慢性失眠及安眠药物使用31张课件

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,*,*,*,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,慢性失眠及安眠藥物使用,慢性失眠及安眠藥物使用慢性失眠及安眠藥物使用慢性失眠及安眠藥物的使用個案描述一 28歲的王先生，唸專科時期開始就有經常睡不好，經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。學校畢業後因為家庭經濟因素開始工作，睡眠狀況還是不理想。王先生曾經在一般開業醫師診所處方過安眠藥，效果還不錯。但是他很擔心常用會成癮，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，而且越來越沒耐性，常常提不起勁來，感覺自己快要垮了，近半年來已經把休假請光，還請了不少病假，最近才由朋友介紹到精神科看門診。,慢性失眠及安眠藥物使用慢性失眠及安眠藥物使用慢性失眠及安眠藥,1,慢性失眠及安眠药物使用31张课件,2,慢性失眠及安眠药物使用31张课件,3,慢性失眠及安眠药物使用31张课件,4,慢性失眠及安眠药物使用31张课件,5,Insomnia Has Several Definitions,NHLBI,. Am Fam Physician,. 1999;59 (abstract).,Difficulty falling asleep,Next-day consequences,Difficulty staying asleep,Non-refreshing sleep,Early morning awakenings,+,Given adequate opportunity to sleep,Insomnia Has Several Definitio,6,Chronic Insomnia: Definition,Chronic insomnia vs. Acute insomnia,Acute insomnia may occur in anyone at one time or another,Varied definitions for chronic insomnia,Durations ranging from 30 days 6 months,Chronic insomnia is often associated with a wide range of adverse conditions including:,Mood disturbances,Difficulties with concentration and memory,Some cardiovascular, pulmonary, and gastrointestinal disorders,NIH Statement.,Sleep.,2005;28:1049-1057.,Insomnia is the most common sleep complaint across all stages of adulthood, and for millions, the problem is chronic,Insomnia can be a symptom of other disorders, like depression, or it can be a primary disorder in itself,Chronic Insomnia: DefinitionCh,7,The Majority of Insomniacs is Chronically Ill,Mild,insomnia,Severe,insomnia,Insomnia (DSM-III-R),Elderly, difficulty falling asleep,Elderly, disturbed sleep continuity,%,%,%,%,%,Mean 68%,% Isomniacs with Persistence of Complaints in Two-Years Follow-Up in Primary Care Surveys,Ganguli et al. 1996; Hohagen et al. 1993; Katz and McHorney 1998,The Majority of Insomniacs is,8,Chronic Insomnia: Epidemiology,Prevalence,30% of general population complains of sleep disruption,10% has daytime functional impairment,Natural History,Few studies describe the course and duration of insomnia,Incidence,Very little is known about chronic insomnias incidence,Only a few studies have examined incidence,Risk Factors,Higher prevalence of insomnia in:,Women (especially postmenopausal),Divorced, separated, widowed adults,Psychiatric and physical illnesses,Other risk factors include cigarette smoking, alcohol, coffee consumption, and numerous prescription drugs,NIH Statement.,Sleep.,2005;28:1049-1057.,Chronic Insomnia: Epidemiology,9,Chronic Insomnia: Consequences,Some evidence suggests a relationship between chronic insomnia and impaired memory, cognitive functioning, and depressed mood,Chronic Insomnia,Consequences,Associated with high health care utilization,Direct and Indirect Costs: estimated in the tens of billions of dollars annually,Quality of Life,Reduces quality of life,Hinders social functioning,Related to impaired work performance,NIH Statement.,Sleep.,2005;28:1049-1057.,Comorbidities,Seldom appears without one or more other disorders,Common comorbidities: depression, generalized anxiety, substance abuse, attention deficit, and a variety of physical problems,Public Health Burden,Difficult to evaluate because literature is not developed,Focus is on populations rather than people,Chronic Insomnia: Consequences,10,Comorbid Psychiatric Disorders With Insomnia,*,P,.001 compared with those with no sleep complaint.,P,.05 compared with those with no sleep complaint.,Ford DE et al.,JAMA,. 1989;262:1479-1484.,Percentage,*,*,*,*,Comorbid Psychiatric Disorders,11,Medical Conditions Associated With Insomnia,*,P,.001;,P,.05.,P,.01.,CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.,Katz DA et al.,Arch Intern Med,. 1998;158:1099-1107.,*,*,Adjusted Odds Ratio,Medical Conditions Associated,12,Impact of Sleep Difficulties on Daily Functioning,Rating Ability as Poor (%),Doghramji PP.,J Clin Psychiatry,. 