Pharmacological correction of sleep disorders. Medicinal methods for the treatment of insomnia Treatment of insomnia pharmacology

IN This review by American authors provides recommendations for the practical treatment of insomnia and the scientific basis for modern treatments. Insomnia tends to increase with age and is more common among women, although laboratory studies show that older men are more affected by sleep disturbance. Divorced, widowed, or separated people are more likely to report insomnia than married people; low socioeconomic status is also correlated with insomnia. Persistent insomnia is a risk factor and a harbinger of depression. Thus, effective treatment of insomnia may make it possible to prevent major depression. Chronic insomnia has also been linked to an increased risk of car accidents, increased alcohol consumption, and daytime sleepiness. Therefore, patients suffering from insomnia deserve serious attention.
The duration of insomnia in a patient is of great diagnostic value. Short-term insomnia lasting only a few days is often the result of severe stress, acute illness, or self-medication. Insomnia lasting more than three weeks is considered chronic and usually has a variety of causes. Diagnostic and pharmacotherapeutic findings depend on whether the symptoms are transient or chronic.
Chronic primary insomnia is diagnosed when there is difficulty in inducing or maintaining sleep, or when there is no restorative sleep for at least an entire month, causing significant distress or impairment of social, occupational, or other important functions. The sleep disturbance in primary or psychophysiological insomnia is not caused by some other cause of the sleep disturbance, a psychiatric disorder, or drug exposure.
Doctors should try to determine the cause of insomnia.
The first step is to identify the main symptom of sleep - for example, insomnia, excessive sleepiness or restless behavior during sleep. Physicians should then consider possible causes, which include: comorbid conditions or their treatment; the use of substances such as caffeine, nicotine or alcohol; mental disorders (state of anxiety, fear); acute or chronic stress, such as occurs as a result of bereavement (loss of loved ones); violation of circadian rhythms (caused by night shifts); sleep apnea (accompanied by snoring or obesity); nocturnal myoclonus (convulsive muscle twitching), etc.
The most common obstacle in establishing a diagnosis is the difficulty in understanding that chronic insomnia has many causes.

Behavioral Therapy

Patients should be taught to go to bed only when they feel sleepy and to use the bedroom only for sleep and sex, not for reading, watching TV, eating, or working. If patients cannot fall asleep after 15-20 minutes in bed, they should get out of bed and move to another room. They should read in low light and avoid watching television, which emits bright light and therefore has an exciting effect; Patients should only go back to bed when they feel like sleeping. The goal is to restore the psychological connection between the bedroom and sleep, not between the bedroom and insomnia. Patients should get out of bed at the same time each morning, regardless of how much sleep they had during the previous night. This stabilizes the sleep-wake schedule and improves sleep efficiency. Finally, short naps during the daytime should be minimized or avoided altogether to increase the drive to sleep at night. If the patient needs daytime naps, a 30-minute nap at noon will probably not disturb sleep at night.
Another useful behavioral intervention that has been shown to be effective is limiting bedtime to only actual sleep time. This approach, known as sleep restriction treatment, has been shown to be effective in a randomized clinical trial with older people. This method allows for a slight "accumulation of sleep debt", which increases the patient's ability to fall asleep and stay asleep. The time allowed to stay in bed is gradually increased, as much as is required for a good sleep. For example, if a patient with chronic insomnia sleeps 5.5 hours at night, his time in bed is limited to 5.5-6 hours. The patient then adds approximately 15 minutes per week to the start of each nightly bed time, getting up at the same time each morning, until at least 85% of bed time is spent sleeping.

Treatment with drugs

Rational pharmacotherapy of insomnia, especially chronic insomnia in adults and senile people, is characterized by five basic principles: use the lowest effective doses; use hopping dosage (two to three times a week); prescribe medicines for short-term use (i.e., regular use for no more than three to four weeks); stop using the medicine gradually; and to ensure that insomnia does not recur after it has ceased. In addition, drugs with a short half-life are generally preferred to minimize daytime sedation. Alcohol and over-the-counter drugs (such as antihistamines) have only minimal effect in inducing sleep, further disrupting sleep quality, and adversely affecting performance the next day. In table. Table 1 lists the sedative hypnotic drugs that are commonly prescribed, with information on dose (adults and seniles), onset of action, half-life, and the presence or absence of active metabolites. In table. Table 2 lists the most commonly used drugs that interfere with sleep.
Table 1. Drugs commonly prescribed

to treat insomnia

Based on clinical efficacy trials in adult patients with chronic insomnia, the authors reviewed 123 controlled drug trials (total number of patients 9114) and 33 controlled behavioral intervention trials (1324 patients). American researchers have concluded that the subjective symptoms and objective signs of chronic insomnia respond to brief behavioral and pharmacological interventions. Both interventions characteristically reduce the amount of time it takes to fall asleep by 15-30 minutes compared to the time before treatment, and the frequency of waking by one to three per night. Although pharmacological agents seem to work more reliably in the short term, and behavioral interventions seem to produce longer-term effects, there are no direct comparisons based on long-term efficacy. Based on data from controlled trials, benzodiazepines, zolpidem, antidepressants, and melatonin (only one controlled trial) are effective pharmacological agents. Stimulus control, sleep restriction, relaxation strategies, and cognitive behavioral therapy are effective behavioral interventions for short-term treatment.
Table 2 Commonly prescribed drugs that

