Treatment of Insomnia (Extended Abstract)

David J., Kupfer M.D. and Charles F. Reynolds III, M.D.

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IN This review by American authors provides recommendations on the practical treatment of insomnia and the scientific basis of modern treatment methods. Insomnia tends to increase with age and is more prevalent among women, although laboratory studies show that older men are more likely to suffer from sleep disturbances. People who are divorced, widowed, or separated are more likely to report experiencing insomnia than those who are married; low socioeconomic status is also associated with insomnia. Persistent insomnia is a risk factor and a harbinger of depression. Thus, effective treatment of insomnia may provide an opportunity to prevent serious depression. Chronic insomnia is also associated with an increased risk of car accidents, increased alcohol consumption, and sleepiness during the day. Therefore, patients suffering from insomnia deserve serious attention.
The duration of insomnia in a patient has important diagnostic significance. Short-term insomnia, lasting only a few days, is often the result of severe stress, acute illness, or self-medication. Insomnia that lasts more than three weeks is considered chronic and usually has a variety of causes. Diagnostic and pharmacotherapeutic conclusions depend on whether symptoms are short-lived or chronic.
A diagnosis of chronic primary insomnia is made when inducing or maintaining sleep is difficult, or when restorative sleep has failed for at least an entire month, causing significant distress or reduction in social, occupational, or other important functioning. The sleep disturbance of primary or psychophysiological insomnia is not caused by another cause of sleep disturbance, a mental disorder, or the influence of a medication.
Doctors should try to determine the cause of insomnia.
The first step is to identify the main sleep symptom - for example, insomnia, excessive sleepiness or restless behavior during sleep. Doctors should then consider possible causes, which include: underlying disease conditions or their treatment; the use of substances such as caffeine, nicotine or alcohol; mental disorders (state of anxiety, fear); acute or chronic stress, such as occurs as a result of bereavement (loss of loved ones); disruption of circadian rhythms (caused by night shifts); apnea (accompanied by snoring or obesity); nocturnal myoclonus (convulsive muscle twitching), etc.
The most common obstacle to diagnosis is difficulty understanding that chronic insomnia has many causes.

Behavioral therapy

Patients should be taught to go to bed only when they are sleepy and to use the bedroom only for sleep and sex and not for reading, watching TV, eating, or working. If patients cannot fall asleep after 15 to 20 minutes in bed, they should get out of bed and move to another room. They should read in low light and avoid watching television, which emits bright light and therefore has a stimulating effect; Patients should return to bed only when they feel sleepy. The goal is to restore the psychological connection between the bedroom and sleep, not between the bedroom and insomnia. Patients should get out of bed at the same time every morning, regardless of how much sleep they had the previous night. This stabilizes your sleep-wake schedule and improves sleep efficiency. Finally, short naps during the day should be minimized or avoided altogether to increase the desire to sleep at night. If the patient requires a nap during the day, a 30-minute nap at midday will probably not disturb sleep at night.
Another useful behavioral intervention that has been shown to be effective is limiting time in bed to actual sleep time. The effectiveness of this approach, known as sleep restriction treatment, was demonstrated in a randomized clinical trial conducted with older adults. This method allows for a slight “sleep debt,” which increases the patient's ability to fall asleep and stay asleep. The time allowed for staying in bed is gradually increased, as much as is required for proper sleep. For example, if a patient with chronic insomnia sleeps 5.5 hours at night, his time in bed is limited to 5.5-6 hours. The patient then adds approximately 15 minutes per week to the start of each night's time in bed, rising at the same time each morning, until he is asleep at least 85% of the time in bed.

Treatment with drugs

Rational pharmacotherapy of insomnia, especially chronic insomnia in adults and the elderly, is characterized by five basic principles: use the lowest effective doses; use intermittent dosage (two to three times a week); prescribe medications for short-term use (i.e., regular use for no more than three to four weeks); stop using the medicine gradually; and ensure that insomnia does not recur after it has stopped. In addition, drugs with a short half-life are generally preferred to minimize daytime sedation. Alcohol and over-the-counter drugs (such as antihistamines) have only a minimal effect in inducing sleep, further interfering with sleep quality and adversely affecting performance the next day. In table 1 lists the sedative-hypnotic drugs that are commonly prescribed, with information regarding dosage (adults and geriatrics), onset of action, half-life, and the presence or absence of active metabolites. In table Table 2 lists the most common medications that interfere with sleep.
Table 1. Medicines commonly prescribed

for the treatment of insomnia

Considering clinical effectiveness trials in adults with chronic insomnia, the authors reviewed 123 controlled trials of drug treatment (total number of 9114 patients) and 33 controlled trials of behavioral intervention treatment (1324 patients). American researchers concluded that subjective symptoms and objective signs of chronic insomnia respond to short-term behavioral and pharmacological interventions. Both types of intervention typically reduced the amount of time it takes to fall asleep by 15 to 30 minutes compared to the time before treatment, and the frequency of waking up by one to three times per night. Although pharmacological interventions appear to work more reliably in the short term and behavioral interventions appear to produce longer-lasting effects, direct comparisons based on long-term effectiveness are lacking. Based on data from controlled trials, benzodiazepines, zolpidem, antidepressants, and melatonin (only one controlled trial) are effective pharmacological agents. Stimulus control, sleep restriction, relaxation strategies, and cognitive behavioral therapy are effective behavioral interventions for short-term treatment.
Table 2. Commonly prescribed medications that