2001;62(suppl 10):18-26.,Greater Impaired Function,Impact of Sleep Difficulties o,13,Impact of Insomnia on Physical and Emotional Health and Social Functioning,*Scale ranges from 0 to 100, with higher scores reflecting greater quality of life.,Adapted from Zammit GK et al.,Sleep,1999;22,(suppl 2):S379-S385.,SF-36 Subscales*,*,P,0.0001,Greater Interference,Impact of Insomnia on Physical,14,Impact of Insomnia in the Workplace,Daytime functioning and loss of productivity,Two to three times as many days of poor productivity and concentration in individuals with insomnia as in good sleepers,Absenteeism,Severe insomniacs were absent from work twice as often as good sleepers,Work accidents,Seven times higher rate of work accidents in insomniacs than in good sleepers,Metlaine A, et al.,Industrial Health,. 2005;43:1119.,Impact of Insomnia in the Work,15,Therapeutic Goals in Treating Insomnia,Sleep Onset,Sleep Maintenance,Number of awakenings,Duration of awakenings,Time to fall asleep,Sleep Duration,Total sleep time,Alertness,Functioning,Vitality,Next-Day Functioning,Therapeutic Goals in Treating,16,Initial Screening,Nature of complaint,Daytime consequences,Frequency,Duration,Precipitating events,Exacerbating factors,Sleep-wake schedule,Other nocturnal symptoms,Associated behaviors,Cognitions,Previous treatments,Psychiatric disorders,Substance abuse,Concomitant medications,Medical/neurological illness,Other sleep disorders,Assessment of Insomnia,Adapted from Winkleman JW. Available at: medscape/viewprogram/3807,Additional History for Persistent Insomnia,Initial ScreeningPrecipitati,17,Chronic Insomnia: Treatment Considerations,TREATMENT,Cognitive Behavioral Therapy (CBT),Benzodiazepine Receptor Agonist,Benzodiazepines,Non-Benzodiazepines,Antidepressants*,Atypical Antipsychotics*,OTC,Alternative Meds:,Melatonin and Herbal Remedies,*Not FDA approved for treatment of insomniaNIH Statement.,Sleep.,2005;28:1049-1057.,Chronic Insomnia: Treatment C,18,Treat Insomnia with Drugs,Before treating insomnia with drugs, consider:,Is the underlying cause being treated ( depression, mania, breathing difficulties, urinary frequency, pain, etc.)?,Are other drugs being given at appropriate times (i.e. stimulating drugs in the morning, sedating drugs at night)?,Are the patients expectations of sleep realistic ( sleep requirements decrease with age)?,Have all sleep hygiene approaches (see table below) been tried?,Treat Insomnia with Drugs B,19,Guidelines for Prescribing Hypnotics,Use the lowest effective dose,Use intermittent dosing (alternate nights or less) where possible,Prescribe for short-term use (no more than 4 weeks) in the majority of cases,Discontinue slowly,Be alert for rebound insomnia/withdrawal symptoms,Advise patients of the interaction with alcohol and other sedating drugs,Avoid the use of hypnotics in patients with respiratory disease or severe hepatic impairment and in addiction-prone individuals,Prescribing Guidelines, The Maudsley, 2007,Guidelines for Prescribing Hyp,20,The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs,J Gen Intern Med. 2007 Sep;22(9):1335-50. Epub 2007 Jul 10,BACKGROUND: Hypnotics have a role in the management of acute insomnia; however, the efficacy and safety of pharmacological interventions in the management of chronic insomnia is unclear.,OBJECTIVE: The objective of this paper is to conduct a systematic review of the efficacy and safety of drug treatments for chronic insomnia in adults.,DATA SOURCES: Twenty-one electronic databases were searched, up to July 2006.,STUDY SELECTION: Randomized double-blind, placebo-controlled trials were eligible. Quality was assessed using the Jadad scale. Data were pooled using the random effects model.,DATA SYNTHESIS: One hundred and five studies were included in the review.,Sleep onset latency,as measured by