慢性失眠及

安眠藥物的使用個案描述一28歲的王先生，唸?？茣r期開始就有經(jīng)常睡不好，經(jīng)常得要躺超過一個小時才能入睡，遇到有考試壓力或者和朋友之間有些爭執(zhí)時就更不好睡，就算睡著了，一有聲響很容易就醒過來，又得躺好一陣子才能再入睡。學(xué)校畢業(yè)後因為家庭經(jīng)濟(jì)因素開始工作，睡眠狀況還是不理想。王先生曾經(jīng)在一般開業(yè)醫(yī)師診所處方過安眠藥，效果還不錯。但是他很擔(dān)心常用會成癮，總是盡量不用安眠藥，有時一整個星期都沒有一天睡得好。他聽別人說什麼方法可以治失眠，都會去試，但是效果都不好。到後來每天一天黑就覺得要找一點上床準(zhǔn)備睡覺，但是又覺得害怕、怕那一天又會睡不好或睡不著…。長期下來，白天不但會常頭暈，而且越來越?jīng)]耐性，常常提不起勁來，感覺自己快要垮了，近半年來已經(jīng)把休假請光，還請了不少病假，最近才由朋友介紹到精神科看門診。個案描述二36歲的陳女士離婚後因為背負(fù)卡債及家庭經(jīng)濟(jì)重?fù)?dān)，有入睡困難和睡眠中斷的睡眠障礙已有4、5年。剛開始看精神科時，吃1、2顆安眠鎮(zhèn)靜藥物就可以睡上幾個小時，但是總覺得睡不夠，半夜一醒過來就再吃2顆，有時已經(jīng)塞了7、8顆安眠藥還是睡不好。後來藥不夠時她就到另一家醫(yī)院的精神科開藥。雖然有醫(yī)師建議她應(yīng)該要嘗試其他改善睡眠的方法，並且控制使用安眠藥，但是她就是擔(dān)心不吃睡不著，雖然她也知道其實吃了也不一定睡得好，有時候就乾脆把安眠藥配著啤酒吃，最近喝酒的量也漸漸多起來。InsomniaHasSeveralDefinitionsNHLBI.AmFamPhysician.1999;59(abstract).DifficultyfallingasleepNext-day

consequencesDifficultystayingasleepNon-refreshingsleepEarlymorningawakenings+GivenadequateopportunitytosleepChronicInsomnia:DefinitionChronicinsomniavs.AcuteinsomniaAcuteinsomniamayoccurinanyoneatonetimeoranotherVarieddefinitionsforchronicinsomniaDurationsrangingfrom30days–6monthsChronicinsomniaisoftenassociatedwithawiderangeofadverseconditionsincluding:MooddisturbancesDifficultieswithconcentrationandmemorySomecardiovascular,pulmonary,andgastrointestinaldisordersNIHStatement.Sleep.2005;28:1049-1057.Insomniaisthemostcommonsleepcomplaintacrossallstagesofadulthood,andformillions,theproblemischronicInsomniacanbeasymptomofotherdisorders,likedepression,oritcanbeaprimarydisorderinitselfTheMajorityofInsomniacsisChronicallyIllMildinsomniaSevereinsomniaInsomnia(DSM-III-R)Elderly,difficultyfallingasleepElderly,disturbedsleepcontinuity%%%%%Mean68%%IsomniacswithPersistenceofComplaintsinTwo-YearsFollow-UpinPrimaryCareSurveysGangulietal.1996;Hohagenetal.1993;KatzandMcHorney1998ChronicInsomnia:ConsequencesSomeevidencesuggestsarelationshipbetweenchronicinsomniaandimpairedmemory,cognitivefunctioning,anddepressedmoodChronicInsomniaConsequencesAssociatedwithhigh

healthcareutilizationDirectandIndirectCosts:estimatedinthetensofbillionsofdollarsannuallyQualityofLifeReducesqualityoflifeHinderssocialfunctioningRelatedtoimpairedworkperformanceNIHStatement.Sleep.2005;28:1049-1057.ComorbiditiesSeldomappearswithoutoneormoreotherdisordersCommoncomorbidities:depression,generalizedanxiety,substanceabuse,attentiondeficit,andavarietyofphysicalproblemsPublicHealthBurdenDifficulttoevaluatebecauseliteratureisnotdevelopedFocusisonpopulationsratherthanpeopleComorbidPsychiatricDisordersWithInsomnia*P<.001comparedwiththosewithnosleepcomplaint.?P<.05comparedwiththosewithnosleepcomplaint.FordDEetal.JAMA.1989;262:1479-1484.Percentage****??MedicalConditions

AssociatedWithInsomnia*P≤.001;?P≤.05.?P≤.01.CHF=congestiveheartfailure;COPD=chronicobstructivepulmonarydisease.KatzDAetal.ArchInternMed.1998;158:1099-1107.??*?*????AdjustedOddsRatio?ImpactofInsomniaonPhysicalandEmotionalHealthandSocialFunctioning*Scalerangesfrom0to100,withhigherscoresreflectinggreaterqualityoflife.AdaptedfromZammitGKetal.Sleep1999;22(suppl2):S379-S385.