known to cause insomnia

The authors monitored randomized, double-blind trials in elderly patients with chronic insomnia from various causes. In 23 trials involving 1,082 patients, including 516 psychogeriatric patients or residents of nursing homes, Pittsburgh psychiatrists found scientific support for the short-term (up to three weeks) effectiveness of zolpidem and triazolam in the elderly, as well as temazepam, flurazepam and quazepam , but not chloral hydrate.
The half-life of sedative-hypnotics has wide variability. Side effects such as decreased mental capacity, weakness, excessive drowsiness and accidents occur much more frequently at high doses and when active metabolites accumulate. Flurazepam and quazepam have the longest half-lives (36 to 120 hours) and therefore have the advantage of providing next-day anxiolytic effects and reducing the likelihood of relapse of insomnia. However, long-term use of these drugs can lead to daytime sleepiness, impaired cognition and coordination, and worsening depression. Drugs with an intermediate half-life (10 to 24 hours) without active metabolites include temazepam and estazolam. They are less likely to be associated with excessive daytime sleepiness. Drugs with a very short elimination period (2 to 5 hours) include triazolam and zolpidem.
The effectiveness of zolpidem, one of the imidazopyridines, was found to be similar to that of benzodiazepines in studies of acute and chronic insomnia. Although zolpidem and benzodiazepines exert their effects through modulation of the GABA (gamma-aminobutyric acid) receptor complex, zolpidem rather than benzodiazepines is less likely to disrupt sleep patterns and have adverse effects on cognition and psychomotor abilities (and may have less effect on withdrawal symptoms). Although these potential benefits suggest that zolpidem may be useful in the treatment of acute and chronic insomnia because it acts through the GABA receptor complex, it theoretically carries the same risk of dependence as benzodiazepines and, as a result, its use for more than 4 years weeks is usually not encouraged.
Before prescribing any sleeping pills, a physician should consider basic safety concerns. For example, pregnant women, patients with possible sleep apnea, which may be aggravated by the use of sleeping pills, and patients with kidney or liver failure may be at greater risk of side effects sedatives. Physician concerns about possible dependence on benzodiazepines and zolpidem and their side effects, along with monitoring needs such as writing triplicate prescriptions, have led to last years to a 30% reduction in benzodiazepine prescriptions and a 100% increase in the use of antidepressants as sleep aids.
Serotonin-specific antidepressants, such as trazodone and paroxitene, improve the sleep disturbance that accompanies depression and have fewer side effects than tricyclic antidepressants. The beneficial effects of serotonin-specific antidepressants in chronic insomnia have not yet been systematically evaluated. It is possible that the use of treatment with a safe serotonergic antidepressant could reduce the burden of chronic insomnia and prevent dangerous depression. Antidepressants are now widely used, and are prescribed in lower doses, to treat insomnia than for depression. This practice has spread in the absence of controlled clinical trial data. It is possible that using a low-dose antidepressant treatment (eg, 20 mg paroxythene per day) may both improve sleep and help prevent depression in chronic insomnia.

Description:

Insomnia is a disorder characterized by difficulty falling asleep or staying asleep. Moreover, insomnia is characterized by poor sleep quality, causing physical and emotional symptoms during the daytime, which affects social and cognitive functioning.

Insomnia is a common disorder that is difficult to diagnose and treat, requiring clear strategies and planning. Insomnia, whether it is a symptom, a syndrome or an independent disorder, has serious professional, social consequences and imposes a significant economic burden on society. The Brazilian Sleep Association has developed new guidelines for the diagnosis and treatment of insomnia in adults and children, which were published in the journal Arquivos de Neuro-Psiquiatria (2010; 68 (4): 666-675). The paper discusses general issues related to sleep problems, as well as methods of clinical and psychosocial assessment, diagnosis, selection and prescription of drug and psychotherapeutic treatment.

In November 2008, at the initiative of the Brazilian Society of Sleep Medicine, various specialists in the field of sleep medicine were invited to Sao Paulo to discuss the creation of new guidelines for the diagnosis and treatment of insomnia. At this event, the following topics were discussed: clinical and psychosocial verification of diagnosis, recommendations for polysomnography, pharmacological treatment, behavioral and cognitive therapy, concomitant pathology in children.

Types of insomnia (insomnia):

1. Adaptive insomnia (acute insomnia). This sleep disorder occurs due to acute stress, conflict or environmental change. The consequence is an increase in the overall activation of the nervous system, making it difficult to fall asleep when falling asleep in the evening or waking up at night. With this form of sleep disturbances, the cause that caused them can be determined with great confidence; adaptive insomnia lasts no more than three months.

2. Psychophysiological insomnia. If sleep disturbances persist for a longer period, they become overgrown with psychological disorders, the most typical of which is the formation of “fear of sleep.” At the same time, somatized tension increases in the evening hours, when the patient tries to “force” himself to fall asleep quickly, which leads to worsening sleep disturbances and increased anxiety the next evening.

3. Pseudo-insomnia. The patient claims that he sleeps very little or does not sleep at all, however, when conducting a study that objectifies the picture of sleep, the presence of sleep is confirmed in an amount exceeding what is subjectively felt. Here, the main symptom-forming factor is a disturbance in the perception of one’s own sleep, associated primarily with the peculiarities of the sense of time at night (periods of wakefulness at night are well remembered, and periods of sleep, on the contrary, are amnesic), and fixation on one’s own health problems associated with sleep disturbance.

4. Idiopathic insomnia. Sleep disturbances in this form of insomnia have been observed since childhood, and other causes of their development are excluded.

5. Insomnia in mental disorders. 70% of patients with neurotic mental disorders have problems initiating and maintaining sleep. Often, sleep disturbance is the main “symptom-forming” radical, due to which, according to the patient, numerous “vegetative” complaints develop (headache, fatigue, palpitations, blurred vision, etc.) and social activity is limited.

6. Insomnia due to poor sleep hygiene. In this form of insomnia, sleep problems occur in the context of activities that lead to increased activation of the nervous system in the periods preceding bedtime. This could be drinking coffee, smoking, physical and mental stress in evening time or other activities that interfere with the initiation and maintenance of sleep (going to bed at different times of the day, using bright lights in the bedroom, an uncomfortable sleep environment).