polysomnography, was significantly decreased for benzodiazepines (BDZ), (weighted mean difference: -10.0 minutes; 95% CI: -16.6, -3.4), non-benzodiazepines (non-BDZ) (-12.8 minutes; 95% CI: -16.9, -8.8) and antidepressants (ADP) (-7.0 minutes; 95% CI: -10.7, -3.3).,Sleep onset latency assessed by sleep diaries,was also improved (BDZ: -19.6 minutes; 95% CI: -23.9, -15.3; non-BDZ: -17.0 minutes; 95% CI: -20.0, -14.0; ADP: -12.2 minutes; 95% CI: -22.3, -2.2). Indirect comparisons between drug categories suggest BDZ and non-BDZ have a similar effect.,All drug groups had a statistically significant higher risk of harm compared to placebo,(BDZ: risk difference RD: 0.15; non-BDZ RD: 0.07; and ADP RD: 0.09), although the most commonly reported adverse events were minor. Indirect comparisons suggest that non-BDZ are safer than BDZ.,CONCLUSIONS:,Benzodiazepines and non-benzodiazepines are effective treatments in the management of chronic insomnia, although they pose a risk of harm.,There is also some evidence that antidepressants are effective and that they pose a risk of harm.,The efficacy and safety of dru,21,Insomnia: Challenges for PhysiciansInitiating Treatment,Insomnia is challenging for clinicians because of the lack of guidelines for assessment and treatment,General populations poor understanding of the importance of insomnia and available treatments,Forty percent of insomniacs self-medicate either with over-the-counter medications or with alcohol,Only 0.9% of patients in a large managed care group reported visiting a physician specifically for sleep problems,Yet, 34.2% of these patients reported symptoms of insomnia,One in 3 patients seeking health care is likely to have insomnia with daytime dysfunction, but is unlikely to seek care for that specific problem,Benca RM. Psychiatr Serv. 2005;56:332343.,Ancoli-Israel S, Roth T.,Sleep,. 199922 (suppl 2):S347-S353.Doghramji PP.,J Clin Psychiatry.,2004;65(suppl 16):23-26.,Insomnia: Challenges for Physi,22,Insomnia: Challenges for Physicians,In an international study of consequences of insomnia over a 12-month period,Many respondents took no action to alleviate their insomnia symptoms, and this may be due to fear of the implications of treatment, including the possible risks of dependence on medications,Focus groups of patients describing their insomnia experience reported that they felt that the impact of insomnia on their lives was pervasive and misunderstood by others who were significant to them or treating their sleep complaints,More research is necessary to determine the long-term effects of insomnia treatments,Current treatment options do not address the needs of difficult-to-treat patients with chronic insomnia, such as the elderly, and those with comorbid medical and psychiatric conditions.,Benca RM. Psychiatr Serv. 2005;56:332343.,L,ger D, Poursain B.,Curr Med Res Opin,. 2005; 21:1785-1792. Carey TJ et al.,Behav Sleep Med,. 2005;3:73-86.,Insomnia: Challenges for Physi,23,台灣鎮靜安眠類藥品使用盛行率以及相關後遺症之研究,行政院衛生署管制藥品管理局九十六年度委託科技研究計畫報告,民國97年,吳佳璇、張家銘、張憶壽、林克明、賴虹均、王金龍、蔡芳榆。,分析健保歸人檔資料獲得鎮靜安眠類藥品使用年盛行率，使用量，使用方式，以及使用者相關之人口學背景與醫療使用率。,預定連續分析數年(20012004)健保資料，探討變化趨勢。,台灣鎮靜安眠類藥品使用盛行率以及相關後遺症之研究行政院衛生,24,The prevalence, using amount and characters of BZD users,from 2001 to 2004,台灣鎮靜安眠類藥品使用盛行率以及相關後遺症之研究,行政院衛生署管制藥品管理局九十六年度委託科技研究計畫報告,民國97年,The prevalence, using amount a,25,The prescribing pattern among different specialities,from 2001-2004,台灣鎮靜安眠類藥品使用盛行率以及相關後遺症之研究,行政院衛生署管制藥品管理局九十六年度委託科技研究計畫報告,民國97年,The prescribing pattern among,26,The prescribing frequency among different BZDs,from 2001-2004,台灣鎮靜安眠類藥品使用盛行率以及相關後遺症之研究,行政院衛生署管制藥品管理局九十六年度委託科技研究計畫報告,民國97年,The prescribing frequency amon,27,The prescribing amount among different BZDs,from 2001-2004,台灣鎮靜安眠類藥品使用盛行率以及相關後遺症之研究,行政院衛生署管制藥品管理局九十六年度委託科技研究計畫報告,民國97年,The prescribing amount among d,28,ZOLPIDEM 使用率與使用量增加趨勢值得關注,ZOLPIDEM 單品項使用率在2001至2004年間增加幅度明顯，與同屬於BZD receptor agonists的ZOLPICLONE相對平穩的使用率相較，ZOLPIDEM被廣泛使用，其原因除可能的藥理優越性外，值得進一步探討。