European guideline for the diagnosis and treatment of insomnia

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

[Algorithms for diagnosis and therapy of sleep disorders in general practice]. / Algorithmus zur Diagnostik und Therapie von Schlafstörungen. Schritt für Schritt auf dem Weg zum erholsamen Schlaf.

Complaints of insomnia, i.e. problems to fall asleep or maintain asleep and/or non-restorative sleep are very common in general practice. This article presents the clinical algorithm non-restorative sleep which was devised by the German Society for Sleep Research and Sleep Medicine. This algorithm presents a guideline for the diagnosis and the treatment of insomnia.

[NISAS-2000: The "Nationwide Insomnia Screening and Awareness Study". Prevalence and interventions in primary care]. / NISAS-2000: Die "Nationwide Insomnia Screening and Awareness Study." Prävalenz und Verschreibungsverhalten in der allgemeinärztlichen Versorgung.

AIM: To estimate the point prevalence of insomnia, recognition and prescription behavior in primary care. METHODS: Nationwide sample of 539 primary care settings along with their characterization (stage 1). Standardized assessment of all attenders (N = 19.155 patients) on the NISAS target day using a sleep questionnaire (PSQI) and additional questions to cover psychosocial and additional clinical variables. All patients were evaluated by the primary care doctors using a standardized clinical appraisal questionnaire, including a CGI-rating. RESULTS: Prevalence insomnia according to DSM-IV was 26.5%. Recognition of presence of any clinically significant sleep disorder was 72%, recognition of insomnia was poor 54.3%. 85.6% of insomnia patients were rated as chronic. Close to 50% of all insomnia cases did not receive a specific insomnia therapy. Herbals, followed by hypnotics and sedatives and antidepressants were the three most frequent treatments applied, psychotherapy was only seldomly indicated. DISCUSSION: NISAS provides for the first time nationally representative estimates of interventions for insomnia in primary care. The relatively low treatment rates and the high proportion of chronic patients receiving longterm prescription of benzodiazepines seem to be critical. Priorities for future agenda to improve this situation are discussed.

Sequential analysis of the brain's transfer properties during consecutive REM episodes.

Classical analysis of the spontaneous sleep EEG has revealed alterations of REM sleep in psychiatric diseases and under the influence of drugs. In order to elucidate possible functional differences between different REM episodes even in healthy subjects we investigated in 10 volunteers the transfer properties of the brain by measuring auditory (AEP) and visual evoked potentials (VEP) from scalp positions Fz, Cz and Pz during the night. According to linear system theory we computed the so-called amplitude-frequency characteristics (AFC) from averaged AEPs and VEPs during the first and each of the following 3 REM episodes. These functions describe the relationship between the input and output of the investigated system. A 3-factorial analysis of variances with the independent factors frequency band, REM episode and electrode position revealed a statistically significant main effect for the factor REM episode under auditory stimulation (P = 0.05), whereas no significant main effect for REM episode was found under visual stimulation (P = 0.88). Applying a 2-factorial analysis of variance with the independent factors REM episode and electrode position in the case of auditory stimulation we could demonstrate a statistically significant main effect (P = 0.029) for the factor REM episode in the beta range (12.5-20 Hz). A subsequent analysis of contrasts revealed that the first REM episodes could be differentiated from each other. For auditory stimulation the beta resonance during the first REM episode appears enhanced compared to each of the later REM episodes. These findings point to a functional difference of the brain's transfer functions between the first and the 3 following REM episodes, indicating different information processing during consecutive paradoxical sleep.

[Case report: treatment of a patient with sleep phase advance disorder with phototherapy]. / Kasuistik: Behandlung einer Patientin mit vorverlagerter Schlafphase mit Lichttherapie.

We report on a patient with a moderate form of a sleep-phase advance syndrome. As a biological correlate we found an early temperature and cortisol minimum before midnight, respectively. Light therapy during the evening hours (2500 Lux) given over 17 months induced a complete remission of the symptoms. The good treatment outcome could be maintained after the end of daily light therapy by only sporadic application.