A growing number of people are concerned about their sleep in the United States. There are an estimated 40 million US citizens with chronic sleep disorders. The cost to society of sleep disorders has been estimated at greater than $90 billion US dollars. Despite this enormous cost to society, there remains a pervasive lack of attention provided to medical management of this problem. This is compounded by inadequate funding of sleep disorders research. There are treatments available to improve insomnia. These include different behavioral and pharmacologic regimes that can be used separately or in combination. Successful treatment requires thorough knowledge of the differential diagnosis of insomnia. The greatest public health challenge in the management of insomnia is how to develop effective educational programs that will allow the general public to improve their sleep. This will require greater cooperation from primary care providers and the government. Sleep disorders are the most important public health problem not being addressed in the United States.

The effect of treatment (28 days) with zopiclone, triazolam, flunitrazepam and placebo on sleep quality and daytime well-being was proven in a randomised, double-blind, parallel group, multicentre study in private practice. Results of an exploratory statistic of treatment efficacy in a subgroup of 1,291 patients suffering from insomnia are presented. Patients met the following criteria: insomnia lasting at least four weeks and the presence of at least two of the following: 1) sleep latency ≥ 45 minutes, 2) total sleep time ≤ 6 hours, and 3) nocturnal awakening ≥3 times. Treatment efficacy was assessed according to the following factors: either a shortening of sleep latency by at least 15 minutes, or prolongation of total sleep time by at least 20%, or reduction of the number of nocturnal awakenings to three or less and a refreshed feeling in the morning as well as no impairment in daytime well-being due to tiredness or anxiety. The total response rate was markedly higher with zopiclone (42.3%; p = 0.0003) than with placebo (29.0%). Triazolam (36.6%; p = 0.0905) and flunitrazepam (33.1%; p = 0.3401) were also more effective than the placebo, but they both tended to have a lower response rate than with zopiclone (p = 0.1199 and 0.0151, respectively). Total response was found to be essentially a reflection of the response of the socially important parameter of daytime well-being. These results suggest that zopiclone is more effective in the treatment of insomnia than either triazolam or flunitrazepam. Since the response of daytime well-being to therapy was generally poor, this parameter embodies the next main therapeutic challenge in the treatment of patients with insomnia.

This objectives of this study were three-fold: retrospectively evaluate anxiolytic/hypnotic consumption by psychiatric inpatients, identify the risk factors of prolonged intakes, and prospectively measure the impact of hospitalisation on the use of those drugs. Three hundred and seventy-six patients hospitalised in 11 psychiatric departments in the Paris region were studied using a structured interview for the anxiolytic/hypnotic treatments, DSM-III-R criteria, GHQ-12, HAD, Spiegel's questionnaire, COVI's anxiety scale and the CGI. Eighty-five per cent of the patients had taken one anxiolytic/hypnotic or more in the 3 months preceding hospitalisation. Hospitalisation induced little change in anxiolytic/hypnotic use: dosage frequency increased from 77% to 84% between the week preceding hospitalisation and that preceding discharge; 26% of consumers were taking at least two anxiolytics or two hypnotics in the first period vs. 23% in the second. The absence of withdrawal during hospitalisation was related to the high age and a diagnosis of depression rather than schizophrenia, to the existence of continuous intake over the 3 months preceding hospitalisation and to higher drug doses during the 7 days preceding hospitalisation. Prescription of treatment at the end of hospitalisation in previously non-user subjects was related to a higher HAD anxiety score at discharge.

The efficacy of zolpidem, a non benzodiazepine hypnotic agent with a short elimination half life, was reviewed, analysing more than 50 international clinical trials published since 1986. The hypnotic activity of zolpidem has been explored in different patient populations including normal volunteers, general practice outpatients and psychiatric out- or in-patients with varying sleep disorders; both transient and chronic. Assessment methods used have included objective and subjective measures of hypnotic efficacy for different treatment durations, with results confirming that 10 mg is superior to placebo. Zolpidem was shown to be superior in most trials on sleep parameters such as total sleep time, sleep onset latency and nocturnal awakenings, but total REM sleep and REM latency were usually unmodified. Zolpidem maintained normal sleep physiology as demonstrated by the preservation of slow wave stages and no, or minimal, effects on sleep architecture after abrupt discontinuation. Consequently, 10 mg is the recommended dose for the short-term treatment of insomnia in the non-elderly; in elderly patients 5 mg has been shown to be effective at inducing sleep whilst giving an optimum safety profile.

