Adherence to behavioral recommendations of cognitive behavioral therapy for insomnia predicts medication use after a structured medication taper

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBTI) has been paired with supervised medication tapering to help hypnotic-dependent individuals discontinue their hypnotics. This study examined the hypothesis that higher participant adherence to behavioral recommendations of CBTI will predict lower odds of using sleep medications 3 months after completion of a combined CBTI/sleep medication tapering protocol.

METHODS

Fifty-eight individuals who used sedative hypnotics completed four CBTI sessions followed by sleep medication tapering. Logistic regression was used to examine the association of stability of time in bed and stability of rise time (measured as the within-person standard deviation) at completion of CBTI with two outcomes at 3-month follow-up: use of sedative hypnotics and use of any medication/substance for sleep.

RESULTS

Participants with more stability in their rise time after CBTI than at baseline (ie, a decrease in their within-person standard deviation) had 69.5% lower odds of using sedative hypnotics at follow-up (odds ratio = 0.305, 95% confidence interval = 0.095-0.979, P = .046) than individuals who had no change or a decrease in the stability of their rise time. Results were similar for time in bed: participants with more stability in their time in bed after CBTI than at baseline had 83.2% lower odds of using sedative hypnotics (odds ratio = 0.168, 95% confidence interval = 0.049-0.580, P = .005). Increase in stability of rise time and stability of time in bed was also associated with reduced odds of using any medication/substance for sleep at follow-up.

CONCLUSIONS

Participants who implement behavioral recommendations of CBTI appear to have more success with discontinuing use of sleep medications.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: The Role of Tapering Pace and Selected Traits on Hypnotic Discontinuation; URL: https://clinicaltrials.gov/ct2/show/NCT02831894; Identifier: NCT02831894.

CITATION

Edinger JD, Wamboldt FS, Johnson RL, et al. Adherence to behavioral recommendations of cognitive behavioral therapy for insomnia predicts medication use after a structured medication taper. J Clin Sleep Med. 2023;19(8):1495-1503.

Prescribing decision making by medical residents on night shifts: A qualitative study

INTRODUCTION

Prescribing of medications with well-known adverse effects, like antipsychotics or benzodiazepines, during hospitalisation is extremely common despite guideline recommendations against their use. Barriers to optimal prescribing, including perceived pressure from allied health professionals and fatigue, may be particularly pronounced for less experienced medical residents, especially during night shifts when these medications are often prescribed. Under these circumstances, physicians may be more likely to use 'quick', often referred to as System 1 choices, rather than 'considered' System 2 strategies for decisions. Understanding how medical residents use, these different cognitive approaches could help develop interventions to improve prescribing.

METHODS

To understand decision-making and contextual contributors that influence suboptimal prescribing during night coverage by medical residents, we conducted semi-structured qualitative interviews with residents in general medicine inpatient settings. The interviews elicited perspectives on shift routines, stressful situations, factors influencing prescribing decision making and hypothetical measures that could improve prescribing. Interviews were audio-recorded and transcribed. Data were analysed using codes developed by the team to generate themes using immersion/crystallisation approaches.

RESULTS

We conducted interviews with 21 medical residents; 47% were female, 43% were White, and 43% were Asian. We identified five key themes: (i) time pressures affecting prescribing decisions, (ii) fears of judgement by senior physicians and peers and being responsible for patient outcomes, (iii) perceived pressure from nursing staff, amplified by nurses' greater experience, (iv) clinical acuity as a key factor influencing prescribing, and (v) strategies to improve communication between members of the care team, like ensuring adequate hand-off by day teams.

CONCLUSION

Medical residents highlighted numerous contextual factors that promote quick thinking rather than slower thinking when prescribing on night shifts, particularly time constraints, perceived pressure and patient clinical acuity. Interventions aimed at reducing prescribing should address how to manage stress and perceived pressure in decision making.

Prescription medications for insomnia are associated with suicidal thoughts and behaviors in two nationally representative samples

STUDY OBJECTIVES

Z-drugs (eszopiclone, zolpidem, and zaleplon) are commonly used for insomnia but are also associated with suicide risk. However, it is unclear if this association is unique to Z-drugs. Therefore, the present study estimated the associations between multiple prescription insomnia medications and suicidal thoughts and behaviors.

METHODS

Data were acquired from the National Survey on Drug Use and Health for 2015-2018 and the National Health and Nutrition Examination Survey for 2005-2018. Samples were balanced on sociodemographic and mental health covariates using inverse probability of treatment weighting. Associations of Z-drugs, trazodone, and sedative benzodiazepines (temazepam, triazolam, flurazepam) with suicidal ideation, planning, and attempts were estimated using binomial logistic regression.

