The pharmacology and mechanisms of action of new generation, non-benzodiazepine hypnotic agents

The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations

Behavioural and psychological symptoms of dementia (BPSD) are a clinical challenge for the lack of a sound taxonomy, frequent presentation with comorbid BPSD, lack of specific pharmacologic interventions, poor base of methodologically sound evidence with randomized clinical trials, contamination from the treatment of behavioural disturbances of young and adult psychiatric conditions, and small efficacy window of psychotropic drugs. We present here a treatment workflow based on a concept-driven literature review based on the notions that (i) the aetiology of BPSD can be mainly neurobiological (so-called 'primary' symptoms) or mainly environmental and functional ('secondary' symptoms) and that this drives treatment; (ii) the clinical efficacy of psychotropic drugs is driven by their specific profile of receptor affinity; (iii) drug treatment should follow the rules of 'start low-go slow, prescribe and revise'. This article argues in support of the distinction between primary and secondary BPSD, as well as their characteristics, which until now have been just sketchily described in the literature. It also offers comprehensive and pragmatic clinician-oriented recommendations for the treatment of BPSD.

Abrupt Withdrawal From Chronic High-Dose Zolpidem Use: A Case Report of Resulting Delirium

We report the case of a male in his twenties who was prescribed 10 mg of zolpidem daily for sleep disturbances. Within one month, he self-augmented the dose to 30 mg daily. Unable to secure an authorized refill, he sought unauthorized suppliers and increased his daily intake to 70 mg over eight months. One day after his medication supply was depleted, he presented to the emergency department with symptoms indicative of acute delirium. Delirium was successfully alleviated within six hours using lorazepam. This was followed by a five-day lorazepam tapering regimen during the patient's hospital stay and then a subsequent four-day taper in an outpatient setting. This case highlights the dangers associated with zolpidem misuse, the swift onset of withdrawal symptoms following abrupt discontinuation, and the crucial importance of rigorous prescription monitoring and patient education regarding the risks of unguided dosage modifications and the sudden cessation of zolpidem.

Sleep Pathologies and Eating Disorders: A Crossroad for Neurology, Psychiatry and Nutrition

The intricate connection between eating behaviors and sleep habits is often overlooked in clinical practice, despite their profound interdependence. Sleep plays a key role in modulating psychological, hormonal and metabolic balance and exerting an influence on food choices. Conversely, various eating disorders may affect sleep continuity, sometimes promoting the development of sleep pathologies. Neurologists, nutritionists and psychiatrists tend to focus on these issues separately, resulting in a failure to recognize the full extent of the clinical conditions. This detrimental separation can lead to underestimation, misdiagnosis and inappropriate therapeutic interventions. In this review, we aim to provide a comprehensive understanding of the tangled relationship between sleep, sleep pathologies and eating disorders, by incorporating the perspective of sleep experts, psychologists and psychiatrists. Our goal is to identify a practical crossroad integrating the expertise of all the involved specialists.

Optimising recovery of consciousness after coma. From bench to bedside and vice versa

BACKGROUND

Several methods have been proposed to foster recovery of consciousness in patients with disorders of consciousness (DoC).

OBJECTIVE

Critically assess pharmacological and non-pharmacological treatments for patients with chronic DoC.

METHODS

A narrative mini-review, and critical analysis of the scientific literature on the various proposed therapeutic approaches, with particular attention to level of evidence, risk-benefit ratio, and feasibility.

RESULTS AND DISCUSSION

Personalised sensory stimulation, median nerve stimulation, transcranial direct current stimulation (tDCS), amantadine and zolpidem all have favourable risk-benefit ratios and are easy to implement in clinical practice. These treatments should be proposed to every patient with chronic DoC. Comprehensive patient management should also include regular lifting, pain assessment and treatment, attempts to restore sleep and circadian rhythms, implementation of rest periods, comfort and nursing care, and a rehabilitation program with a multi-disciplinary team with expertise in this field. More invasive treatments may cause adverse effects and require further investigation to confirm preliminary, encouraging results and to better define responders' intervention parameters. Scientific studies are essential and given the severity of the disability and handicap that results from DoC, research in this area should aim to develop new therapeutic approaches.

Insights into the medicinal chemistry of heterocycles integrated with a pyrazolo[1,5-a]pyrimidine scaffold

Pyrazolo[1,5-a]pyrimidines are the dominant motif of many drugs; for instance, zaleplon and indiplon are sedative agents and ocinaplon was identified as an anxiolytic agent. The importance of this class of compounds lies in its varied and significant biological activities, and accordingly, considerable methods have been devised to prepare these compounds. Hence, other derivatives of this class of compounds were prepared by substitution reactions with different nucleophiles exploiting the activity of groups linked to the ring carbon and nitrogen atoms. The methods used vary through the condensation reactions of the aminopyrazoles with 1,2-allenic, enaminonitriles, enaminones, 1,3-diketones, unsaturated nitriles, or unsaturated ketones. Alternatively, these compounds are prepared through the reactions of acyclic reagents, as these methods were recently developed efficiently with high yields. The current review highlighted the recent progress of the therapeutic potential of pyrazolo[1,5-a]pyrimidines as antimicrobial, anticancer, antianxiety, anti-proliferative, analgesic, and antioxidant agents, carboxylesterase, translocator protein and PDE10A inhibitors, and selective kinase inhibitors.

Structural and dynamic mechanisms of GABAA receptor modulators with opposing activities

γ-Aminobutyric acid type A (GABA_A) receptors are pentameric ligand-gated ion channels abundant in the central nervous system and are prolific drug targets for treating anxiety, sleep disorders and epilepsy. Diverse small molecules exert a spectrum of effects on γ-aminobutyric acid type A (GABA_A) receptors by acting at the classical benzodiazepine site. They can potentiate the response to GABA, attenuate channel activity, or counteract modulation by other ligands. Structural mechanisms underlying the actions of these drugs are not fully understood. Here we present two high-resolution structures of GABA_A receptors in complex with zolpidem, a positive allosteric modulator and heavily prescribed hypnotic, and DMCM, a negative allosteric modulator with convulsant and anxiogenic properties. These two drugs share the extracellular benzodiazepine site at the α/γ subunit interface and two transmembrane sites at β/α interfaces. Structural analyses reveal a basis for the subtype selectivity of zolpidem that underlies its clinical success. Molecular dynamics simulations provide insight into how DMCM switches from a negative to a positive modulator as a function of binding site occupancy. Together, these findings expand our understanding of how GABA_A receptor allosteric modulators acting through a common site can have diverging activities.

GABA_A receptors are important targets for anxiety, sedation and anesthesia. Here, the authors present structures bound by zolpidem (Ambien), the most prescribed hypnotic in the US, and DMCM, a negative modulator, providing insights into receptor modulation.

