Are there gender differences in the prescribing of hypnotic medications for insomnia?

Gender differences in the prescribing patterns of general classes of medications for insomnia were examined. The classes of medications included: zopiclone, antidepressants, benzodiazepines, antihistamines and no medication. The sample comprised a sub-set of respondents from 2620 questionnaires of the Canadian Multicentre Sleep Database. Respondents for this database were contacted through physicians, announcements in the media and local pharmacies. The results indicated that gender alone was not associated with differential prescribing for insomnia, nor was gender associated with patterns of medication use such as frequency of taking medication, length of use, taking more or less medication than prescribed or attempts to stop taking medication. Demographic factors were included in the analysis and age and marital status were associated with different prescribing patterns for men and women with insomnia. It is possible that physicians refer to stereotypic expectations when prescribing hypnotics.

Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of excessive daytime sleepiness in narcolepsy.

Seventy-five patients meeting international diagnostic criteria for narcolepsy enrolled in a 6-week, three-period, randomized, crossover, placebo-controlled trial. Patients received placebo, modafinil 200 mg, or modafinil 400 mg in divided doses (morning and noon). Evaluations occurred at baseline and at the end of each 2-week period. Compared with placebo, modafinil 200 and 400 mg significantly increased the mean sleep latency on the Maintenance of Wakefulness Test by 40% and 54%, with no significant difference between the two doses. Modafinil, 200 and 400 mg, also reduced the combined number of daytime sleep episodes and periods of severe sleepiness noted in sleep logs. The likelihood of falling asleep as measured by the Epworth Sleepiness Scale was equally reduced by both modafinil dose levels. There were no effects on nocturnal sleep initiation, maintenance, or architecture, nor were there any effects on sleep apnea or periodic leg movements. Neither dose interfered with the patients' ability to nap voluntarily during the day nor with their quantity or quality of nocturnal sleep. Modafinil produced no changes in blood pressure or heart rate in either normotensive or hypertensive patients. The only significant adverse effects were seen at the 400-mg dose, which was associated with more nausea and more nervousness than either placebo or the 200-mg dose. As little as a 200-mg daily dose of modafinil is therefore an effective and well-tolerated treatment of excessive daytime somnolence in narcoleptic persons.

Forensic sleep medicine: nocturnal wandering and violence.

Forty-one subjects between 12 and 63 years of age with a complaint of nocturnal wandering were reviewed retrospectively, and a prospective investigation of their compliance to treatment was performed. Twenty-nine of 41 subjects committed violence against themselves or others ("violent group"). Clinical investigation of their problem involved polysomnography, wake and sleep EEGs and ambulatory EEG recording in the home environment. The nocturnal wandering may have started from NREM sleep or REM sleep, and violence was observed in both of these sleep states. Arousal from sleep may have been triggered by sleep-disordered breathing or may have been related to temporal lobe abnormalities, and, in some cases, no abnormal polygraphic features were noted. Violence was always preceded by many instances of nocturnal wandering that had received little clinical attention. Temporal lobe abnormalities, a rare cause of nocturnal wandering, were present only in the "violent" group. This group also had a higher percentage of men than the "nonviolent" group. In both groups, the frequency of nocturnal wandering increased with an increase in daytime stressors. Pharmacological and psychiatric treatment approaches were beneficial in both groups.

Differential illness intrusiveness associated with sleep-promoting medications.

Differences in daytime sleepiness, lifestyle disruptions, and emotional distress were compared across nine groups taking sleep-promoting substances. Groups included individuals taking zopiclone (n = 274), amitriptyline (n = 107), lorazepam (n = 258), oxazepam (n= 141), diphenhydramine HCl (n = 99), triazolam(n = 137), long acting benzodiazepines (n = 120), temazepam (n = 176), and miscellaneous other medications (n = 286). Data were gathered by self-report, using standardized instruments in a mail-back questionnaire procedure. Respondents included the first 1,598 participants enrolled in a Canadian multicentre project, including six sites attached to academic psychiatric units. Results indicated that quality of life effects differed across groups in both daytime sleepiness and lifestyle disruptions (illness intrusiveness), but not in depressive symptoms. Daytime sleepiness was significantly higher among people taking diphenhydramine HCl as compared to temazepam, zopiclone, lorazepam, and oxazepam. Illness intrusiveness was significantly higher among patients taking amitriptyline as compared to those taking triazolam, oxazepam, long-acting benzodiazepines, and zopiclone. It may be useful to inform patients of differences in psychosocial outcomes when prescribing hypnotic medications.

The positive diagnosis of narcolepsy and narcolepsy's borderland.

We studied the validity of cataplexy and number of sleep-onset rapid-eye-movement periods (SOREMPs) during one Multiple Sleep Latency Test (MSLT) as determinants of narcolepsy in 306 subjects with excessive daytime sleepiness not related to obstructive sleep apnea or other known syndromes. The subgroup defined by a history of cataplexy was the most homogeneous in clinical and polygraphic variables. However, only 83% of these subjects had two or more SOREMPs in one MSLT. The subgroup defined by two or more SOREMPs included many patients without cataplexy. A disproportionate number of these subjects were older women whose chances of developing cataplexy are remote. This group of older women had a higher number of periodic leg movements during sleep than the other groups. Patients with both cataplexy and two or more SOREMPs have the greatest chance of being DR2 DQw1 positive. Thus, the combination of history of cataplexy and two or more SOREMPs is the best clinical determinant of narcolepsy. However, two or more SOREMPs is a poorer discriminant of narcolepsy than history of cataplexy.

Violence association with sleep disorders - abstract

Over the past few years, there have been isolated court cases in which defendants are acquitted for violent acts and, in one case, homicide because of sleep disorders which appeared to precipitate the violence. The literature has been scanty and the authors decided to follow up with some sleep lab observations. The presentation will include a brief summary about sleep states and findings which show sleep abnormalities under laboratory conditions. There will be a video presentation of violent behaviour and a brief discussion about the potential for further studies (AU)

Patient assaults on psychiatric residents: the Canadian experience.

There have been fairly limited reports in the literature of assaults on residents in psychiatric facilities. Assaults on residents and staff tend to be underreported and, for a variety of reasons, not adequately dealt with by the administration. For this reason, security in psychiatric facilities may be lacking in many instances. In order to prepare a position paper of guidelines specifying minimum security requirements for psychiatric facilities in Canada, the Residents' Section of the Canadian Psychiatric Association gathered data on this issue from psychiatric residents. We present the results of a questionnaire sent to all psychiatric residents who are members of the Canadian Psychiatric Association. Results indicate that 40.2% of residents have been assaulted at least once. We present some interesting findings that relate to the residents' perception of their training and the appropriateness of the facilities for assessing patients. Requests for improved security were made by 36.9% of the residents, but only 22.9% of this group found the response by acceptable. Some of the residents' explanations for the assaults suggest interesting dynamics. These and other findings suggest an urgent need to address this issue.