,BZD receptor agonists是否依賴性與成癮性均優於傳統的BZD，雖有報告*，仍有待更多資料檢驗。但將近六成醫師認同上列陳述，讓醫師傾向以BZD receptor agonists取代長效的BZD，成為處理睡眠障礙的藥物首選。,因應BZD receptor agonists（特別是ZOLPIDEM）近年大量使用之趨勢，宜有全面性、系統性的評估，以證實其療效並瞭解可能的不良反應，必要時制定相關使用準則，以確保治療效果及用藥安全。,*,Jerome H. Jaffe, Roger Bloor, Ilana Crome, Malcolm Carr, Farrukh Alam, Arnol Simmons & Roger E. Meyer (2004). A postmarketing study of relative abuse liability of hypnotic sedative drugs.,Addiction,99, 165173.,ZOLPIDEM 使用率與使用量增加趨勢值得關注,29,Thanks for Your Attentions!,Thanks for Your Attentions!,30,31,、只有永远躺在泥坑里的人，才不会再掉进坑里。,黑格尔,32,、希望的灯一旦熄灭，生活刹那间变成了一片黑暗。,普列姆昌德,33,、希望是人生的乳母。,科策布,34,、形成天才的决定因素应该是勤奋。,郭沫若,35,、学到很多东西的诀窍，就是一下子不要学很多。,洛克,31、只有永远躺在泥坑里的人，才不会再掉进坑里,31,慢性失眠及安眠藥物使用,慢性失眠及安眠藥物使用慢性失眠及安眠藥物使用慢性失眠及安眠藥物的使用個案描述一 28歲的王先生，唸專科時期開始就有經常睡不好，經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。學校畢業後因為家庭經濟因素開始工作，睡眠狀況還是不理想。王先生曾經在一般開業醫師診所處方過安眠藥，效果還不錯。但是他很擔心常用會成癮，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，而且越來越沒耐性，常常提不起勁來，感覺自己快要垮了，近半年來已經把休假請光，還請了不少病假，最近才由朋友介紹到精神科看門診。,慢性失眠及安眠藥物使用慢性失眠及安眠藥物使用慢性失眠及安眠藥,32,慢性失眠及安眠药物使用31张课件,33,慢性失眠及安眠药物使用31张课件,34,慢性失眠及安眠药物使用31张课件,35,慢性失眠及安眠药物使用31张课件,36,Insomnia Has Several Definitions,NHLBI,. Am Fam Physician,. 1999;59 (abstract).,Difficulty falling asleep,Next-day consequences,Difficulty staying asleep,Non-refreshing sleep,Early morning awakenings,+,Given adequate opportunity to sleep,Insomnia Has Several Definitio,37,Chronic Insomnia: Definition,Chronic insomnia vs. Acute insomnia,Acute insomnia may occur in anyone at one time or another,Varied definitions for chronic insomnia,Durations ranging from 30 days 6 months,Chronic insomnia is often associated with a wide range of adverse conditions including:,Mood disturbances,Difficulties with concentration and memory,Some cardiovascular, pulmonary, and gastrointestinal disorders,NIH Statement.,Sleep.,2005;28:1049-1057.,Insomnia is the most common sleep complaint across all stages of adulthood, and for millions, the problem is chronic,Insomnia can be a symptom of other disorders, like depression, or it can be a primary disorder in itself,Chronic Insomnia: DefinitionCh,38,The Majority of Insomniacs is Chronically Ill,Mild,insomnia,Severe,insomnia,Insomnia (DSM-III-R),Elderly, difficulty falling asleep,Elderly, disturbed sleep continuity,%,%,%,%,%,Mean 68%,% Isomniacs with Persistence of Complaints in Two-Years Follow-Up in Primary Care Surveys,Ganguli et al. 1996; Hohagen et al. 1993; Katz and McHorney 1998,The Majority of Insomniacs is,39,Chronic Insomnia: Epidemiology,Prevalence,30% of general population complains of sleep disruption,10% has daytime functional impairment,Natural History,Few studies describe the course and duration of insomnia,Incidence,Very little is known about chronic insomnias incidence,Only a few studies have examined incidence,Risk Factors,Higher prevalence of insomnia in:,Women (especially postmenopausal),Divorced, separated, widowed adults,Psychiatric and physical illnesses,Other risk factors include cigarette smoking, alcohol, coffee consumption, and numerous prescription drugs,NIH Statement.,Sleep.,2005;28:1049-1057.,Chronic Insomnia: Epidemiology,40,Chronic Insomnia: Consequences,Some evidence suggests a relationship between chronic insomnia and impaired memory, cognitive functioning, and depressed mood,Chronic Insomnia,Consequences,Associated with high health care utilization,Direct and Indirect Costs: estimated in the tens of billions of dollars annually,Quality of Life,Reduces quality of life,Hinders social functioning,Related to impaired work performance,NIH Statement.,Sleep.,2005;28:1049-1057.,Comorbidities,Seldom appears without one or more other disorders,Common comorbidities: depression, generalized anxiety, substance abuse, attention deficit, and a variety of physical problems,Public Health Burden,Difficult to evaluate because literature is not developed,Focus is on populations rather than people,Chronic Insomnia: Consequences,41,Comorbid Psychiatric Disorders With Insomnia,*,P,.001 compared with those with no sleep complaint.,P,.05 compared with those with no sleep complaint.,Ford DE et al.,JAMA,. 