Pharmakotherapie der primären Insomnie - Über die Wirksamkeit, Sicherheit und Effektivität verschiedener Therapieoptionen

Die Wirksamkeit, Sicherheit und Effektivität der pharmakologischen Therapie insomnischer Beschwerden wurde in den letzten 20 Jahren vielerseits diskutiert. Im vorliegenden Artikel werden auf der Basis publizierter Metaanalysen die verschiedenen Behandlungsoptionen bestehend aus Benzodiazepin-Rezeptor-Agonisten, sedierenden Antidepressiva, Melatonin und alternativen Pharmakotherapien sowie kognitiv-verhaltenstherapeutischen Interventionen dargestellt und verglichen. Bis auf wenige Ausnahmen liegen bisher keine Langzeitstudien vor. Als gesichert scheint, dass die Benzodiazepin-Rezeptor-Agonisten in der Kurzzeitbehandlung der Insomnie zweifellos effektiv sind und sedierende Antidepressiva mittlerweile einen festen Platz in der Behandlung der chronischen Form einnehmen. Trotzdem sind weiterhin Langzeituntersuchungen notwendig, um zu belegen, dass diese pharmakologischen Substanzen langfristig effektiv und gut verträglich sind.

In the last 20 years efficacy, effectiveness and safety of the different drugs to treat chronic insomnia has been discussed extensively. Based on meta-analyses of the relevant literature an overview on the pharmacotherapy of insomnia and a comparison to cognitive behavioral therapy is given. Pharmacological options are benzodiazepine receptor agonists, sedating antidepressants, melatonin, and alternative pharmacotherapies, like herbal agents. The literature review shows that there are actually only a few long-term studies designed over months. It seems to be established that in short-term treatment benzodiazepine receptor agonists are clearly efficacious and it is obvious that sedating antidepressants have become almost ”mainstream” for the treatment of chronic insomnia. However, it is still absolutely necessary to test whether these substances are effective also in the long-term and are not harmful for the patients in the long run.

Key words

Insomnia - pharmacotherapy - benzodiazepine receptor agonists - sedating antidepressants - melatonin

Literatur

• 1 American Academy of Sleep Medicine. .The International Classification of Sleep Disorders. 2nd edition (ICSD-2). Westchester, Illinois 2005
• 2 Ancoli-Israel S, Roth T.. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation survey. I.  Sleep. 1999;  22
• 3 Backhaus J, Müller-Popkes K, Hajak G. et al. . Prevalence, diagnosis and treatment of insomnia in general practice.  J Sleep Res. 1998;  7
• 4 Backhaus J, Riemann D.. Schlafstörungen. Fortschritte der Psychotherapie. Bd. VII. Göttingen: Hogrefe 1999
• 5 Buscemi N, Vandermeer B, Hooton N. et al. . The efficacy and safety of exogenous melatonin for primary sleep disorders.  J Gen Intern Med. 2005;  20 1151-1158
• 6 Compton-McBride S, Schweitzer PK, Walsh JK.. Most commonly used drugs to treat insomnia in 2002.  Sleep. 2004;  27
• 7 Dündar Y, Boland J, Strobl J. et al. . Newer hypnotic drugs for the short-term management of insomnia: a systematic review and economic evaluation.  Health Technol Assess. 2004;  8 1-125
• 8 Dündar Y, Dodd S, Strobl J. et al. . Comparative efficacy of newer hypnotic drugs for the short-term management of insomnia: a systematic review and meta-analysis.  Hum Psychopharmacol. 2004;  19 305-322
• 9 Gillin JC, Sitaram N, Wehr T. et al. .Sleep and affective illness. In: Post RM, Ballenger JC (eds). Neurobiology of mood disorders, Vol. 1. Frontiers of clinical neuroscience. Baltimore: Williams & Wilkins 1984: 157-189
• 10 Glass J, Lanctôt L K, Herrmann N. et al. . Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.  BMJ. 2005;  331 1169-1175
• 11 Hajak G, Rodenbeck A, Voderholzer U. et al. . Doxepin in the treatment of primary insomnia: a placebo-controlled, double-blind, polysomnographic study.  J Clin Psychiatry. 2001;  62 453-463
• 12 Hohagen F, Montero RF, Weiss E. et al. . Treatment of primary insomnia with trimipramine: an alternative to benzodiazepine hypnotics?.  Eur Arch Psychiatry Clin Neurosci. 1994;  244 65-72
• 13 Holbrook AM, Crowther R, Lotter A. et al. . Meta-analysis of benzodiazepine use in the treatment of insomnia.  Can Med Assoc J. 2000;  162 225-233
• 14 Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW.. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison.  Arch Intern Med. 2004;  164 1888-1896
• 15 Krystal AD, Walsh JK, Laska E. et al. . Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia.  Sleep. 2003;  26 793-799
• 16 McClusky HY, Milby JB, Switzer PK. et al. . Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia.  Am J Psychiatry. 1991;  148 121-126
• 17 Morin CM, Culbert JP, Schwartz SM.. Non-pharmacological interventions for insomnia: A meta-analysis of treatment efficacy.  Am J Psychiatry. 1994;  151 1172-1180
• 18 Murtagh DR, Greenwood KM.. Identifying effective psychological treatments for insomnia: a meta-analysis.  J Consult Clin Psychol. 1995;  63 79-89
• 19 Nowell PD, Mazumdar S, Buysse DJ. et al. . Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy.  JAMA. 1997;  278 2170-2177
• 20 Ohayon MM.. Epidemiology of insomnia: what we know and what we still need to learn.  Sleep Med Rev. 2002;  6 97-111
• 21 Ohayon MM, Caulet M, Arbus L. et al. . Are prescribed medications effective in the treatment of insomnia complaints?.  J Psychosom Res. 1999;  47 359-368
• 22 Perlis ML, Giles DE, Mendelson WB. et al. . Psychophysiological insomnia: the behavioural model and a neurocognitive perspective.  J Sleep Res. 1997;  6 179-188
• 23 Riemann D.. Ratgeber Schlafstörungen. Göttingen: Hogrefe 2004
• 24 Riemann D, Voderholzer U.. Primary insomnia: a risk factor to develop depression?. J Affect Disord 2003: 255-259
• 25 Riemann D, Voderholzer U, Cohrs S. et al. . Trimipramine in primary insomnia: results of a polysomnographic double-blind controlled study.  Pharmacopsychiatry. 2002;  35 165-174
• 26 Shipley JE, Kupfer DJ, Griffin SJ. et al. . Comparison of effects of desipramine and amitriptyline on EEG sleep of depressed patients.  Psychopharmacology. 1985;  8 14-22
• 27 Smith MT, Perlis ML, Park A. et al. . Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia.  Am J Psychiatry. 2002;  159 5-11
• 28 Stevinson C, Ernst E.. Valerian for insomnia: a systematic review of randomized clinical trials.  Sleep Med. 2000;  1 91-99
• 29 Walsh JK, Schweitzer PK.. Ten-year trends in the pharmacological treatment of insomnia.  Sleep. 1999;  22 371-375
• 30 Zhang B, Wing K. Y. Sex differences in insomnia: a meta-analysis.  Sleep. 2006;  29 85-93

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