Effect of Hibiscus syriacus Linnaeus extract and its active constituent, saponarin, in animal models of stress-induced sleep disturbances and pentobarbital-induced sleep

Treatment of sleep disorders promotes the long-term use of commercially available sleep inducers that have several adverse effects, including addiction, systemic fatigue, weakness, loss of concentration, headache, and digestive problems. Therefore, we aimed to limit these adverse effects by investigating a natural product, the extract of the Hibiscus syriacus Linnaeus flower (HSF), as an alternative treatment. In the electric footshock model, we measured anxiety and assessed the degree of sleep improvement after administering HSF extract. In the restraint model, we studied the sleep rate using PiezoSleep, a noninvasive assessment system. In the pentobarbital model, we measured sleep improvement and changes in sleep-related factors. Our first model confirmed the desirable effects of HSF extract and its active constituent, saponarin, on anxiolysis and Wake times. HSF extract also increased REM sleep time. Furthermore, HSF extract and saponarin increased the expression of cortical GABAA receptor α1 (GABAAR α1) and c-Fos in the ventrolateral preoptic nucleus (VLPO). In the second model, HSF extract and saponarin restored the sleep rate and the sleep bout duration. In the third model, HSF extract and saponarin increased sleep maintenance time. Moreover, HSF extract and saponarin increased cortical cholecystokinin (CCK) mRNA levels and the expression of VLPO c-Fos. HSF extract also increased GABAAR α1 mRNA level. Our results suggest that HSF extract and saponarin are effective in maintaining sleep and may be used as a novel treatment for sleep disorder. Eventually, we hope to introduce HSF and saponarin as a clinical treatment for sleep disorders in humans.

Early post-treatment blood oxygenation level-dependent responses to emotion processing associated with clinical response to pharmacological treatment in major depressive disorder

INTRODUCTION

Pre-treatment blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging (fMRI) has been used for the early identification of patients with major depressive disorder (MDD) who later respond or fail to respond to medication. However, BOLD responses early after treatment initiation may offer insight into early neural changes associated with later clinical response. The present study evaluated both pre-treatment and early post-treatment fMRI responses to an emotion processing task, to further our understanding of neural changes associated with a successful response to pharmacological intervention.

METHODS

MDD patients who responded (n = 22) and failed to respond (n = 12) after 8 weeks of treatment with either citalopram or quetiapine extended release, and healthy controls (n = 18) underwent two fMRI scans, baseline (pre-treatment), and early post-treatment (one week after treatment commencement). Participants completed an emotional face matching task at both scans.

RESULTS

Using threshold-free cluster enhancement (TFCE) and non-parametric permutation testing, fMRI activation maps showed that after one week of treatment, responders demonstrated increased activation in the left parietal lobule, precentral gyrus, and bilateral insula (all P < 0.05 threshold-free cluster enhancement (TFCE) family-wise error-corrected) to negative facial expressions. Non-responders showed some small increases in the precentral gyrus, while controls showed no differences between scans. Compared to non-responders, responders showed some increased activation in the superior parietal lobule and middle temporal gyrus at the post-treatment scan. There were no group differences between responders, non-responders, and controls at baseline.

CONCLUSIONS

One week after treatment commencement, BOLD signal changes in the parietal lobules, insula, and middle temporal gyrus were related to clinical response to pharmacological treatment.

Sleep-related eating disorder associated with zolpidem: cases compiled from a literature review

Objective

Zolpidem is associated with sleep-related eating disorder (SRED). We compiled case reports and performed a descriptive study to identify etiology and aggravating factors.

Methods

A literature search on PubMed's MeSH search feature, CINAHL, and SciFinder was performed using search terms "Zolpidem," "Feeding and Eating Disorders/chemically induced," "Dyssomnias," "sleep eating disorder," and "sleep-related eating disorder." Three reviewers examined all English and Spanish citations and extracted pertinent information. A narrative synthesis of the evidence was prepared.

Results

We identified 40 case reports of which 65% were female, and the mean age was 53 years. SRED onset was most commonly seen with daily zolpidem doses of 10 mg or higher (95% of patients). Prior medical history included obstructive sleep apnea (OSA) (35%), depression (32.5%), and restless leg syndrome (RLS) (25%). Even with controlled RLS and OSA, SRED developed in some patients. All patients had either partial or full amnesia with compulsive eating. Onset of SRED occurred as early as the first dose to after 9 years of use. SRED symptoms occurred nightly in 57.5% of patients. Discontinuation of zolpidem resolved SRED in all patients (n = 36).

Conclusion

SRED associated with zolpidem can occur with any dose, but was most common with higher doses of zolpidem. Therefore, prescribers should initiate lower doses of zolpidem. Interestingly, many patients had underlying disorders known to affect sleep (RLS, OSA, depression). Although it is recommended to control these underlying disorders prior to initiating zolpidem, SRED may still occur. Zolpidem discontinuation resolved all cases of SRED.

Identification and characterization of new impurities in zopiclone tablets by LC-QTOF-MS

Zopiclone, a non-benzodiazepine hypnotic, is the first-line treatment for insomnia. The quality and stability of zopiclone tablets directly affects its efficacy and safety. However, the impurity investigation in zopiclone tablets remain incomplete. In this study, the accelerated and long-term stabilities of zopiclone tablets, as well as the stability characteristics under thermal and photolytic conditions were evaluated according to the ICH guidelines. In addition, a sensitive and specific LC-QTOF-MS method was developed for the separation and identification of all the impurities in zopiclone tablets and its stability test samples. Nine impurities were found in the test samples, five among them have not been reported before. Based on the accurate mass and elemental compositions of the parent and product ions obtained, the structures of all the detected impurities were identified. Combined with the formulation composition analysis and stability studies, the origins and the formation mechanisms of these impurities were elucidated. The obtained results are useful for the establishment of the optimum formulation, storage condition, manufacturing processes and quality control of zopiclone tablets.

Polymeric nanoencapsulation of zaleplon into PLGA nanoparticles for enhanced pharmacokinetics and pharmacological activity

Zaleplon (ZP) is a sedative and hypnotic drug used for the treatment of insomnia. Despite its potent anticonvulsant activity, ZP is not commonly used for the treatment of convulsion since ZP is characterized by its low oral bioavailability as a result of poor solubility and extensive liver metabolism. The following study aimed to formulate specifically controlled release nano-vehicles for oral and parenteral delivery of ZP to enhance its oral bioavailability and biological activity. A modified single emulsification-solvent evaporation method of sonication force was adopted to optimize the inclusion of ZP into biodegradable nanoparticles (NPs) using poly (dl-lactic-co-glycolic acid) (PLGA). The impacts of various formulation variables on the physicochemical characteristics of the ZP-PLGA-NPs and drug release profiles were investigated. Pharmacokinetics and pharmacological activity of ZP-PLGA-NPs were studied using experimental animals and were compared with generic ZP tablets. Assessment of gamma-aminobutyric acid (GABA) level in plasma after oral administration was conducted using enzyme-linked immunosorbent assay. The maximal electroshock-induced seizures model evaluated anticonvulsant activity after the parenteral administration of ZP-loaded NPs. The prepared ZP-PLGA NPs were negatively charged spherical particles with an average size of 120-300 nm. Optimized ZP-PLGA NPs showed higher plasma GABA levels, longer sedative, hypnotic effects, and a 3.42-fold augmentation in oral drug bioavailability in comparison to ZP-marketed products. Moreover, parenteral administration of ZP-NPs showed higher anticonvulsant activity compared to free drug. Oral administration of ZP-PLGA NPs achieved a significant improvement in the drug bioavailability, and parenteral administration showed a pronounced anticonvulsant activity.

How do medical and non-medical use of z-drugs relate to psychological distress and the use of other depressant drugs?