7. Behavioral insomnia in childhood. It occurs when children form incorrect associations or attitudes related to sleep (for example, the need to fall asleep only when rocked to sleep, reluctance to sleep in their crib), and when trying to remove or correct them, the child manifests active resistance, leading to a reduction in sleep time.

8. Insomnia in somatic diseases. Manifestations of many diseases of internal organs or the nervous system are accompanied by disturbances in night sleep (hunger pains with peptic ulcer, nocturnal, painful neuropathies, etc.).

9. Insomnia associated with taking medications or other substances. The most common type of insomnia is the abuse of sleeping pills and alcohol. In this case, the development of addiction syndrome (the need to increase the dose of the drug to obtain the same clinical effect) and dependence (the development of withdrawal syndrome when stopping the drug or reducing its dose) is noted.

Accompanying illnesses:

1. Obstructive sleep apnea syndrome.
In 1973, Guilleminolt et al described the association between insomnia and obstructive sleep apnea; This phenomenon became known as “obstructive sleep apnea syndrome.” The relationship between these two common sleep disorders is complex and not fully understood. There is an increased incidence of breathing disorders in patients with insomnia compared to the general population. The severity of insomnia symptoms is directly related to the severity of apnea, thus determining their comorbidity. Listein et al demonstrated that a significant number of individuals, especially older adults, have a combination of these two conditions: undiagnosed sleep apnea and insomnia. Thus, polysomnography can help detect significant breathing disturbances associated with insomnia.
Peri- and postmenopausal women are more likely to suffer from insomnia compared to women of fertile age. Hormone replacement therapy (estrogen and progesterone) can improve sleep quality and have a beneficial effect on the symptoms of obstructive sleep apnea syndrome. Benzodiazepines cause sedation, decreased airway muscle tone, and decreased ventilation, leading to hypoxemia. In this regard, in the presence of obstructive sleep apnea syndrome, the use of drugs in this group is not recommended. The use of various devices to improve airway patency (for example, based on the creation of positive air pressure) also negatively affects the quality of sleep, especially during the adaptation phase.

Under the term “sleep disorder - dyssomnia” in International classification diseases of the 10th revision (ICD-10) is generally understood as a violation of the quantity, quality or timing of sleep, which in turn can lead to daytime sleepiness, difficulty concentrating, memory impairment and anxiety.

To describe sleep disorders, a two-component model was created, taking into account both subjective and objective signs of disorders. The authors of this model proceeded from the following assumption: “the clinical picture of clinical “bad” sleep occurs if and only if a somatic disturbance in the rhythm of sleep and wakefulness coincides with the patient’s increased neurotic tendency to complain.” But this model can also be considered dynamically: an initially organically caused disturbance in the rhythm of sleep and wakefulness can increase reflection and the tendency to complain. On the other hand, external and internal conflict can cause tension or agitation that negatively affects sleep, and disturbed sleep, in turn, can itself have a negative impact on the mental state.

As Yu. A. Aleksandrovsky notes, from the point of view of mental activity, sleep is an extremely important factor, since its deprivation leads to irritability, drowsiness, and difficulties in solving interpersonal and professional problems. Mental exhaustion requires sleep much more often than physical fatigue. However, the ratio of sleep and wakefulness largely depends on the emotional state of a person and his satisfaction with life.

Epidemiological studies conducted abroad indicate that at least 35% (28-45%) of the adult population suffer from sleep disorders (for comparison, according to WHO, patients with diabetes account for 3%, AIDS - 3%). The spectrum of these disorders is wide and includes more than 70 nosological units, closely related to pulmonology, neurology, epileptology, cardiology, pediatrics, resuscitation, otolaryngology and dentistry. Persistent insomnia is a risk factor and predictor of depression. Thus, early diagnosis and effective treatment of insomnia can prevent severe depression, which often leads to suicide. Chronic insomnia is also associated with an increased risk of car accidents and the use of alcohol and other substances. Short-term insomnia, lasting only a few days, is often the result of mental stress, acute illness, or the thoughtless use of various medications for self-medication. Millions of people suffer from disrupted sleep due to social factors related to lifestyle. People who are divorced, widowed or separated, and poor are more likely to suffer from insomnia. Diagnostic and therapeutic implications depend on whether symptoms of disrupted sleep are short-term or chronic.

At the same time, despite the high relevance of studying sleep and the impact of its disturbances on the quality of life, issues of somnology have not yet received sufficient coverage in educational programs for a wide range of practicing doctors.

Diagnosis of sleep disorders should precede treatment.

The modern classification of sleep disorders includes insomnia, hypersomnia and parasomnia. The term “insomnia” has a subjective connotation, while the term “insomnia” is scientifically based. “Insomnia” is defined as a state of difficulty initiating sleep and maintaining it, often in combination with daytime weakness, fatigue, decreased performance and drowsiness. “Insomnia” is a painful symptom and requires a medical approach to diagnosis and treatment. This approach, first of all, requires a differential diagnosis of these disorders. The causes of insomnia are varied: 1) psychophysiological

reactions to stressors; 2) neurotic disorders; 3) endogenous mental illnesses; 4) somatic diseases; 5) abuse of psychotropic drugs and alcohol; 6) endocrine and metabolic diseases; 7) organic brain diseases; 8) syndromes that occur during sleep (sleep apnea syndrome, movement disorders during sleep); 9) pain phenomena; 10) time zone changes; 11) constitutionally determined shortening of night sleep.

The clinical phenomenology of insomnia includes presomnia, intrasomnia, and postsomnia disorders.