1989;262:1479-1484.,Percentage,*,*,*,*,Comorbid Psychiatric Disorders,42,Medical Conditions Associated With Insomnia,*,P,.001;,P,.05.,P,.01.,CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.,Katz DA et al.,Arch Intern Med,. 1998;158:1099-1107.,*,*,Adjusted Odds Ratio,Medical Conditions Associated,43,Impact of Sleep Difficulties on Daily Functioning,Rating Ability as Poor (%),Doghramji PP.,J Clin Psychiatry,. 2001;62(suppl 10):18-26.,Greater Impaired Function,Impact of Sleep Difficulties o,44,Impact of Insomnia on Physical and Emotional Health and Social Functioning,*Scale ranges from 0 to 100, with higher scores reflecting greater quality of life.,Adapted from Zammit GK et al.,Sleep,1999;22,(suppl 2):S379-S385.,SF-36 Subscales*,*,P,0.0001,Greater Interference,Impact of Insomnia on Physical,45,Impact of Insomnia in the Workplace,Daytime functioning and loss of productivity,Two to three times as many days of poor productivity and concentration in individuals with insomnia as in good sleepers,Absenteeism,Severe insomniacs were absent from work twice as often as good sleepers,Work accidents,Seven times higher rate of work accidents in insomniacs than in good sleepers,Metlaine A, et al.,Industrial Health,. 2005;43:1119.,Impact of Insomnia in the Work,46,Therapeutic Goals in Treating Insomnia,Sleep Onset,Sleep Maintenance,Number of awakenings,Duration of awakenings,Time to fall asleep,Sleep Duration,Total sleep time,Alertness,Functioning,Vitality,Next-Day Functioning,Therapeutic Goals in Treating,47,Initial Screening,Nature of complaint,Daytime consequences,Frequency,Duration,Precipitating events,Exacerbating factors,Sleep-wake schedule,Other nocturnal symptoms,Associated behaviors,Cognitions,Previous treatments,Psychiatric disorders,Substance abuse,Concomitant medications,Medical/neurological illness,Other sleep disorders,Assessment of Insomnia,Adapted from Winkleman JW. Available at: medscape/viewprogram/3807,Additional History for Persistent Insomnia,Initial ScreeningPrecipitati,48,Chronic Insomnia: Treatment Considerations,TREATMENT,Cognitive Behavioral Therapy (CBT),Benzodiazepine Receptor Agonist,Benzodiazepines,Non-Benzodiazepines,Antidepressants*,Atypical Antipsychotics*,OTC,Alternative Meds:,Melatonin and Herbal Remedies,*Not FDA approved for treatment of insomniaNIH Statement.,Sleep.,2005;28:1049-1057.,Chronic Insomnia: Treatment C,49,Treat Insomnia with Drugs,Before treating insomnia with drugs, consider:,Is the underlying cause being treated ( depression, mania, breathing difficulties, urinary frequency, pain, etc.)?,Are other drugs being given at appropriate times (i.e. stimulating drugs in the morning, sedating drugs at night)?,Are the patients expectations of sleep realistic ( sleep requirements decrease with age)?,Have all sleep hygiene approaches (see table below) been tried?,Treat Insomnia with Drugs B,50,Guidelines for Prescribing Hypnotics,Use the lowest effective dose,Use intermittent dosing (alternate nights or less) where possible,Prescribe for short-term use (no more than 4 weeks) in the majority of cases,Discontinue slowly,Be alert for rebound insomnia/withdrawal symptoms,Advise patients of the interaction with alcohol and other sedating drugs,Avoid the use of hypnotics in patients with respiratory disease or severe hepatic impairment and in addiction-prone individuals,Prescribing Guidelines, The Maudsley, 2007,Guidelines for Prescribing Hyp,51,The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs,J Gen Intern Med. 2007 Sep;22(9):1335-50. Epub 2007 Jul 10,BACKGROUND: Hypnotics have a role in the management of acute insomnia; how