BACKGROUND

Z-drugs are hypnotic drugs used for insomnia with considerable potential of abuse. We investigated the relationship of past-year medical and non-medical use of z-drugs with past-year: i) psychological distress; ii) medical use, non-medical use, and DSM-IV use disorder of Benzodiazepine (BZD) tranquilizers; iii) use and DSM-IV alcohol and marijuana use disorders, recreational drugs with a depressant effect on the central nervous system.

METHODS

Data came from the 2015-2017 NSDUH (n = 128,740). Participants aged 18+ were asked if they had used any Z-Drug medically or non-medically in the past year. We investigated the associations between the three-level z-drugs variable with psychological distress and BZD, alcohol, and marijuana variables in multinomial logistic regression models.

RESULTS

Past-year prevalences of z-drug use were 3.3% for medical and 0.5% for non-medical use. Medical and non-medical users of z-drugs had higher risk of psychological distress, compared to non-users. Medical and non-medical users of z-drugs had higher risk of medical use, non-medical use, and BZD use disorders. Compared to non-users of z-drugs, medical users had higher risk of marijuana and alcohol use and alcohol use disorders, while non-medical users had higher risk of marijuana use and marijuana use disorders and alcohol.

CONCLUSION

Z-drug users have elevated risk of use and dependence of BZDs and recreational drugs, possibly due to concurrent prescribing and self-medication.

Real-world evidence on the use of benzodiazepine receptor agonists and the risk of venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a life-threatening disease, and some studies reported that benzodiazepine receptor agonist (BZRA) use could increase the risk of VTE, but this association lacks population-based evidence.

OBJECTIVES

To investigate the association between BZRA use and the risk of VTE.

PATIENTS/METHODS

A nested case-control study analyzing Taiwan's claims database was conducted of patients with at least one new BZRA prescription on record from January 1, 2002, to December 31, 2012. We included new users who did not have any BZRA prescriptions in the preceding 2 years and identified cases with VTE and disease risk score matched control subjects. We used a logistic regression model to investigate the association between BZRA exposure and the risk of VTE. The exposure duration, dose, and classes of BZRAs were comprehensively evaluated.

RESULTS

We identified 2800 VTE cases and 2800 matched controls. Current BZRA prescription (≤90 days) was associated with VTE occurrence (adjusted odds ratio [aOR]: 1.83; 95% confidence interval [CI], 1.62-2.06). The point estimates of benzodiazepine hypnotics (aOR: 2.00; 95% CI, 1.45-2.76) had a marginally higher risk of VTE than nonbenzodiazepine hypnotics (aOR: 1.39; 95% CI, 1.07-1.81). The VTE risk was increased with combination BZRA use, number of BZRA used, and a higher dose of BZRA. On examination of individual BZRA, the risk of VTE was higher with flunitrazepam use (aOR: 2.99; 95% CI, 1.43-6.28) than other BZRAs.

CONCLUSIONS

This study presents that current BZRA use may increase the risk of VTE. Also, benzodiazepine hypnotics, especially flunitrazepam, have a higher risk of VTE.

Cannabinoids, Endocannabinoids and Sleep

Sleep is a vital function of the nervous system that contributes to brain and bodily homeostasis, energy levels, cognitive ability, and other key functions of a variety of organisms. Dysfunctional sleep induces neural problems and is a key part of almost all human psychiatric disorders including substance abuse disorders. The hypnotic effects of cannabis have long been known and there is increasing use of phytocannabinoids and other formulations as sleep aids. Thus, it is crucial to gain a better understanding of the neurobiological basis of cannabis drug effects on sleep, as well as the role of the endogenous cannabinoid system in sleep physiology. In this review article, we summarize the current state of knowledge concerning sleep-related endogenous cannabinoid function derived from research on humans and rodent models. We also review information on acute and chronic cannabinoid drug effects on sleep in these organisms, and molecular mechanisms that may contribute to these effects. We point out the potential benefits of acute cannabinoids for sleep improvement, but also the potential sleep-disruptive effects of withdrawal following chronic cannabinoid drug use. Prescriptions for future research in this burgeoning field are also provided.

Dieckol, a Major Marine Polyphenol, Enhances Non-Rapid Eye Movement Sleep in Mice via the GABAA-Benzodiazepine Receptor

We had previously demonstrated that phlorotannins, which are marine polyphenols, enhance sleep in mice via the GABA_A-benzodiazepine (BZD) receptor. Among the constituents of phlorotannin, dieckol is a major marine polyphenol from the brown alga Ecklonia cava. Although phlorotannins are known to exert hypnotic effects, the sleep-enhancing effect of dieckol has not yet been determined. We evaluated the effect of dieckol on sleep-wake state of mice by analyzing electroencephalograms (EEGs) and electromyograms. Flumazenil, a GABA_A-BZD antagonist, was used to investigate the molecular mechanism underlying the effects of dieckol on sleep. The polygraphic recordings and corresponding hypnograms revealed that dieckol accelerated the initiation of non-rapid eye movement sleep (NREMS); it shortened sleep latency and increased NREMS duration. According to the change in time-course, dieckol showed sleep-enhancing effects by increasing the amount of NREMS and decreasing wakefulness during the same hours. Additionally, sleep quality was evaluated by analyzing the EEG power density, and dieckol was found to not affect sleep intensity while zolpidem was found to reduce it. Finally, we treated mice with zolpidem or dieckol in combination with flumazenil and found the latter to inhibit the sleep-enhancing effect of dieckol and zolpidem, thereby indicating that dieckol exerts sleep-enhancing effects by activating the GABA_A-BZD receptor, similar to zolpidem. These results implied that dieckol can be used as a promising herbal sleep aid with minimal side effects, unlike the existing hypnotics.

Zolpidem Use and Suicide Death in South Korea: A Population-Based Case-Control Study

OBJECTIVE

To investigate whether zolpidem use is associated with suicide death in adults.

METHOD

We conducted a case-control study using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database. Cases were adults with a suicide record (ICD-10 codes; X-60-X84, Y87.0) between January 1, 2004 and December 31, 2013. 10 Controls were matched to each case by age, sex, index year, region, income level, and health insurance type. Zolpidem use during 2 years before suicide was quantified. Adjusted odd ratios (aORs) with 95% confidence intervals (CIs) were estimated using conditional logistic regression.

RESULTS

The percentage of zolpidem users was significantly higher in cases (451 of 1,928 [23.4%]) than in controls (832 of 18,404 [4.5%]). After controlling for potential confounders, zolpidem use was significantly associated with suicide (aORs, 2.09; 95% CI, 1.74-2.52). Dose-response relationships were observed (for trend, p < .0001). Consistent findings were observed when analyses were restricted to suicide death (aORs, 2.08; 95% CI, 1.73-2.51) and nonmedication poisoning suicide death cases (aORs, 2.10; 95% CI, 1.74-2.53).

CONCLUSIONS

We found a significant and positive association between zolpidem use and suicide. Zolpidem should be prescribed cautiously and with due caution of increased suicide risk.

Use of non-benzodiazepine hypnotics is associated with falls in nursing home residents: a longitudinal cohort study

BACKGROUND

Falls and related injuries are common among older people, and several drug classes are considered to increase fall risk.

AIMS

This study aimed to investigate the association between the use of certain drug classes and falls in older nursing home residents in Sweden, and relate these to different age groups.

