Abstract:Insomnia is a prevalent disorder with deleterious effects such as decreased quality of life, and a predisposition to a number of psychiatric disorders. Fortunately, numerous approved hypnotic treatments are available. This report reviews the state of the art of pharmacotherapy with a reference to cognitive behavioral therapy for insomnia (CBT-I) as well. It provides the clinician with a guide to all the Food and Drug Administration (FDA) approved hypnotics (benzodiazepines, nonbenzodiazepines, ramelteon, low dose sinequan, and suvorexant) including potential side effects. Frequently, chronic insomnia lasts longer than 2 years. Cognizant of this and as a result of longer-term studies, the FDA has approved all hypnotics since 2005 without restricting the duration of use. Our manuscript also reviews off-label hypnotics (sedating antidepressants, atypical antipsychotics, anticonvulsants and antihistamines) which in reality, are more often prescribed than approved hypnotics. The choice of which hypnotic to choose is discussed partially being based on which segment of sleep is disturbed and whether co-morbid illnesses exist. Lastly, we discuss recent label changes required by the FDA inserting a warning about "sleep-related complex behaviors", e.g., sleep-driving for all hypnotics. In addition, we discuss FDA mandated dose reductions for most zolpidem preparations in women due to high zolpidem levels in the morning hours potentially causing daytime carry-over effects.
Tinnitus is a prevalent medical disorder which frequently becomes chronic and severe. Furthermore, quality of life can become compromised with many experiencing comorbid insomnia. We hypothesize that insomnia is a highly prevalent symptom and diagnostic category accompanying tinnitus. Our article reviews the tinnitus literature examining the prevalence of insomnia, the sleep disturbances found, and any methodological issues. Our literature search included a number of databases such as PubMed, Cochrane, and Embase. We found that 16 prior studies had sufficient data presented that allowed for an assessment of the prevalence rate of insomnia in tinnitus; the prevalence rate ranged from 10% to 80% (most rates were over 40%). The overwhelming majority of these studies inadequately defined insomnia as a diagnosis but described it only as a symptom. They focused predominantly on questionnaires (sent via the mail) asking only 1 to 4 questions on whether tinnitus disturbs sleep. Frequently, the only question asked was whether tinnitus disturbed a patient's sleep without clarifying whether there were problems with daytime functioning. Thus, a valid insomnia diagnosis could not be established. Even in the few studies that asked the necessary information to establish a diagnosis of insomnia, only 1 study provided it. The presence of insomnia in tinnitus was associated with a more severe form of tinnitus. Alarmingly, insomnia was mainly untreated despite evidence supporting that successful treatment of insomnia might also help comorbid tinnitus. Because insomnia is significantly prevalent in tinnitus patients and appears to potentially further impact negatively on one's quality of life, clinicians should address this possibility with a detailed clinical evaluation; incorporating self-rating questionnaires on sleep could be clinically helpful. If insomnia is present, therapy should be considered.
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