Presomnia disorders are problems falling asleep. With the long-term existence of presomnia disorders, obsessive-compulsive symptoms are formed in the form of “bedtime rituals”, “fear of bed”, “fear of inability to fall asleep”. In a polysomnographic study of these patients, a significant increase in the time of falling asleep and frequent transitions from stages I and II of the first sleep to wakefulness are noted.

Intrasomnia disorders include frequent awakenings at night, after which the patient cannot fall asleep for a long time, and a feeling of “shallow” and “shallow” sleep. Polysomnographic correlates of these sensations are a significant representation of superficial stages of sleep (I, II FMS - phases of slow-wave sleep), frequent awakenings, long periods of wakefulness within sleep, reduction of delta sleep, and an increase in motor activity during sleep.

Post-somnia disorders are early awakenings (outside the division of people into “night owls” and “larks”) and disorders that occur shortly after awakening. This group includes poor health immediately after sleep and the phenomenon of “sleep intoxication,” when active wakefulness occurs slowly. With these disorders, patients are dissatisfied with the night they spent and characterize their sleep as

"non-restorative". They experience a feeling of “overwhelm” and reduced performance. Urgent daytime sleepiness, which occurs in 56% of patients, can also be classified as a post-somnia disorder.

The algorithm for the diagnostic process and choice of therapy consists of the following elements

A) Differential diagnosis and identification of causes of insomnia.

First, the leading symptom of sleep disorders is determined - insomnia, excessive sleepiness or restless behavior during sleep. Possible causes of sleep disturbances must then be considered, which include: underlying disease conditions or their treatment; use of substances such as caffeine, nicotine or alcohol; mental disorders (states of depression, anxiety or fear); acute or chronic stress; disruption of circadian rhythms; apnea (accompanied by snoring or obesity); nocturnal myoclonus. Depression, which requires the prescription of antidepressants, requires special attention. In most depressed patients, sleep disorders are manifested by the following symptoms: 1) difficulty falling asleep and interrupted sleep with early

awakening; 2) a decrease in the depth of sleep (slow waves, stages 3 and 4), primarily in the first sleep cycle; 3) shortened first non-REM sleep period (stages 2-4), which leads to premature entry into the first REM sleep phase (shortened REM latency); 4) uniform distribution of REM sleep in all phases of sleep.

B) Consideration of the influence of drugs that cause insomnia.

When identifying the causes of insomnia, internists should take into account the fact that some drugs usually prescribed by general practitioners medical practice(not by psychiatrists) cause sleep disturbances. The following groups of drugs that contribute to the occurrence of sleep disorders are distinguished:

1) antihypertensive drugs;

2) stimulants of the central nervous system;

3) antitumor drugs;

4) beta blockers;

5) hormones;

6) oral contraceptives;

7) thyroid preparations;

8) anticholinergics;

9) sympathomimetic agents;

10) bronchodilators;

11) decongestants;

12) cough and cold medications available over the counter.

B) Behavioral therapy for insomnia.

Treatment of insomnia should begin with hygiene measures aimed at changing behavior. Patients should be taught to go to bed only when they are sleepy, and to use the bedroom only for sleep and intimacy and not for reading, watching TV, eating, or working. If patients cannot fall asleep within 15 to 20 minutes of being in bed, they should get out of bed and move to another room. It is not recommended to watch TV at this time, but read in low light. Patients should return to bed only when they feel sleepy. The goal is to restore the psychological connection between the bedroom and sleep, not between the bedroom and insomnia. If you have sleep disorders, even short sleep during the day should be avoided. Another useful behavioral intervention that has been shown to be effective is limiting time in bed to actual sleep time.

D) Drug therapy for insomnia.

Rational pharmacotherapy of insomnia, especially chronic insomnia, in adult or elderly patients is characterized by five basic principles:

1) use of the lowest effective doses;

2) use of an intermittent intake regimen (two to three times a week);

3) prescribing a medication for short-term use (i.e., regular use for no more than three to four weeks);

4) stopping the use of medications gradually;

5) ensure that insomnia does not recur after stopping medication.

The attending physician's awareness of the properties of certain sleeping pills contributes to the correct choice of sleeping pills. Preferred drugs are those that do not disrupt sleep structure, selectively act on the symptoms of insomnia, have a short half-life, and do not cause behavioral toxicity and dependence due to the euphoric effect. When prescribing therapy, previous experience in treating and self-medicating patients with insomnia should be taken into account. The most common history of patients suffering from insomnia is that doctors can identify self-medication with alcohol and over-the-counter drugs. Alcohol and antihistamines, commonly taken as sleep aids, have only minimal effects on sleep and, with continued use, interfere with sleep quality and cause behavioral toxicity. Herbal medicines, as a rule, do not have direct hypnotic properties, but rather sedative ones; they are difficult to dose and predict the aftereffect.

Many drugs used as hypnotics of the first and second generation have become a thing of the past and are no longer used in practice. Based on data obtained by American researchers when studying the effectiveness of therapy for adult patients (9114 people) suffering from insomnia. The most effective sleep aids are benzodiazepines, zopiclone, zolpidem, antidepressants and melatonin. At the same time, each of the identified groups of drugs has its own indications. Benzodiazepines have ataractic, sedative and hypnotic effects. However, due to the euphoric and relaxing effect, their use is fraught with drug dependence. In addition, many of them cause behavioral toxicity due to the accumulation of metabolites. Antidepressants have an undeniable advantage in the treatment of insomnia associated with depression. Doctors' concerns about possible dependence on benzodiazepines and zolpidem and their side effects, along with the need for control, have led in recent years, according to American researchers, to a 30% decrease in the use of benzodiazepines and a 100% increase in the use of antidepressants as sleep aids. Serotonin-specific antidepressants such as trazodone and paroxetine relieve sleep disturbances and have fewer side effects than tricyclic antidepressants. It is possible that the use of safe serotonergic antidepressants for treatment can reduce the burden of chronic insomnia and prevent depression, which is dangerous in relation to suicide. Currently, antidepressants are used to treat chronic insomnia in lower doses than for the treatment of depression and anxiety. Melatonin as a sleep aid has not yet been sufficiently studied and its action is preferable for insomnia associated with disruption of circadian rhythms. The third generation drugs of modern hypnotics are zopiclone and zolpidem, which are similar in their psychopharmacological qualities. The drug that has been studied and approved for use in Ukraine is zopiclone, which is represented by a number of generic drugs. A high-quality drug is zopiclone produced by the Latvian company Grindex with the trade name Somnol.