METHODS

Information on falls that occurred in the previous year and regular use of possible fall risk drugs including non-benzodiazepine hypnotics (zopiclone and zolpidem) was collected from 331 nursing home residents during 2008-2011. Over the following 6 months, the occurrence of serious falls, requiring a physician visit or hospital care, was registered. Association between serious falls and drug use was compared between an older (≥ 85 years) and a younger group.

RESULTS

An increased fall risk (Downton Fall Risk Index ≥ 3) was found in 93% of the study subjects (aged 65-101 years). Baseline data indicated an association between falls that occurred in the previous year and regular use of non-benzodiazepine hypnotics (p = 0.005), but not with the other studied drug classes. During the following 6 months, an association between use of non-benzodiazepine hypnotics and serious falls in the older group (p = 0.017, odds ratio 4.311) was found. No association was found between the other studied drug classes and serious falls.

DISCUSSION

These results indicate an association between falls and the use of non-benzodiazepine hypnotics, compounds that previously have been considered generally well-tolerated in older people.

CONCLUSIONS

Caution is advocated when using non-benzodiazepine hypnotics regularly in older people living in nursing homes.

Relationship Between Constipation and Medication

Constipation is very common and can be caused by adverse drug reactions as a result of many drugs. While the adverse effects of several medications such as opioids and anticholinergic agents are well established and well known, other commonly prescribed drugs, such as hypnotics, are less well understood. This review presents the results of an analysis of the relationship between constipation and drugs.

GABAA Receptor Subtypes and the Abuse-Related Effects of Ethanol in Rhesus Monkeys: Experiments with Selective Positive Allosteric Modulators

BACKGROUND

Previous studies have investigated α1GABA_A and α5GABA_A receptor mechanisms in the behavioral effects of ethanol (EtOH) in monkeys. However, genetic studies in humans and preclinical studies with mutant mice suggest a role for α2GABA_A and/or α3GABA_A receptors in the effects of EtOH. The development of novel positive allosteric modulators (PAMs) with functional selectivity (i.e., selective efficacy) at α2GABA_A and α3GABA_A receptors allows for probing of these subtypes in preclinical models of the discriminative stimulus and reinforcing effects of EtOH in rhesus macaques.

METHODS

In discrimination studies, subjects were trained to discriminate EtOH (2 g/kg, intragastrically) from water under a fixed-ratio (FR) schedule of food delivery. In oral self-administration studies, subjects were trained to self-administer EtOH (2% w/v) or sucrose (0.3 to 1% w/v) under an FR schedule of solution availability.

RESULTS

In discrimination studies, functionally selective PAMs at α2GABA_A and α3GABA_A (HZ-166) or α3GABA_A (YT-III-31) receptors substituted fully (maximum percentage of EtOH-lever responding ≥80%) for the discriminative stimulus effects of EtOH without altering response rates. Full substitution for EtOH also was engendered by a nonselective PAM (triazolam), an α5GABA_A -preferring PAM (QH-ii-066) and a PAM at α2GABA_A , α3GABA_A , and α5GABA_A receptors (L-838417). A partial (MRK-696) or an α1GABA_A -preferring (zolpidem) PAM only engendered partial substitution (i.e., ~50 to 60% EtOH-lever responding). In self-administration studies, pretreatments with the functionally selective PAMs at α2GABA_A and α3GABA_A (XHe-II-053 and HZ-166) or α3GABA_A (YT-III-31 and YT-III-271) receptors increased EtOH, but not sucrose, drinking at doses that had few, or no, observable sedative-motor effects.

CONCLUSIONS

Our results confirm prior findings regarding the respective roles of α1GABA_A and α5GABA_A receptors in the discriminative stimulus effects of EtOH and, further, suggest a key facilitatory role for α3GABA_A and potentially α2GABA_A receptors in several abuse-related effects of EtOH in monkeys. Moreover, they reveal a potential role for these latter subtypes in EtOH's sedative effects.

The Discriminative Stimulus Properties of Drugs Used to Treat Depression and Anxiety

Drug discrimination is a powerful tool for evaluating the stimulus effects of psychoactive drugs and for linking these effects to pharmacological mechanisms. This chapter reviews the primary findings from drug discrimination studies of antidepressant and anxiolytic drugs, including novel pharmacological mechanisms. The stimulus properties revealed from these animal studies largely correspond to the receptor affinities of antidepressant and anxiolytic drugs, indicating that subjective effects may correspond to either therapeutic or side effects of these medications. We discuss drug discrimination findings concerning adjunctive medications and novel pharmacologic strategies in antidepressant and anxiolytic research. Future directions for drug discrimination work include an urgent need to explore the subjective effects of medications in animal models, to better understand shifts in stimulus sensitivity during prolonged treatments, and to further characterize stimulus effects in female subjects. We conclude that drug discrimination is an informative preclinical procedure that reveals the interoceptive effects of pharmacological mechanisms as they relate to behaviors that are not captured in other preclinical models.

The effect of nonbenzodiazepines sedative hypnotics on apnea-hypopnea index: A meta-analysis

INTRODUCTION:

Nonbenzodiazepine (non-BZD) sedative hypnotics (NBSH) refer to non-BZD sedatives that act as BZD receptor agonists such as zolpidem, zaleplon, and eszopiclone. Today, there is a high prevalence of insomnia with or without concurrent obstructive sleep apnea (OSA). Our goal was to study how NBSH use impacts the baseline apnea–hypopnea index (AHI) in patients with or without OSA.

METHODS:

PubMed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were searched.

RESULTS:

Seventeen studies comprising a cumulative total of 2099 patients were identified in the last 30 years (between 1988 and 2017) that evaluated the effect of NBSH on respiratory parameters during sleep. The AHI mean (M) ± standard deviation (SD) in NBSH group was 13.17 ± 16.27 versus 15.94 ± 19.31 (mean difference [MD]-95% confidence interval [CI], 2.77 [1.463–4.076]). Six studies (100 patients) compared zolpidem with either placebo or no medication and demonstrated an AHI MD of −0.61 events/h (95% CI − 1.94, 0.71), overall effect Z = 0.9, P = 0.36. Four studies (362 patients) compared eszopiclone with placebo and demonstrated an AHI MD of −5.73 events/h0 (95% CI − 8.90, −0.2.57). Two large studies (979 patients) compared both zolpidem and eszopiclone to no medication and found AHI MD of −1.66 events/h (95% CI − 5.87, 0.2.55).

CONCLUSIONS:

The majority of patients using NBSH did not develop any worsening of existing AHI, when using NBSH, regardless of their baseline AHI values (mild, moderate, severe, or no OSA). On average, the AHI improved minimally with NBSH and eszopiclone showed the largest difference in AHI with an MD of −5.73 events/h.