Different forms of insomnia are present as symptoms of many psychiatric and other disorders. The first step for a treatment strategy is therefore a correct diagnosis. As insomnia is more common in patients with psychiatric disorders than in the general population, a careful consideration should be given, depressive and anxiety disorders should especially be carefully investigated. There are reasons to believe that even in so-called insomnia not obviously related to psychiatric disorders, stressful life situations may play a role. Therefore a co-morbidity with emotional disorders which may follow these events is worth considering. Insomnia should always be considered as pan of a sleep-wake schedule disturbance and this has an impact on the importance of the pharmacological properties of the drugs used to treat insomnia. The recent trend for more specific agents both on receptor sub-populations and on relevant sites of the GABA receptor complex will help very much in selecting the most appropriate drug for treating patients.

Increases in psychosocial stress and disruption of the biological clock due to irregular sleep-wake schedules as well as an increase in the elderly population have resulted in an increase in sleep disorders, most notably insomnia. In order to manage insomnia, correction of a poor sleep environment is of primary importance. We now have many good GABA A receptor agonists such as benzodiazepines and cyclopyrrolones (zopiclone) for use as hypnotics, but to achieve improvements in nocturnal sleep and restoration of daytime functions, short- or ultra-short acting hypnotics are recommended. Zopiclone has been reported to show weaker effects on sleep architecture than other benzodiazepines and does not exacerbate mild or moderate sleep apnea syndrome. Some patients are therapeutic-dose dependent on hypnotics or anxiolytics without showing detectable side effects. It may be possible for some insomniacs, particularly forelderly people, to use the minimum necessary dose of hypnotics to achieve good sleep and live a happy life from the standpoint of good quality of life.

The effect of zopiclone (7.5 mg) on attention, vigilance and memory components was evaluated during a nocturnal period in comparison to a placebo, to zolpidem (10 mg) and to flunitrazepam (1 mg) in a double blind, randomized study, after administration of a single dose in 16 young healthy volunteers. It appears that there is a clear effect on attention and vigilance; this effect is apparent during the kinetic phase of the absorption of the medication. The effect on memory is transient and is absent four hours after the ingestion of the drug. The objective results are not strictly consistent with the chronology of the subjective parameters (Leeds scale — Visual Analogue Scale). The three hypnotics under comparison do not fundamentally differ except in their kinetic/pharmacodynamic effect relationship. One important fact, taking the parameters as a whole, is that there is no objective “residual” effect.

A survey of the history of psychopharmacotherapy is presented.

In Antiquity some psycho-active plant extracts were already known . Since the rise of chemistry in early nineteenth century, sedative drugs were synthesized first. Since the fifties of this century the four groups of psychotherapeutic drugs proper, anxiolytics, hypnotics, antipsychotics and antidepressants have been discovered.

Astute clinical or preclinical observation and the understanding of coincidences, serendipity, has been the basis of these discoveries. Since the prototypes were discovered, no real breakthroughs have been achieved.

The present review deals with preventive and treatment strategies for sleep and wake disorders, and the other problems of shift workers. Management must take into account the direction, speed and other parameters of the rotation schedule. Good sleep-wake hygiene may alleviate the problems. Further, additional napping may compensate – at least partially – for sleep deprivation and fatigue. Hypnotics must be avoided as much as possible. Finally, new techniques for manipulation of circadian rhythms are discussed: light, melatonin and benzodiazepines.

Hsu W-Y, Chiu N-Y, Liu J-T, Wang C-H, Chang T-G, Liao Y-C, Kuo P-I. Sleep quality in heroin addicts under methadone maintenance treatment.

Background: Sleep disturbance is a common phenomenon among opiate addicts. The side effects of opiate addiction or opiate withdrawal might result in sleep disturbance. However, their problems might be related to sedative medication abuse, alcohol abuse or heroin relapse. Sleep is an important issue in this population.

Objective: To evaluate the prevalence of sleep disorders in heroin addicts receiving methadone maintenance treatment (MMT) and analyse the correlation between related factors, such as age at opiate exposure, opiate exposure duration, duration in MMT, methadone current dosage, methadone attendance rate and the severity of sleep disorders.

Method: We enrolled 121 heroin addicts who were receiving MMT. We collected data on the duration of insomnia, hypnotic history, Visual Analogue Scale-10 of sleep quality, Pittsburgh Sleep Quality Index (PSQI), methadone dosage, methadone history and opiate history.