Zopiclone (Somnol) belongs to a new class of psychotropic drugs (hypnotics) - cyclopyrrolone derivatives. The mechanism of its action is associated with the gamma-aminobutyric acid (GABA-A) receptor complex. Zopiclone modulates the effect of GABA on the GABA-A complex through the benzodiazepine receptor, enhancing the activity of the cellular pump for pumping chloride ions into the cell. Although zopiclone is a non-selective benzodiazepine receptor agonist, its binding site is different from that of benzodiazepines. Unlike benzodiazepines, zopiclone exhibits certain selectivity for the cerebral cortex, cerebellum and hippocampus. The clinical profile of zopiclone can be described as exclusively hypnotic and tranquilizing. Zopiclone has very low toxicity: LD50 is 2000-3000 times higher than the therapeutic dose. At the established single dose of 7.5 mg/day, zopiclone does not have a cumulative effect, but for people over 65 years of age and patients with liver and kidney damage, it is recommended to use a half dose (1/2 tablet) of the drug.

Comparative dynamic electroencephalographic (EEG) studies of the effectiveness of benzodiazepine (phenazepam) and zopiclone showed that after completion of a course of treatment with phenazepam, there was an increase in 5- and 9-activity, an increase in the power of the a-band in the central and occipital regions, and a smoothing of zonal differences. In 50% of patients, a slowdown of the a-rhythm by 1 Hz was detected. These changes are due to increased synchronizing influences from the mid-stem structures of the brain, which clinically correlated with a decrease in the level of wakefulness. In patients receiving zopiclone, the dynamics of EEG indicators had a completely different character: a decrease in the spectral power of the 5- and 9-bands and a decrease in a-activity in the occipital regions were recorded. The increased disorganizing effects on the a-band may be due to the desynchronizing (activating) effect on the cerebral cortex from the brainstem formations, which increased the level of daytime wakefulness while improving the quality of night sleep.

Zopiclone (Somnol) has the following set of qualities: 1) ensures rapid falling asleep when taking a minimum dose; 2) does not require increasing the dose to achieve the desired effect; 3) selectively binds to the receptor and causes only a hypnotic effect; 4) causes sleep that is close to physiological in structure and duration; 5) does not cause aftereffects (vigor is quickly restored in the morning, memory, reaction speed and cognitive functions do not deteriorate); 6) non-toxic, does not interact with other drugs and their metabolites; 7) does not cause addiction, overdose and drug dependence.

Thus, zopiclone (Somnol) is close in its properties to the “ideal hypnotic” and has a therapeutic effect on all types of insomnia - short-term, episodic and chronic.

The duration of short-term insomnia usually ranges from 1 to 3 weeks. The etiological factors of short-term insomnia can be (in order of importance): 1) life difficulties; 2) psychological stress; 3) various somatic diseases; 4) snoring; 5) excessive motor activity during sleep. When treating short-term insomnia with zopiclone for 10 days, both subjective assessment and objective somnographic sleep structure improved in all treated patients.

Episodic insomnia is most often a consequence of the emotional stress of everyday life, emergency situations, desynchronosis, and the individual’s reaction to a somatic disease (nosogeny). Episodic insomnia is often associated with long flights. Moreover, it has been shown that the influence of desynchronosis during long flights more often occurs when moving from east to west than from north to south. Studies by French scientists have shown that in case of sleep disorders due to desynchronosis, the use of zopiclone (7.5 mg) has a positive effect on adaptation to life in a new time zone.

Treatment of chronic insomnia is more difficult, since its causes are multiple, and these patients have combined somatic and mental pathology. The use of zopiclone in combination with the main pathogenetic therapy for chronic insomnia is very effective.

Thus, timely diagnosis and treatment of sleep disorders in general medical (non-psychiatric) practice indicates the qualifications of a family doctor. Knowledge of somnology is a mandatory subject for pre-graduate and post-graduate training of doctors. Modern treatment of insomnia is impossible without knowledge of third-generation hypnotics, among which one of the leading places is occupied by zopiclone (Somnol).

Sleep disorders include a variety of syndromes colloquially referred to as insomnia. This condition negatively affects the mental and physical state of a person. The body does not get enough time to fully rest and restore its reserves. Therefore, timely treatment of insomnia is important. Read about what drugs and medicines, as well as folk remedies can be used for this, in this material. The term “insomnia”, so often used even among doctors, is erroneous. Even with the most severe complaints about lack of sleep (“no sleep” - insomnia), patients still sleep. The correct term for sleep disorders is insomnia.

Insomnia is a sleep disorder accompanied by the following mandatory criteria: 1. Sleep is disturbed for several nights.2. Sleep is disturbed, despite the fact that a person has enough time to sleep, i.e. Lack of sleep in intensively working people cannot be considered insomnia.3. As a result of sleep disturbances, the patient’s usual “daytime” activities change: attention decreases, mood worsens, daytime sleepiness appears, etc.

Insomnia - what is it?