Newly Emerging Drugs of Abuse

Drug use and the associated overdose deaths have been a serious public health threat in the United States and the world. While traditional drugs of abuse such as cocaine remain popular, recreational use of newer synthetic drugs has continued to increase, but the prevalence of use is likely underestimated. In this review, epidemiology, chemistry, pharmacophysiology, clinical effects, laboratory detection, and clinical treatment are discussed for newly emerging drugs of abuse in the following classes: (1) opioids (e.g., fentanyl, fentanyl analogues, and mitragynine), (2) cannabinoids [THC and its analogues, alkylindole (e.g., JWH-018, JWH-073), cyclohexylphenol (e.g., CP-47,497), and indazole carboxamide (e.g., FUB-AMB, ADB-FUBINACA)], (3) stimulants and hallucinogens [β-keto amphetamines (e.g., methcathinone, methylone), pyrrolidinophenones (e.g., α-PVP, MDPV), and dimethoxyphenethylamine ("2C" and "NBOMe")], (4) dissociative agents (e.g., 3-MeO-PCP, methoxetamine, 2-oxo-PCE), and (5) sedative-hypnotics (e.g., gabapentin, baclofen, clonazolam, etizolam). It is critically important to coordinate hospital, medical examiner, and law enforcement personnel with laboratory services to respond to these emerging threats.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α₂δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H₁ antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.

Effectiveness of zolpidem and sleep hygiene counseling in the treatment of insomnia in solid tumor patients

OBJECTIVE

To study the effectiveness of zolpidem and sleep hygiene counseling in managing insomnia in solid tumor patients.

METHODS

Cancer patients with a Pittsburgh Sleep Quality Index score ≥ 5 were grouped into two. Both groups received treatment for insomnia in the form of either zolpidem 5 mg for 7 days or sleep hygiene counseling.

RESULT

At baseline, zolpidem and counseling group had a mean Pittsburgh Sleep Quality Index score of 14.82 ± 2.61 and 11.67 ± 3.32, respectively. The difference in mean Pittsburgh Sleep Quality Index score was found to be 4.03 in patients using zolpidem and 1.5 in counseled patients (p = 0.003). The components of Pittsburgh Sleep Quality Index namely difficulty falling asleep within 30 min (sleep latency), overall sleep quality, trouble staying awake during daytime and trouble staying motivated to get things done showed statistically significant improvement after treatment with zolpidem. Following sleep hygiene counseling, the proportion of patients with sleep latency > 30 min reduced considerably. Waking up to use the bathroom was the most common problem reported by approximately 94% patients in both groups before treatment which remained the most prevalent problem even after treatment. Night or early morning awakenings seemed to decrease significantly in patients taking zolpidem (p = 0.039) while it did not show any improvement with counseling. Counseling seemed to get patients to sleep within 30 min.

CONCLUSION

Patients on zolpidem showed a reduction in their Pittsburgh Sleep Quality Index scores thereby suggesting it as a treatment for insomnia in solid tumor patients. Sleep hygiene counseling, though not as effective as zolpidem, made a slight difference in the overall sleep.

Z-drugs and risk for falls and fractures in older adults-a systematic review and meta-analysis

Objective

zolpidem, zopiclone, eszopiclone and zaleplon, also known as 'Z-drugs', are commonly used as alternatives to benzodiazepines (BZDs) to treat insomnia. Z-drugs are often perceived as safer than BZDs. We conducted a systematic review and meta-analysis evaluating the association between Z-drugs and fracutres, falls and injuries.

Methods

a systematic review was performed using MEDLINE, EMBASE and ClinicalTials.gov. Pooled effect-sizes were calculated comparing Z-drugs users with non-users, using fixed and random-effect models with corresponding 95% confidence of intervals (CI).

Results

we identified 14 eligible studies reporting on the association between Z-drugs and outcomes of interest. Z-Drugs were associated with a statistically significant increased risk for fractures, with evidence of considerable heterogeneity (OR = 1.63; 95% CI: 1.42-1.87; I2 = 90%; n = 830,877). Likewise, there was a trend suggesting a 2-fold increase in the odds for falls, however, this result was not statistically significant and there was evidence of considerable heterogeneity (OR = 2.40; 95% CI: 0.92-6.27; I2 = 95%; n = 19,505). In an analysis assessing the risk for injuries following exposure to zolpidem we found a statistically significant increased risk of injuries, with no evidence of heterogeneity (OR = 2.05; CI 95%: 1.95-2.15; I2 = 0; n = 160,502). Results were similar in sensitivity analyses, including analyses restricted to studies of high-quality, studies with control groups suffering from insomnia, and with specific Z-drugs.

Conclusion

our results indicate that Z-drugs are associated with an increased risk for fractures, and suggest a possible increased risk for falls and injuries as well. However, studies included were observational and susceptible to confounding. Physicians should consider these potential risks before prescribing these medications in older adults.

Conversion factors for assessment of driving impairment after exposure to multiple benzodiazepines/z-hypnotics or opioids

AIMS

Norway has introduced legal concentration limits in blood for 28 non-alcohol drugs in driving under the influence cases. As of 2016 this legislation also regulates the assessment of combined effects of multiple benzodiazepines and opioids. We herein describe the employed methodology for the equivalence tables for concentrations of benzodiazepines/z-hypnotics and opioids implemented in the Norwegian Road Traffic Act.

METHODS

Legislative limits corresponding to impairment at blood alcohol concentrations (BAC) of 0.02%, 0.05% and 0.12% were established for 15 different benzodiazepines and opioids. This was based on a concept of a linear relationship between blood drug concentration and impairment in drug naïve users. Concentration ratios between these drugs were used to establish conversion factors and calculate net impairment using diazepam and morphine equivalents.

RESULTS

Conversion factors were established for 14 benzodiazepines/z-hypnotics (alprazolam, bromazepam, clobazam, clonazepam, etizolam, flunitrazepam, lorazepam, nitrazepam, nordiazepam, oxazepam, phenazepam, temazepam, zolpidem and zopiclone) and two opioids (methadone and oxycodone).

CONCLUSIONS

Conversion factors to calculate diazepam and morphine equivalents for benzodiazepines/z-hypnotics and selected opioids, respectively, have been operative in the Norwegian Road Traffic Act as of February 2016. Calculated equivalents can be applied by the courts to meter out sanctions.

Potential benefits of zolpidem in disorders of consciousness

INTRODUCTION

It has been suggested that zolpidem may arouse patients with decreased level of consciousness. Zolpidem may partially or even completely reverse abnormal cell metabolism following brain damage. In this article, available evidences regarding effects of zolpidem on disorders of consciousness were reviewed. Areas covered: A literature review was conducted using PubMed, Scopus, Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar as online databases. Search Keywords were 'vegetative state', 'minimally conscious state', 'semi-comatose', 'arousal', 'zolpidem', 'wakefulness', 'awareness', and 'loss of consciousness'. All English language studies that evaluated the effects of zolpidem on disorders of consciousness as a main surrogate endpoint were included. Finally 21 articles within this subject were included. Expert commentary: Zolpidem showed positive effects in several conditions with decreased level of consciousness. However, benefits of zolpidem were not detected in all patients with disorders of consciousness. Patients with post-anoxic encephalopathy or traumatic brain injury did not experience benefits of zolpidem. Available evidences support positive effects of zolpidem on brain functions in patients with non-brain stem injuries.

Benzodiazepine, z-drug and pregabalin prescriptions and mortality among patients in opioid maintenance treatment-A nation-wide register-based open cohort study

BACKGROUND

Use of sedatives may increase risk of death in opioid users. The aim of the study was to assess whether prescription of sedatives may be associated with mortality in patients in opioid maintenance treatment.

