu SC et al. APSS 2005 Persistent Insomnia Is Associated With an Increased Risk of Psychiatric Disorders % Patient Odds ratio adjusted for sex, age, socioeconomic status, race, and marital status with no insomnia the reference P<.001 compared with no insomnia P<.01 compared with no insomnia P<.05 compared with no insomnia At 1-Year Follow-Up Ford DE, Kamerow DB. JAMA. 1989

3 Frequency of insomnia report in patients with OSAHS 105 OSAHS patients 41 (31%) insomnia ISI 15 Sleep complaints: duration more than 6 months SOL or WASO longer than 30 min on PSG At least one negative daytime consequence Smith S et al. Sleep Med.2004 Restless Legs Syndrome (RLS) 1. Did you have the uncontrollable sensation of urge to move the legs? 2. Did the sensation of urge to move the legs occur or exacerbate when you are sitting or lying down? 3. Did the symptoms of urge to move the legs can be relieved when get up and walks around? 4. Comparing to daytime, did the symptoms of urge to move the legs worsen at evening or night? ICSD-2, 2005 Prevalence of Chronic Insomnia in RLS Medical Causes of Insomnia Status Prevalence RLS (4 criteria) No RLS Total Chronic insomnia 31.75% 11.75% 12.07% p<0.05 p<0.05 Chen NH et al (unpublished) Thase ME Gen. Hosp. Psychiatry, 2005

4 Medical Causes of Insomnia (cont d) Commonly Prescribed Drugs Associated with Insomnia Thase ME Gen. Hosp. Psychiatry, 2005 Thase ME Gen. Hosp. Psychiatry, 2005 Circadian rhythm sleep disorder Reite M. et al Concise Guide to Evaluation and Management of Sleep Disorder 2nd 1997 P.51 A Comparison of Rates of Residual Insomnia Following Pharmacotherapy or CBT for Major Depressive Disorder 88% 51% 90% 53% 87% 50% The Causes of Primary Insomnia or Comorbid Insomnia % Pre- and post-treatment of insomnia in those completing treatment and remitting from depression Carney et al. J Clin Psychiatry 2007

5 Factors in The Development of Chronic Insomnia Sleep Disturbance Intensity Predisposing Precipitating Perpetuating Spielman AJ et al Psychiatr Clin of North Am1987 Insomnia Threshold A Micro-Analytic Model of Chronic Insomnia Arousal Emotional Cognitive Physiologic Dysfunctional Cognitions Worry over sleep loss Rumination over consequences Unrealistic expectations Misattribution/amplification Maladaptive Habits Excessive time bed INSOMNIA Irregular sleep schedule Daytime napping Sleep-incompatible activities Consequences Mood disturbances Fatigue Performance impairments Social discomfort 带着暂时着进们当时时间 5; ;00 饭觉时间须许学习学习务试着动给写这为这样学觉间压满爱庆虽学习时着头脑处兴奋状报这会样没齿态学压学习课时难贫农过着 9:00--11:00 间脑会们县点这学响这样况撑毕业时着学强学习学习点脑终处奋状态着当级学试孙长时间没来着这时续为时个强顿时胀强愤绪满间责 4 个学习够这愤压绪续 3 个学压调国内处医觉带这强绪开发现药济统兴奋觉时头脑兴奋绝对势为习惯实这时开该办这从从过来总惫时见说梦话着这样为变过烦为过劳动过饮对这总结说这为对进诊谢时间来续 4 碍浅总将压虑绪 Management of Insomnia 1.Treatment of Primary Cause Mental disorders, Physical condition, Substance or Drug, Specific Sleep Disorders etc. 2.Insomnia, esp. primary insomnia Nonpharmacological treatment Sleep hygiene Cognitive behavior therapy Pharmacological treatment nightly sedating agent use non-nightly sedating agent use Combination therapy

6 Sleep regulation Management of Insomnia 1.Treatment of Primary Cause Mental disorders, Physical condition, Substance or Drug, Specific Sleep Disorders etc. 2.Insomnia, esp. primary insomnia Nonpharmacological treatment Sleep hygiene Cognitive behavior therapy Pharmacological treatment nightly sedating agent use non-nightly sedating agent use Combination therapy Comparisons of scores on the Sleep Hygiene Practice Scale (SHPS) between insomnia patients and good sleepers. Management of Insomnia SHPS Scores Sleep Schedule Arousal-related Behavior Drinking / Eating Sleep Environment Total Score Insomniac Mean SD Good Sleeper Mean SD t-value p Treatment of Primary Cause Mental disorders, Physical condition, Substance or Drug, Specific Sleep Disorders etc. 2.Insomnia, esp. primary insomnia Nonpharmacological treatment Sleep hygiene Cognitive behavior therapy Pharmacological treatment nightly sedating agent use non-nightly sedating agent use Combination therapy Yang CM et al. SLEEP 2006

7 ----- Stimulus Control Therapy Stimulus Control Therapy Number of times out of bed Days of Therapy Bootzin et al Behavioral treatments for insomnia. Progress in behavior modification 1978 Management of Insomnia 1.Treatment of Primary Cause Mental disorders, Physical condition, Substance or Drug, Specific Sleep Disorders etc. 2.Insomnia, esp. primary insomnia Nonpharmacological treatment Sleep hygiene Cognitive behavior therapy Pharmacological treatment nightly sedating agent use non-nightly sedating agent use Combination therapy

8 Benzodiazepines Benzodiazepines 93/3/16 93/3/16 History of Hypnotics Launching Time Half-life 1912 Phenobarbital 1963 Diazepam 1965 Nitrazepam 1975 Flunitrazepam 1977 Flurazepam 1978 Lormetazepam 1978 Temazepam 1981 Triazolam 1987 Zopiclone 1989 Zolpidem 1998 Zaleplone Mechanism of Action of Zolpidem As Needed Pharmacotherapy Combined With Stimulus Control Therapy(n=2690) Zolpidem ω1 Receptor Benzodiazepines ω2 Receptor % Patients Global Improvement (CGI) 77 Much or very much improved 22 Minimal or no improvement 1 Worse or much worse Zolpidem as needed + stimulus control Hajak et al., 2003

9 Number of Tablets Tablet intake per week Week 1 Week 3 Hajak et al., 2003 Morin et al. (1999), JAMA Indication of Polysomnography Hypersomnia or excessive daytimes Sleepiness Sleep apnea syndrome Periodic limb movements disorder Confirmed the diagnosis of parasomnia Sleep walking disorder, REM sleep behavior disorder etc. Insomnia: not indication in clinical practice, for exclusion the possibility of sleep apnea or periodic limb movements disorders etc.

10 Retino-hypothalamic Tract Pineal Gland Tel: ext.2479 Suprachiasmatic Nuclei Hypothalamus Pressman&Orr Understanding sleep1997 Spielman et al Treatment of chronic insomnia by restriction of time in bed. Sleep 1987

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