I have difficulty falling asleep (presomnia disorders). I often wake up and then cannot fall back to sleep (intrasomnia disorder). I wake up very early and feel groggy all day (post-somnia disorder). If a patient makes such complaints, then he knows what insomnia is. How does a sleep disorder manifest itself?

• The desire to sleep goes away in bed.
• Painful thoughts and memories appear.
• Motor activity increases in an effort to find a comfortable position.
• The ensuing drowsiness is interrupted by the slightest sound, a shudder.
• Falling asleep takes up to 120 minutes or more, while a healthy person falls asleep within 3-10 minutes.
• Frequent awakenings at night, provoked by various reasons (frightening dreams, fears and nightmares, pain, breathing problems, tachycardia, etc.), after which it is difficult to fall asleep.
• Feelings of “shallow” sleep.
• Sleepwalking and dream-talking.
• Early morning awakening, as a result of which performance decreases.
• Feeling “broken” after a long sleep.
• Dissatisfaction with sleep.
• Daytime sleepiness with sufficient sleep.

Treatment of insomnia and sleep disorders

Insomnia is not a disease, but only a syndrome (a set of symptoms), so the treatment of insomnia is based on identifying and eliminating the cause that led to sleep disturbances. The first approach to treating insomnia is the elimination of factors (external and internal) that negatively affect the sleep process. To fully treat a sleep disorder, you must:

• Go to bed and get up at the same time;
• Avoid active mental and physical activity 1 hour before bedtime;
• Avoid a heavy dinner before bed, give preference to light foods rich in carbohydrates (dairy products, baked goods);
• Avoid coffee, strong tea, stimulants (containing cola) or alcoholic drinks;
• Provide a comfortable sleeping environment (dark room, no noise, not too soft or hard bed);
• It is recommended to get up in the morning at the same time, regardless of the day of the week;
• Do morning exercises (30 minutes) or a walk (40-60 minutes);
• Maintain the maximum level of illumination indoors in the morning;
• Exercise regularly (at least 3 times a week for 60-90 minutes). The maximum positive effect on sleep is exerted 6 hours before you are supposed to go to bed (about 17-18 hours).

Treatment of sleep disorders

The second approach to treating sleep disorders is to actively influence the ability to fall asleep and the structure of sleep itself. This type of therapy is performed under the guidance of an experienced physician.

Methods and means of treating insomnia

Psychotherapeutic methods of treating insomnia are aimed at finding and eliminating the cause of the condition that led to the development of insomnia. To achieve the effect, fairly long sessions with a psychotherapist are required. Treatments for insomnia include phototherapy using very bright white light (intensity of at least 2000 lux). Light affects the melatonergic systems of the brain, which provide synchronization regulation and are also involved in the regulation of emotions, behavior, and endocrine functions. This method is most effective for insomnia associated with disturbances of biological rhythms. Encephalophonia (“Music of the Brain”) is the patient listening to music obtained on the basis of his electroencephalogram using special computer processing methods, which contributes to a change in the functional state of a person. The method is very effective.

Sleep disorder: what to do

If you don’t know what to do if you have sleep disturbances and are afraid to take medications, we recommend that you pay attention to unconventional methods treatment. Various variations of reflexology. The algorithm for their use is complex and depends on the concept used and the personality of the reflexologist. The use of various essential oils and their combinations in order to achieve relaxation is one of the most ancient methods of treating sleep disorders, however, the effectiveness of their use for the treatment of sleep disorders has not been confirmed by evidence-based medicine.

Medicines and drugs for insomnia

Medicines for insomnia are divided into herbal and chemical.1. Treatment should begin with herbal sedative over-the-counter drugs. Popular and effective preparations are valerian, motherwort, peony, peppermint, hops and their combinations. These drugs for insomnia do not have side effects. A new direction in the treatment of insomnia is the use of synthetic analogs of the hormone melatonin (Melaxen). Melatonin is produced at night by the pineal gland (epiphysis) and is an internal regulator and stabilizer of the function of the human biological clock. Melatonin taken orally helps shorten the time it takes to fall asleep and normalizes the sleep-wake rhythm. This medicine for insomnia helps to normalize the biological rhythms of the human body.2. If over-the-counter drugs are ineffective, it is necessary to select the most suitable short-acting drugs (selected by a doctor). An over-the-counter arsenal for visitors with nervous disorders. Anxiety, difficulty falling asleep and insomnia, anxiety, apathy, lethargy - this is not a complete list of nervous disorders characteristic of a resident of a modern metropolis. Herbal medicine comes to the fore in cases of mild anxiety, sleep disorders, depressive states and similar health disorders that reduce the quality of life.

Traditional treatment for insomnia

If you want to use folk treatment for insomnia, then you need plants with sedative properties Valerian, a rhizome with roots. This treatment for insomnia can be used without consulting a specialist only if you are sure that you are not allergic to herbs. Tincture, 1-2 teaspoons 2 times a day. Film-coated tablets, 1 tablet 2-3 times a day. Features of taking valerian. Valerian has a pronounced effect only in high doses (1-2 teaspoon of tincture per dose). Enhances the effect of sleeping pills, narcotics, anticonvulsants. The reaction rate may decrease when controlling mechanisms. The pronounced sedative effect of valerian can be enhanced by a rational combination with lemon balm herb (for states of nervous excitement). In case of chronic fatigue, plants with mild tonic properties (so-called “food” adaptogens) are needed:

• Schisandra, fruits.
• Tincture, extract 20-30 drops 30 minutes before meals.
• Infusion (10 g of crushed raw materials per 200 ml of boiling water) 1 tablespoon 2 times a day on an empty stomach Leuzea, rhizome with roots.