METHODS

This retrospective register-based open cohort study included nation-wide register data including all individuals who were dispensed methadone or buprenorphine as opioid maintenance treatment for opioid dependence between July, 2005 and December, 2012 (N=4501). Outcome variables were overdose mortality and non-overdose mortality, respectively. Extended Cox regression analyses examined associations between type of sedative prescriptions and death, controlling for sex, age, previous overdoses and suicide attempts, psychiatric in-patient treatment and opioid maintenance treatment status. Opioid maintenance was assumed to last for 90days (or 30days in a sensitivity analysis) after the last methadone or buprenorphine prescription.

RESULTS

Benzodiazepine prescriptions were associated with non-overdose death (HR: 2.02, 95% CI: 1.29-3.18) but not significantly associated with overdose death (1.49, 0.97-2.29). Z-drug (1.60, 1.07-2.39) and pregabalin prescriptions (2.82, 1.79-4.43) were associated with overdose death. In the sensitivity analysis, all categories of sedatives, including benzodiazepines, were significantly associated with overdose death.

CONCLUSIONS

Caution is advised when prescribing sedative drugs, including benzodiazepines, z-drugs and pregabalin, to patients in opioid maintenance treatment.

Identification of Suvorexant in Urine Using Liquid Chromatography-Quadrupole/Time-of-Flight Mass Spectrometry (LC-Q/TOF-MS)

Suvorexant (Belsomra®) is a new hypnotic drug with a novel mechanism of action. In prescribed doses of 10 mg before bedtime, the drug produces rapid onset of sleep by inhibiting the orexin neurons of the arousal system, promoting decreased wakefulness. Suvorexant is a potent and highly selective dual orexin receptor antagonist. Sedative hypnotics are of forensic importance due to their widespread use, potential for additive effects with other central nervous system depressants, impairing effects and potential for misuse. In this report we describe a highly sensitive assay for the identification and quantification of suvorexant in urine. Suvorexant was isolated using liquid/liquid extraction (LLE) and identified using liquid chromatography-quadrupole/time-of-flight mass spectrometry. Suvorexant was quantified using a quadratic calibration model between 5 and 250 ng/mL (R2 = 1.000, n = 6). Processed sample stability was demonstrated for up to 24 h. The limit of detection was 0.5 ng/mL and the limit of quantification (LOQ) was 5 ng/mL. The accuracy, bias and precision of the assay at the LOQ were 99% (81-117%), -1% and 12% (n = 18). Intraassay (n = 5) and interassay (n = 15) precision (% CV) at 10, 50 and 200 ng/mL were ≤8%, and bias ranged from -2% to 4% (98-104% accuracy). No qualitative interferences were detected from matrix, internal standard or 50 common drugs. Matrix effects evaluated at low and high concentrations were -16% and -9%, respectively, and produced CVs of 11% and 5% (n = 20). Suvorexant is a new drug of forensic importance. In this report we describe how a simple acidic/neutral LLE can be used to isolate this lipophilic drug with high recoveries and sound analytical performance.

Effects of a primary care intervention to improve the quality of zolpidem prescriptions in elderly patients

PURPOSE

The objective of this study was to measure the impact of an intervention on the prescription habits of general practitioners (GPs) in order to improve the quality of zolpidem prescriptions in patients aged 75 or older.

METHODS

A prospective multicentric non-randomized trial was performed in the Metropolitan Granada Primary Healthcare Area (Andalusian Public Healthcare Service, Spain), which serves a total population of approximately 675,000 inhabitants. All health centers volunteering to participate in the trial were included. The intervention consisted of training sessions, individualized feedback, clinical information, and financial incentives. A daily dose over 5 mg was considered non-safe. Reduction in non-safe prescriptions of zolpidem in the elderly population became a quality prescribing indicator in a pay-for-performance scheme.

RESULTS

Statistically significant differences versus baseline were found between the intervention and control groups in mean zolpidem prescription prevalence (28.5 vs. 37.5‰, respectively; p = 0.008) and mean non-safe zolpidem prescription prevalence (16.5 vs. 34.2‰, respectively; p < 0.001). At the end of the study period, the total number of non-safe prescriptions was 1309, 35% lower versus baseline, with a significant difference of p < 0.001; the number in the intervention (510 vs. 1118; p < 0.001) and control (799 vs. 893; p = 0.0064) groups was also significantly lower, with a significantly greater percentage reduction in the intervention group (54.4 vs. 10.5%, p < 0.001).

CONCLUSION

The quality prescribing indicator in our area was improved by the intervention developed. Further studies that include an intervention group of GPs who receive no financial incentive are required to evaluate the relative importance of an economic reward in achieving this improvement.

Nonmedical Use of Antihistaminergic Anxiolytics and Other Prescription Drugs among Persons with Opioid Dependence

Background. Nonmedical prescription drug use (NMPDU) is an increasing problem, insufficiently studied among people in opioid maintenance treatment (OMT). This study investigates the prevalence of and factors associated with NMPDU for drug classes insufficiently described in opioid-dependent populations, including antihistaminergic anxiolytics and central stimulants. Methods. Study participants were recruited at two OMT clinics in Malmo, Sweden, between October 2014 and December 2015 (N = 73) and interviewed about their use, motivations for use, and acquisition and administration of prescription drugs. Results. The majority of the sample reported lifetime NMPDU: 60% for benzodiazepine-like hypnotics (z-drugs), 21% for pregabalin, 19% for stimulants, and 12%-15% for antihistaminergic anxiolytics. Lower age was associated with nonmedical benzodiazepine use (Adjusted Odds Ratio = 0.89; 95% Confidence Interval = 0.82-0.97). Illicit acquisition was reported by 61% of people using z-drugs, 46% of people using pregabalin, and 38% of people using prescription stimulants, but only by 6-10% of people using antihistaminergic anxiolytics. Conclusions. The substantial nonmedical use of pregabalin, z-drugs, and prescription stimulants found in this study suggests that clinicians should prescribe these drugs with great caution. Nonmedical use of antihistaminergic anxiolytics does not seem to be a clinical issue among people in OMT in a Swedish setting, but we propose future studies to monitor their use.

Regioselective Synthesis of 7-(Trimethylsilylethynyl)pyrazolo[1,5-a]pyrimidines via Reaction of Pyrazolamines with Enynones

Condensation of enynones readily available from cheap starting material with pyrazolamines provides easy access to fluorescent 7-(trimethylsilylethynyl)pyrazolo[1,5-a]pyrimidines. The reaction is straightforward, does not require the use of any additional reagents or catalysts, and can be performed without inert atmosphere. Various substituents and functional groups in both enynone and pyrazolamine are tolerated. The presented method features full regioselectivity, high isolated yields, and simplicity of both setup and product purification. Fluorescent properties of the obtained pyrazolopyrimidines were studied.

Sedative-hypnotics are widely abused by drivers apprehended for driving under the influence of drugs

BACKGROUND

Sedative-hypnotics are commonly encountered in drivers apprehended for driving under the influence of drugs (DUID). Previous research has mainly concentrated on the residual effects of the drugs.

METHODS

In this study, the extent of sleep medication use and abuse among drivers apprehended on suspicion of DUID was assessed. Additionally, the prevalence and concentrations of the drugs, concomitant use of other drugs of abuse, and the age and sex of the drivers positive for the most commonly prescribed sedative-hypnotics (temazepam, midazolam, nitrazepam, zopiclone, and zolpidem) in DUID cases in Finland in 2009 to 2011 were examined.