Results: The mean of the PSQI was 9.1 ± 5.4, and 70.2% of patients had PSQI scores >5, indicating they were poor sleepers. We also found the PSQI scores were correlated significantly with the methadone dosage.

Conclusions: The sleep disturbance prevalence rate of opiate addicts under MMT was high in Taiwan, as shown in the previous studies, and the severity of sleep disturbance has been underestimated.

Insomnia and other sleep disturbances are common in older people, with up to 40% reporting some difficulty sleeping. Insomnia is a syndrome with multiple causes including medications, other illnesses and environmental factors. An accurate diagnosis is needed for effective management. Sleep disturbances are associated with functional and cognitive impairment and excess mortality. Management should initially be non-pharmacological including sleep hygiene education and behavioural therapy. Medications, including benzodiazepines (BZDs), are second-line with little evidence to support long-term usage. BZD usage in older people is associated with a range of disorders including falls, accidents and cognitive impairment. The management of insomnia in specific situations such as residential care, those with dementia and depressed older people can be challenging. Additional research is needed, particularly on the risks/benefit of long-term pharmacotherapy and to determine whether therapy reduces the consequences of sleep disturbances.

This study investigates the effects of chronic use of benzodiazepines (BZ) as hypnotics on the neuropsychological performance of older adults with insomnia. Twenty-one older persons who had used BZ on a chronic basis (average duration = 21.7 years) for their sleep difficulties were enrolled in a medication withdrawal program. A neuropsychological evaluation was conducted before and after the taper program. A control group composed of older adults not using BZs and without sleep complaints were also evaluated for comparative purpose. The results showed that prolonged use of BZ produces mild and selective impairments of cognitive and psychomotor performance. However, BZ users subjectively evaluated their own performance much more negatively than good sleepers. The results are discussed in terms of a possible amplification of performance deficits among insomnia patients and also as a tolerance to adverse effects that develops with prolonged utilization of BZ.

Objective: To examine the current pattern of use of psychotropic medication in Sydney nursing homes and compare this with the pattern noted 5 and 10 years earlier.

Method: Data were recorded from medication cards concerning psychotropic medications prescribed for the 3093 residents in the 51 nursing homes in the Central Sydney Health Area. Documented diagnoses and demographic details were noted from their clinical files.

Results: In late 2003, 47.2% of residents were taking one or more psychotropic drug regularly and another 3.5% had been given “as required” (prn) doses at least once in the preceding 4 weeks. Fewer residents were taking hypnotics (11.3%) and anxiolytics (4.1%) regularly, when compared to 1998, but more were taking antidepressants (20.5%). Selective serotonin reuptake inhibitors were prescribed to 11.4%, venlafaxine to 2.6%, mirtazapine 1.6% and tricyclics to 3.6%. Although the proportion taking antipsychotics had not fallen since 1998, there were over twice as many residents (16.4%) taking atypical neuroleptic medication in 2003 as there were taking conventional neuroleptics (8.1%). Most of them did not have schizophrenia.

Conclusions: There have been further reductions in the use of hypnotics and anxiolytics in Sydney nursing homes, with increased prescription of antidepressants and a striking change towards use of atypical rather than conventional neuroleptic medication.

In this double-blind placebo controlled study the preoperative cardiovascular and metabolic effects of intramuscular (i.m.) clonidine and midazolam are assessed. Forty-five ASA Grade I patients (n = 15 per group) undergoing plastic surgical procedures were randomly allocated to receive either placebo, clonidine 4 μg kg−1 or midazolam 70 μg kg−1. Drugs were administered into the deltoid muscle [thkap ]90 min prior to the scheduled induction of anaesthesia. The metabolic measurements were performed using an indirect calorimetry device. Heart rate and blood pressure were measured noninvasively. Pre-operative subjective anxiety, dryness of mouth and tiredness were assessed using visual analogue scales (VAS). Clonidine increased subjective tiredness significantly more than placebo. Clonidine also induced moderate decreases in blood pressure and heart rate. Oxygen consumption (̇VO2), CO2) production and energy expenditure (EE) decreased significantly after clonidine and midazolam. The decrease in ̇VO2) and EE was maximally 11–14% on average from the base-lines after clonidine and midazolam. These effects were of longer duration after clonidine and lasted until the end of the 90 min study period. In conclusion, both clonidine and midazolam are effective as a means of decreasing pre-operative ̇VO2) and EE.