Treatment of insomnia with folk remedies

Treatment of insomnia folk remedies can be done using essential oils. Essential oil and principle of action:

• They have a psychostimulating effect and improve the response of the cardiovascular and respiratory systems to physical activity.
• In case of asthenia, adaptogens Ginseng and roots will help.
• Tincture 30-50 drops 2-3 times a day.
• Capsules and tablets are taken with meals in the dose recommended by the manufacturer.
• Eleutherococcus, roots.
• Liquid extract, 20-30 drops 30 minutes before meals.
• Tablets 100-200 mg 3 times a day.

Operating principle: Stimulates the central nervous system: increases performance and concentration, improves mood. Increases the body's overall resistance to infections.

Insomnia medications

Adaptogens are used for insomnia using two methods. The shock method (high doses, individually selected earlier) is used to quickly increase performance. The course method is based on gradually increasing the dose as the body gets used to it, but not more than 3-4 times. Adaptogens are recommended to be taken in the first half of the day to avoid difficulties falling asleep. It is usually not recommended to take adaptogens in case of severe arterial hypertension, fever and acute infections. Adaptogens enhance the effect of psychogenic stimulants (including caffeine). Unlike coffee and tea, plant adaptogens do not are addictive. Complaints - causeless crying, constant depressed mood. Herbal antidepressants are needed St. John's wort, herb. Tea of ​​1-2 teaspoons per 200 ml of boiling water in the morning and evening, 1-2 cups. Tincture 40-50 drops orally 3-4 times in a day. Ready-made drugs: Gelarium Hypericum, Negrustin, Deprim. Operating principle: St. John's wort flavonoids (hyperoside, bisapigenin, hypericin) are able to inhibit the reuptake of serotonin, norepinephrine and dopamine. Features of administration: Increases the antidepressant effect of monoamine oxidase inhibitors. Has photosensitizing properties.

– a pathological condition in which the process of onset and maintenance of sleep is disrupted. Depending on one or another clinical form of insomnia, difficulties in falling asleep (presomnic form), disturbances during the sleep period (intrasomnic form) and after awakening (postsomnic form) are observed; There is also a decrease in sleep efficiency and night awakenings. The diagnosis is established on the basis of a physical examination, history taking, and polysomnography. Treatment of insomnia includes maintaining sleep hygiene, prescribing drug therapy, physical therapy, and psychotherapy.

ICD-10

G47.0 Disturbances in falling asleep and maintaining sleep [insomnia]

General information

Insomnia is a disorder of the sleep-wake cycle. Pathology is determined by a deficiency in the quality and quantity of sleep, which are necessary for normal human functioning. The disease occurs in 30-45% of the world's population. For some of them (10-15%), insomnia is a serious problem requiring medication. It should be noted that with age, problems with falling asleep and maintaining physiologically sound sleep arise more and more often, so older people experience insomnia more often than young people.

Insomnia - more popular name pathology, used by patients and even doctors, is incorrect, since the disease is not accompanied by a complete loss of sleep.

Causes of insomnia

Insomnia may be based on physiological predisposition, psychogenic disorders, diseases of the nervous system and internal organs. Insomnia often occurs in people suffering from neuroses and neurosis-like conditions: psychoses, depression, panic disorders, etc. Difficulties falling asleep and quality of sleep are usually complained about by patients with somatic diseases that cause night pain, shortness of breath, heart pain, breathing disorders (arterial hypertension, atherosclerosis, pleurisy, pneumonia, chronic pain, etc.). Sleep disorders can accompany organic lesions of the central nervous system (stroke, schizophrenia, parkinsonism, epilepsy, hyperkinetic syndromes); pathologies of the peripheral nervous system.

Predisposing factors also have an influence on the development of sleep disorders, namely: life in a metropolis; frequent change of time zones; long-term use of psychotropic drugs; drinking alcohol; constant intake of caffeinated drinks; shift work and other occupational hazards (noise, vibration, toxic compounds); violation of sleep hygiene.

The pathogenesis of insomnia is considered not to be fully understood, however, scientific research and experiments in the field of neurology have shown that patients experience the same increased brain activity during sleep as during wakefulness (this is indicated by a high level of beta waves); increased levels of hormones at night (cortisol, adrenocorticotropic hormone) and a high metabolic rate.

Classification of insomnia

According to the duration of its occurrence, insomnia is divided into:

• Transitional, lasting no more than a few nights
• Short-term (from several days to weeks)
• Chronic (three weeks or more)

Insomnia is also divided into physiological (situational) and permanent (permanent). Based on its origin, a distinction is made between primary insomnia, which occurs as a result of personal or idiopathic (unexplained) causes, and secondary insomnia, which occurs against the background or as a result of psychological, somatic and other pathologies.

According to the severity of clinical symptoms, insomnia is:

• Mild (weakly expressed) - rare episodes of sleep disturbance
• Moderate severity - clinical manifestations are moderately expressed
• Severe - sleep disturbances occur every night and have a significant impact on daily life.

Symptoms of insomnia

Clinical signs of insomnia, depending on the time of their manifestation, are divided into groups: presomnic, intrasomnic and postsomnic disorders. Disturbances before, after and during sleep can occur individually or in combination. All 3 types of disorders are observed only in 20% of middle-aged patients and in 36% of elderly patients with insomnia.

Insomnia leads to decreased daytime activity, impaired memory and alertness. In patients with mental pathology and somatic diseases, the course of the underlying disease is aggravated. Insomnia can cause slow reactions, which is especially dangerous for drivers and workers servicing industrial machines.

Presomnia disorders

Patients complain of problems with sleep onset. Usually the stage of falling asleep lasts 3-10 minutes. A person suffering from insomnia may spend 30 to 120 minutes or more falling asleep.

An increase in the period of sleep onset may be a consequence of insufficient fatigue of the body when waking up late or going to bed early; pain reaction and itching of a somatic nature; taking drugs that stimulate the nervous system; anxiety and fear that arose during the day.