RESULTS

Sedative-hypnotics were found in 3155 samples of the 13,248 that were analyzed. Temazepam was present in over half of the cases (57.9%), along with other benzodiazepines such as midazolam (13.1%) and nitrazepam (7.0%) and the non-benzodiazepine hypnotics zopiclone (12.2%) and zolpidem (9.8%). The mean age of the drivers using the studied sedative-hypnotics was 33.5 years. Many of the drivers were polydrug users; concomitant stimulant use was found in nearly half of the cases. Cannabis and alcohol were also very common co-findings. In nearly 20% of the cases, the driver had taken more than 1 of the studied sedative-hypnotics; only 2.5% had no findings other than a single sedative-hypnotic in their blood. The drug use pattern of those positive for zopiclone and zolpidem was somewhat different from that of users of benzodiazepine sedative-hypnotics; their age was higher and the concomitant use of illegal stimulants was markedly less prevalent than among the users of temazepam, midazolam, and nitrazepam.

CONCLUSIONS

There were very few cases in our study population where the positive sedative-hypnotic finding could have been due to appropriate medical use. The extremely prevalent concomitant use of other psychoactive drugs and the high median serum concentrations of the studied sedative-hypnotics suggest their widespread abuse among apprehended drivers.

Visual hallucinations associated with gabapentin use

PURPOSE

A case of probable gabapentin-induced visual hallucinations in a patient with no psychiatric history is reported.

SUMMARY

A 65-year-old white woman with no history of psychiatric conditions arrived at the pharmacy clinic with specific complaints of daytime sleepiness, fatigue, and visual hallucinations that started after coronary artery bypass graft surgery three years prior. After the surgery she began experiencing neuropathic pain in her chest, which was treated with gabapentin. Approximately one month later, she developed visual hallucinations that continued to occur at least two or three times per month. When first seen in the pharmacy clinic, the patient was taking gabapentin 300 mg orally four times daily plus 600 mg at bedtime, for a total daily dose of 1800 mg. Although gabapentin appears to have been prescribed as 600 mg three times daily, she had been taking it in five divided doses. One month later, she reported that she had self-reduced the gabapentin dosage to 300 mg once daily, after which she noticed improvement in her daytime sleepiness and fatigue and experienced one hallucination approximately one week after the dosage reduction. One month later, she completely discontinued gabapentin use, after which she experienced no further hallucinations. Assessment with the Naranjo et al. adverse drug reaction scale indicated a probable relationship between the patient's visual hallucinations and gabapentin use.

CONCLUSION

A 65-year-old woman with no psychiatric history developed visual hallucinations while taking gabapentin five times daily. Her hallucinations resolved after discontinuation of gabapentin and have remained absent after 1 year of follow-up.

Inhibition of Orexin Signaling Promotes Sleep Yet Preserves Salient Arousability in Monkeys

STUDY OBJECTIVES

In addition to enhancing sleep onset and maintenance, a desirable insomnia therapeutic agent would preserve healthy sleep's ability to wake and respond to salient situations while maintaining sleep during irrelevant noise. Dual orexin receptor antagonists (DORAs) promote sleep by selectively inhibiting wake-promoting neuropeptide signaling, unlike global inhibition of central nervous system excitation by gamma-aminobutyric acid (GABA)-A receptor (GABAaR) modulators. We evaluated the effect of DORA versus GABAaR modulators on underlying sleep architecture, ability to waken to emotionally relevant stimuli versus neutral auditory cues, and performance on a sleepiness-sensitive cognitive task upon awakening.

METHODS

DORA-22 and GABAaR modulators (eszopiclone, diazepam) were evaluated in adult male rhesus monkeys (n = 34) with continuous polysomnography recordings in crossover studies of sleep architecture, arousability to a classically conditioned salient versus neutral acoustical stimulus, and psychomotor vigilance task (PVT) performance if awakened.

RESULTS

All compounds decreased wakefulness, but only DORA-22 sleep resembled unmedicated sleep in terms of underlying sleep architecture, preserved ability to awaken to salient-conditioned acoustic stimuli while maintaining sleep during neutral acoustic stimuli, and no congnitive impairment in PVT performance. Although GABAaR modulators induced lighter sleep, monkeys rarely woke to salient stimuli and PVT performance was impaired if monkeys were awakened.

CONCLUSIONS

In nonhuman primates, DORAs' targeted mechanism for promoting sleep protects the ability to selectively arouse to salient stimuli and perform attentional tasks unimpaired, suggesting meaningful differentiation between a hypnotic agent that works through antagonizing orexin wake signaling versus the sedative hypnotic effects of the GABAaR modulator mechanism of action.

Learning from the past and looking to the future: Emerging perspectives for improving the treatment of psychiatric disorders

Modern neuropsychopharmacology commenced in the 1950s with the serendipitous discovery of first-generation antipsychotics and antidepressants which were therapeutically effective yet had marked adverse effects. Today, a broader palette of safer and better-tolerated agents is available for helping people that suffer from schizophrenia, depression and other psychiatric disorders, while complementary approaches like psychotherapy also have important roles to play in their treatment, both alone and in association with medication. Nonetheless, despite considerable efforts, current management is still only partially effective, and highly-prevalent psychiatric disorders of the brain continue to represent a huge personal and socio-economic burden. The lack of success in discovering more effective pharmacotherapy has contributed, together with many other factors, to a relative disengagement by pharmaceutical firms from neuropsychiatry. Nonetheless, interest remains high, and partnerships are proliferating with academic centres which are increasingly integrating drug discovery and translational research into their traditional activities. This is, then, a time of transition and an opportune moment to thoroughly survey the field. Accordingly, the present paper, first, chronicles the discovery and development of psychotropic agents, focusing in particular on their mechanisms of action and therapeutic utility, and how problems faced were eventually overcome. Second, it discusses the lessons learned from past successes and failures, and how they are being applied to promote future progress. Third, it comprehensively surveys emerging strategies that are (1), improving our understanding of the diagnosis and classification of psychiatric disorders; (2), deepening knowledge of their underlying risk factors and pathophysiological substrates; (3), refining cellular and animal models for discovery and validation of novel therapeutic agents; (4), improving the design and outcome of clinical trials; (5), moving towards reliable biomarkers of patient subpopulations and medication efficacy and (6), promoting collaborative approaches to innovation by uniting key partners from the regulators, industry and academia to patients. Notwithstanding the challenges ahead, the many changes and ideas articulated herein provide new hope and something of a framework for progress towards the improved prevention and relief of psychiatric and other CNS disorders, an urgent mission for our Century.

A review of sleep-promoting medications used in pregnancy

Approximately 4% of adults who have symptoms of insomnia resort to various hypnotic or sedating medications for acute symptom relief. Although typically a common practice for nonpregnant adults, this is not the case for the thousands of pregnant women who also report substantial sleep issues. Unfortunately, a paucity of randomized controlled trials in this population, scant empiric evidence regarding the appropriateness of prescribing options, and the concern of subsequent teratogenicity restricts the ability of clinicians to make informed decisions. We synthesized the current research regarding hypnotics and sedating medications used (both on- and off-label) during pregnancy and their association with adverse outcomes. Medications that we investigated included benzodiazepines, hypnotic benzodiazepine receptor agonists, antidepressants, and antihistamines. Overall, the examined studies showed no correlation of increased risk of congenital malformations. However, benzodiazepines and hypnotic benzodiazepine receptor agonists may increase rates of preterm birth, low birthweight, and/or small-for-gestational-age infants. The small number of studies and the small number of subjects prohibit any definitive interpretation regarding the consequences of the use of hypnotic or sedating medications in pregnancy. Additional case reports, randomized clinical trials, and epidemiologic studies are needed urgently.