SF-36Subscales**P<0.0001GreaterInterferenceImpactofInsomniaintheWorkplaceDaytimefunctioningandlossofproductivityTwotothreetimesasmanydaysofpoorproductivityandconcentrationinindividualswithinsomniaasingoodsleepersAbsenteeismSevereinsomniacswereabsentfromworktwiceasoftenasgoodsleepersWorkaccidentsSeventimeshigherrateofworkaccidentsininsomniacsthaningoodsleepersMetlaineA,etal.IndustrialHealth.2005;43:11–19.TherapeuticGoalsinTreatingInsomniaSleepOnsetSleepMaintenanceNumberofawakeningsDurationofawakeningsTimetofallasleepSleepDurationTotalsleeptimeAlertnessFunctioningVitalityNext-DayFunctioningChronicInsomnia:

TreatmentConsiderationsTREATMENTCognitiveBehavioralTherapy(CBT)BenzodiazepineReceptorAgonist

BenzodiazepinesNon-BenzodiazepinesAntidepressants*AtypicalAntipsychotics*OTCAlternativeMeds:MelatoninandHerbalRemedies*NotFDAapprovedfortreatmentofinsomnia

NIHStatement.Sleep.2005;28:1049-1057.TreatInsomniawithDrugsBeforetreatinginsomniawithdrugs,consider:Istheunderlyingcausebeingtreated(depression,mania,breathingdifficulties,urinaryfrequency,pain,etc.)?Areotherdrugsbeinggivenatappropriatetimes(i.e.stimulatingdrugsinthemorning,sedatingdrugsatnight)?Arethepatient’sexpectationsofsleeprealistic(sleeprequirementsdecreasewithage)?Haveallsleephygieneapproaches(seetablebelow)beentried?GuidelinesforPrescribingHypnoticsUsethelowesteffectivedoseUseintermittentdosing(alternatenightsorless)wherepossiblePrescribeforshort-termuse(nomorethan4weeks)inthemajorityofcasesDiscontinueslowlyBealertforreboundinsomnia/withdrawalsymptomsAdvisepatientsoftheinteractionwithalcoholandothersedatingdrugsAvoidtheuseofhypnoticsinpatientswithrespiratorydiseaseorseverehepaticimpairmentandinaddiction-proneindividualsPrescribingGuidelines,TheMaudsley,2007Insomnia:ChallengesforPhysicians

InitiatingTreatment

InsomniaischallengingforcliniciansbecauseofthelackofguidelinesforassessmentandtreatmentGeneralpopulation’spoorunderstandingoftheimportanceofinsomniaandavailabletreatmentsFortypercentofinsomniacsself-medicateeitherwithover-the-countermedicationsorwithalcoholOnly0.9%ofpatientsinalargemanagedcaregroupreportedvisitingaphysicianspecificallyforsleepproblemsYet,34.2%ofthesepatientsreportedsymptomsofinsomniaOnein3patientsseekinghealthcareislikelytohaveinsomniawithdaytimedysfunction,butisunlikelytoseekcareforthatspecificproblemBencaRM.PsychiatrServ.2005;56:332–343.Ancoli-IsraelS,RothT.Sleep.1999?22(suppl2):S347-S353.

DoghramjiPP.JClinPsychiatry.2004;65(suppl16):23-26.Insomnia:ChallengesforPhysiciansInaninternationalstudyofconsequencesofinsomniaovera12-monthperiodManyrespondentstooknoactiontoalleviatetheirinsomniasymptoms,andthismaybeduetofearoftheimplicationsoftreatment,includingthepossiblerisksofdependenceonmedicationsFocusgroupsofpatientsdescribingtheirinsomniaexperiencereportedthattheyfeltthattheimpactofinsomniaontheirliveswaspervasiveandmisunderstoodbyotherswhoweresignificanttothemortreatingtheirsleepcomplaintsMoreresearchisnecessarytodeterminethelong-termeffectsofinsomniatreatmentsCurrenttreatmentoptionsdonotaddre