RESULTS

In the National Survey on Drug Use and Health, Z-drugs were associated with suicidal ideation (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.14-1.54]), suicide planning (OR, 1.44; 95% CI, 1.19-1.75), and suicide attempts (OR, 1.45; 95% CI, 1.13-1.86) after adjusting for age, sex, race/ethnicity, income, depression, illicit substance use, and the 6-item Kessler Psychological Distress Scale and World Health Organization Disability Assessment Schedule II scores. When analyses accounted for the same factors, sedative benzodiazepines were associated with suicide attempts (OR, 1.76; 95% CI, 1.06-2.87) but not suicidal ideation (OR, 1.37; 95% CI, 0.99-1.88) or suicide planning (OR, 1.39; 95% CI, 0.97-2.00). In the National Health and Nutrition Examination Survey, Z-drugs were associated with suicidal ideation (OR, 2.44; 95% CI, 1.41-4.22), as was trazodone (OR, 2.33; 95% CI, 1.45-3.75), after analyses adjusted for age, sex, race/ethnicity, and exposure to various psychotropic medications.

CONCLUSIONS

Multiple classes of prescription insomnia medications are associated with suicidal thinking and behaviors, even after analyses adjusted for measures of mental health.

[Association Suvorexant and Ramelteon Use with the Risk of Falling: A Retrospective Case-control Study]

Sedative hypnotics are among the classes of drugs reported to influence falls. However, the effects of the sedative hypnotic drugs, suvorexant and ramelteon, on falls are not well known. Therefore, we conducted this retrospective case-control study to examine the association of the use of these two sedative hypnotics with the risk of falls. Conducted at the Sapporo Medical University Hospital in Japan, our study included 360 patients with fall incidents and 819 randomly selected control patients. Patients in the fall group were significantly older with a lower body mass index, and had a history of falls, disabilities in activities of daily living, cognitive impairment, and delirium. Monovariate analysis revealed that patients in the fall group frequently used ramelteon [odds ratio (OR) 2.38, 95% confidence interval (CI): 1.49-3.81, p<0.001], but rarely used suvorexant (OR 0.66, 95% CI: 0.29-1.39, p=0.317), compared with control patients. Furthermore, multivariate analysis revealed that ramelteon use did not increase the risk of falls (adjusted OR 1.43, 95% CI: 0.82-2.48, p=0.207), whereas suvorexant use significantly decreased the risk of falls (adjusted OR 0.32, 95% CI: 0.13-0.76, p=0.009). Although ramelteon tends to be used in patients at a high risk of falls, it may not increase the risk of falls. In contrast, the use of suvorexant may reduce the risk of falls.

Potentially Driver-Impairing Medications: Risks and Strategies for Injury Prevention

Impaired driving is a major cause of motor vehicle accidents, injury, and fatality. Several classes of medication have been found to affect a driver's cognition, judgment, and reaction time and may put patients at increased risk for accidents and injury. This article will explore medications with side effects posing a potential threat to drivers, including anxiolytics, sedative hypnotics, antihistamines, and antidepressants, as well as describe potential strategies for mitigating or minimizing such risks.

Use of non-benzodiazepine sedative hypnotics and risk of falls in older men

BACKGROUND

To ascertain whether use of non-benzodiazepine sedative-hypnotics is associated with risk of falls and compare this to risk of falls associated with use of benzodiazepines.

METHODS

Among 4450 community-dwelling men, aged 71 years and older, enrolled in the population-based prospective cohort study, Osteoporotic Fractures in Men (MrOS), use of nonbenzodiazepine sedative-hypnotics and benzodiazepines was assessed by interview and verified from medication containers at the third annual visit of the MrOS study. Falls in the subsequent one-year period were ascertained by tri-annual questionnaires and a computerized dictionary used to categorize type of medication.

RESULTS

In age-adjusted models, non-benzodiazepine sedative hypnotic use was associated with an increased risk of any falls (one or more falls) (RR 1.44, 95% CI 1.15, 1.81) and recurrent falls (2 or more falls) (RR 1.51, 95% CI 1.07, 2.14). Use of benzodiazepines was associated with a similar increase in age-adjusted risk of falling. Depressive symptoms, inability to stand from a chair, and instrumental activities of daily living (IADL) impairment modestly attenuated these associations. The association between non-benzodiazepine sedative-hypnotic use and falls was most pronounced among men without a history of falls in the previous year: in a multivariable model controlling for multiple potential confounders, the RR of any falls was 1.74 (95% CI 1.13, 2.68) in this subgroup.

CONCLUSIONS

Use of non-benzodiazepine sedative-hypnotics is associated with an increased risk of falls. Non-pharmacologic approaches to sleep disturbances may represent the safest approach to sleep difficulties in older adults.

GABA and the GABAA receptor

The neurotransmitter gamma-aminobutyric acid (GABA) inhibits the activity of signal-receiving neurons by interacting with the GABAA receptor on these cells. The GABAA receptor is a channel-forming protein that allows the passage of chloride ions into the cells. Excessive GABAA activation may play a role in mediating the sedative effects of alcohol and other sedating and anesthetic agents. For example, alcohol enhances the GABAA-mediated chloride flow into cells and may thereby enhance neuronal inhibition. Alcohol's effects on the GABAA-receptor function likely involve other molecules (e.g., other neurotransmitters and proteins that add phosphate groups to the receptor [i.e., protein kinases]). Several experimental approaches also have suggested that changes in GABAA-receptor function contribute to the tolerance to and dependence on alcohol. Finally, individual differences in the GABA system may play a role in determining a person's susceptibility to developing alcohol dependence.