Correlates of dependence and beliefs about the use of hypnotics among zolpidem and zopiclone users

BACKGROUND

Zolpidem and zopiclone are the two most commonly prescribed Z-drugs approved to treat insomnia.

OBJECTIVES

To examine the demographic and clinical correlates of dependence and beliefs about hypnotic use among long-term zolpidem and zopiclone users in psychiatric treatment for insomnia.

METHODS

A total of 392 psychiatric outpatients who received zolpidem or zopiclone treatment for at least 3 months for insomnia were studied. Participants' severity of hypnotic dependence and beliefs about the use of hypnotics to treat sleep problems were assessed. The correlation of dependence and beliefs about zolpidem and zopiclone treatment with demographic characteristics, hypnotic-using behaviors, co-use of addictive substances, and depressive symptoms were analyzed using multiple regression analysis models.

RESULTS

Zolpidem users reported more severe dependence and a lower level of necessity regarding the use of hypnotics than zopiclone users did. High equivalent doses of hypnotics and long duration of use were significantly associated with severe dependence and a low level of necessity. Severe depressive symptoms were signiciantly associated with severe dependence, a low level of necessity, and a low level of concern. Educational level was also associated with the levels of concern and necessity. Conclusions/Importance: There were differences in the level of dependence and belief about hypnotic use between zolpidem and zopiclone users. The correlates of dependence and belief identified in this study can serve as the basis for prevention and intervention programs.

Non-Benzodiazepine Receptor Agonists for Insomnia

Because of proven efficacy, reduced side effects, and less concern about addiction, non-benzodiazepine receptor agonists (non-BzRA) have become the most commonly prescribed hypnotic agents to treat onset and maintenance insomnia. First-line treatment is cognitive-behavioral therapy. When pharmacologic treatment is indicated, non-BzRA are first-line agents for the short-term and long-term management of transient and chronic insomnia related to adjustment, psychophysiologic, primary, and secondary causation. In this article, the benefits and risks of non-BzRA are reviewed, and the selection of a hypnotic agent is defined, based on efficacy, pharmacologic profile, and adverse events.

Changes in cerebral metabolism in patients with a minimally conscious state responding to zolpidem

Background: Zolpidem, a short-acting non-benzodiazepine GABA agonist hypnotic, has been shown to induce paradoxical responses in some patients with disorders of consciousness (DOC), leading to recovery of arousal and cognitive abilities. We here assessed zolpidem-induced changes in regional brain metabolism in three patients with known zolpidem response in chronic post-anoxic minimally conscious state (MCS).

Methods: [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) and standardized clinical assessments using the Coma Recovery Scale-Revised were performed after administration of 10 mg zolpidem or placebo in a randomized double blind 2-day protocol. PET data preprocessing and comparison with a healthy age-matched control group were performed using statistical parametric mapping (SPM8).

Results: Behaviorally, all patients recovered functional communication after administration of zolpidem (i.e., emergence from the MCS). FDG-PET showed increased metabolism in dorsolateral prefrontal and mesiofrontal cortices after zolpidem but not after placebo administration.

Conclusion: Our data show a metabolic activation of prefrontal areas, corroborating the proposed mesocircuit hypothesis to explain the paradoxical effect of zolpidem observed in some patients with DOC. It also suggests the key role of the prefrontal cortices in the recovery of functional communication and object use in hypoxic patients with chronic MCS.

When insomnia is not just insomnia: the deeper correlates of disturbed sleep with reference to DSM-5

Recent scientific evidences have brought a paradigm shift in our approach towards the concepts of insomnia and its management. The differentiation between primary and secondary insomnia was proved more hypothetical than actual and based upon the current evidences insomnia subtypes described in earlier system have been lumped into one-insomnia disorder. Research in this field suggests that insomnia occurring during psychiatric or medical disorders has a bidirectional and interactive relationship with and coexisting medical and psychiatric illnesses. The new approach looks to coexist psychiatric or medical disorders as comorbid conditions and hence specifies two coexisting conditions. Therefore, the management and treatment plans should address both the conditions. A number of sleep disorders may present with insomnia like symptoms and these disorders should be treated efficiently in order to alleviate insomnia symptoms. In such cases, a thorough history from the patient and his/her bed-partner is warranted. Moreover, some patients may need polysomnography or other diagnostic tests like actigraphy to confirm the diagnosis of the underlying sleep disorder. DSM-5 classification system of sleep–wake disorders has several advantages, e.g., it has seen insomnia across different dimensions to make it clinically more useful; it focuses on the assessment of severity and guides the mental health professional when to refer a patient of insomnia to a sleep specialist; lastly, it may encourage the psychiatrists to opt for sleep medicine as a career.

Zolpidem reduces hippocampal neuronal activity in freely behaving mice: a large scale calcium imaging study with miniaturized fluorescence microscope

Therapeutic drugs for cognitive and psychiatric disorders are often characterized by their molecular mechanism of action. Here we demonstrate a new approach to elucidate drug action on large-scale neuronal activity by tracking somatic calcium dynamics in hundreds of CA1 hippocampal neurons of pharmacologically manipulated behaving mice. We used an adeno-associated viral vector to express the calcium sensor GCaMP3 in CA1 pyramidal cells under control of the CaMKII promoter and a miniaturized microscope to observe cellular dynamics. We visualized these dynamics with and without a systemic administration of Zolpidem, a GABAA agonist that is the most commonly prescribed drug for the treatment of insomnia in the United States. Despite growing concerns about the potential adverse effects of Zolpidem on memory and cognition, it remained unclear whether Zolpidem alters neuronal activity in the hippocampus, a brain area critical for cognition and memory. Zolpidem, when delivered at a dose known to induce and prolong sleep, strongly suppressed CA1 calcium signaling. The rate of calcium transients after Zolpidem administration was significantly lower compared to vehicle treatment. To factor out the contribution of changes in locomotor or physiological conditions following Zolpidem treatment, we compared the cellular activity across comparable epochs matched by locomotor and physiological assessments. This analysis revealed significantly depressive effects of Zolpidem regardless of the animal's state. Individual hippocampal CA1 pyramidal cells differed in their responses to Zolpidem with the majority (∼ 65%) significantly decreasing the rate of calcium transients, and a small subset (3%) showing an unexpected and significant increase. By linking molecular mechanisms with the dynamics of neural circuitry and behavioral states, this approach has the potential to contribute substantially to the development of new therapeutics for the treatment of CNS disorders.

Zolpidem-induced suicide attempt: a case report

Zolpidem is a popular drug indicated for the short-term treatment of insomnia. Side effects are not uncommon with zolpidem. Herein we describe an Iranian 27-year-old man with no known mood disorder or neuropsychological disease who attempted suicide upon taking zolpidem. There are two interesting facts about this case: Firstly, the patient had not history of suicide attempt or thinking. Secondly, this case had experienced suicide ideation after taking 20 mg of zolpidem, suggesting a possible correlation between zolpidem psychological effects and dangerous psychological behaviors.