As soon as a person finds himself in bed, the desire to sleep instantly disappears, heavy thoughts arise, and painful memories emerge in the memory. At the same time, some motor activity is observed: the person cannot find a comfortable position. Sometimes there is causeless itching and unpleasant sensations on the skin. Sometimes falling asleep occurs so imperceptibly that a person perceives it as being awake.

Problems falling asleep can create strange bedtime rituals that are unusual for healthy people. Fear may arise from lack of sleep and fear of bed.

Intrasomnia disorders

The patient complains of a lack of deep sleep; even a minimal stimulus causes awakening followed by a prolonged fall asleep. The slightest sound, lights on and other external factors are perceived especially acutely.

Spontaneous awakening can be caused by bad dreams and nightmares, a feeling of bladder fullness (repeated urge to urinate), vegetative breathing disorder, and rapid heartbeat. A healthy person who does not suffer from insomnia can also wake up, but his threshold for awakening is noticeably higher, subsequent falling asleep is not problematic, and the quality of sleep does not suffer.

Intrasomnia disorders also include increased motor activity, manifested by “restless legs” syndrome, when a person makes shaking movements with his legs in his sleep. The cause of sleep apnea syndrome, which is often observed with insomnia, is the activation of a voluntary breathing regulation mechanism. Occurs most often in obesity and is accompanied by snoring.

Post-somnia disorders

Insomnia also manifests itself in the waking state after awakening. It is difficult for a person to wake up early; he feels exhausted throughout his body. Drowsiness and decreased performance may accompany the patient all day. Non-imperative daytime sleepiness is often observed: even in the presence of all the conditions for good night the person cannot sleep.

There are sudden mood swings, which adversely affects communication with other people, often exacerbating psychological discomfort. For some time after waking up, a person complains of headaches, and a rise in blood pressure (hypertension) is possible. This is characterized by a more pronounced increase in diastolic pressure.

Diagnosis of insomnia

Insomnia is diagnosed based on the patient's complaints and physical condition. In this case, the actual duration of sleep is not decisive; The 5-hour mark is a kind of minimum: shorter sleep over 3 days is equivalent to one night without sleep.

There are 2 clear diagnostic criteria for insomnia: a delay in falling asleep by more than 30 minutes and a decrease in sleep efficiency to 85% or lower (the ratio of the time of actual sleep to the time the patient spent in bed).

Disturbance of the circadian rhythm (early falling asleep and early rising - a “morning person” or late falling asleep and late rising - a “night owl”) is diagnosed as a pathology if a person experiences post-somnia disorders and is unable to sleep longer or fall asleep earlier.

Sometimes a person suffering from chronic insomnia is asked to keep a diary for a month, in which periods of wakefulness and sleep are recorded. In cases where insomnia is accompanied by impaired breathing (obstructive apnea) and motor activity, as well as when drug therapy is ineffective, a consultation with a somnologist and polysomnography are prescribed. Computer research provides a complete picture of sleep, determines the duration of its phases and evaluates the functioning of the entire body during sleep.

Diagnosing insomnia is not difficult; it is often more difficult to determine the true cause or combination of factors that caused insomnia. Consultations with specialized specialists are often required in order to identify somatic pathology.

Treatment of insomnia

Transient insomnia usually goes away on its own or after eliminating the causes of its occurrence. Subacute and especially chronic insomnia require a more careful approach, although treatment of the root cause is a fundamental factor.

Successful relief from insomnia involves maintaining sleep hygiene. Falling asleep at the same time every day, avoiding daytime naps, and being active during the day can completely relieve insomnia in older people without the use of medications.

Psychotherapy can eliminate psychological discomfort and restore sleep. Acupuncture and phototherapy (high-intensity white light treatment) have shown good results in the treatment of insomnia.

The use of sleeping pills promotes rapid sleep and prevents frequent awakenings, but hypnotics have a number of adverse effects, ranging from addiction to dependence and rebound effects. That is why drug treatment of insomnia begins with herbal preparations (motherwort, mint, oregano, peony and other medicinal herbs that have a sedative effect) and products containing melatonin. Drugs with a sedative effect (neuroleptics, antidepressants, antihistamines) are prescribed to increase sleep duration and reduce physical activity.

The drugs imidazopyridines (zolpidem) and cyclopyrrolones (zopiclone) have a short duration of action and do not cause post-somnia disorders - these are among the safest chemical hypnotics. A group of tranquilizers - benzodiazepines (diazepam, lorazepam) inhibit brain processes to a greater extent, thereby reducing anxiety and increasing latency to sleep. These drugs are addictive, seriously affect the speed of reaction, and at the same time enhance the effect of barbiturates and analgesics.

Rules for taking medications for insomnia include: compliance with the duration of treatment with sleeping pills - on average 10-14 days (no more than 1 month); drugs can be prescribed in combination, taking into account their compatibility; one or another drug is selected depending on the concomitant somatic pathology and the minimum set of side effects. For preventive purposes, sleeping pills are prescribed 1-2 times a week. It is important to understand that the use of sleeping pills is purely symptomatic treatment. This fact and the mass of undesirable consequences force us to limit their use as much as possible.

Forecast and prevention of insomnia

To completely get rid of insomnia, you should adhere to the following rules: do not delay a visit to a neurologist if there are obvious signs of insomnia; do not take medications without a doctor’s prescription. It is necessary to adhere to a daily routine (proportionate loads, walks and sufficient time for sleep) and to develop one’s own resistance to stress; Emphasis should be placed on psychological techniques and minimal use of medications.

The prognosis for acute and subacute insomnia is favorable; its treatment in most cases does not require the use of hypnotics and tranquilizers. Treatment of advanced chronic insomnia is a long process; Only close interaction between the patient and the doctor will allow choosing an effective treatment regimen and achieving a positive result.