known to cause insomnia

The authors controlled randomized double-blind trials in elderly patients with chronic insomnia due to various causes. In 23 trials involving 1,082 patients, including 516 psychogeriatric patients or residents of nursing homes, Pittsburgh psychiatrists found scientific evidence for the short-term (up to three weeks) efficacy of zolpidem and triazolam in the elderly, as well as temazepam, flurazepam, and quazepam. but not chloral hydrate.
The half-life of sedative hypnotics is highly variable. Side effects such as mental decline, weakness, excessive sleepiness, and accidents are much more common at high doses and when active metabolites accumulate. Flurazepam and quazepam have the longest half-lives (from 36 to 120 hours) and therefore have the advantage of providing an anxiolytic effect the next day and reducing the likelihood of recurrence of insomnia. However, prolonged use of these drugs can lead to daytime sleepiness, impaired cognition and coordination, and worsened depression. Drugs with an intermediate half-life (10 to 24 hours) without active metabolites include temazepam and estazolam. They are less likely to be associated with excessive daytime sleepiness. Drugs with very short elimination times (2 to 5 hours) include triazolam and zolpidem.
The efficacy of zolpidem, one of the imidazopyridines, was found to be similar to that of benzodiazepines in the study of acute and chronic insomnia. Although both zolpidem and benzodiazepines exert their effects through modulation of the GABA (gamma-aminobutyric acid) receptor complex, zolpidem is less likely than benzodiazepines to disrupt sleep patterns and have side effects on cognition and psychomotor abilities (and may have less effect on sleep syndrome). cancellation). Although these potential benefits suggest that zolpidem may be useful in the treatment of acute and chronic insomnia because it acts through the GABA receptor complex, it theoretically carries the same risk, including addiction, as benzodiazepines and, as a result, its use for more than 4 weeks is usually discouraged.
Before prescribing any sleeping pills, the physician must consider the underlying safety concerns. For example, pregnant women, as well as patients with possible sleep apnea, which may be exacerbated by the use of hypnotics, and patients suffering from renal or hepatic insufficiency, may be at greater risk of side effects of sedatives. Physician concerns about possible dependence on benzodiazepines and zolpidem and their side effects, along with control needs such as triplicate prescriptions, have led in recent years to a 30% decrease in benzodiazepine prescriptions and a 100% increase in the use of antidepressants as hypnotics.
Serotonin-specific antidepressants such as trazodone and paroxyten relieve the sleep disturbance that accompanies depression and have fewer side effects than tricyclic antidepressants. The beneficial effects of serotonin-specific antidepressants in chronic insomnia have not yet been systematically evaluated. It is possible that the use of treatment with a safe serotonergic antidepressant could reduce the burden of chronic insomnia and prevent dangerous depression. Antidepressants are now widely used, and prescribed at lower doses, to treat insomnia than depression. This practice has spread in the absence of data from controlled clinical trials. It is possible that the use of treatment in which a low dose of antidepressants (eg, 20 mg of paroxitene per day) can both improve sleep and help prevent depression in chronic insomnia

Description:

Insomnia is a disorder characterized by difficulty in falling asleep or maintaining sleep. Moreover, insomnia is characterized by poor sleep quality, causing physical and emotional symptoms during the daytime, which affects social and cognitive performance.

Insomnia is a common disorder that is difficult to diagnose and treat and requires a clear strategy and planning. Insomnia, whether it is a symptom, a syndrome or a disorder in its own right, has serious occupational, social consequences and imposes a significant economic burden on society. The Brazilian Sleep Association has developed new guidelines for the diagnosis and treatment of insomnia in adults and children, which have been published in the journal Arquivos de Neuro-Psiquiatria (2010; 68 (4): 666-675). The paper discusses general issues related to sleep problems, as well as methods for clinical and psychosocial assessment, diagnosis, selection and prescription of drug and psychotherapeutic treatment.

In November 2008, at the initiative of the Brazilian Society of Sleep Medicine, various experts in the field of sleep medicine were invited to São Paulo to discuss the creation of new guidelines for the diagnosis and treatment of insomnia. At this event, the following topics were considered: clinical and psychosocial verification of the diagnosis, recommendations for polysomnography, pharmacological treatment, behavioral and cognitive therapy, comorbidities in children.

Types of insomnia (insomnia):

1. Adaptive insomnia (acute insomnia). This sleep disorder occurs against the background of acute stress, conflict, or a change in environment. The result is an increase in the overall activation of the nervous system, which makes it difficult to enter sleep during the evening falling asleep or awakening at night. With this form of sleep disorders, it is possible to determine with great certainty the cause that caused them; adaptive insomnia lasts no more than three months.

2. Psychophysiological insomnia. If sleep disturbances persist for a longer period, they are “overgrown” with psychological disorders, the most characteristic of which is the formation of “fear of sleep”. At the same time, somatized tension increases in the evening hours, when the patient tries to “force” himself to fall asleep sooner, which leads to aggravation of sleep disorders and increased anxiety the next evening.

3. Pseudoinsomnia. The patient claims that he sleeps very little or does not sleep at all, however, when conducting a study that objectifies the picture of sleep, the presence of sleep in excess of subjectively felt is confirmed. Here, the main symptom-forming factor is a violation of the perception of one's own sleep, associated primarily with the peculiarities of the sense of time at night (periods of wakefulness at night are well remembered, and periods of sleep, on the contrary, are amnesic), and fixation on problems of one's own health associated with sleep disturbance.

4. Idiopathic insomnia. Sleep disturbances in this form of insomnia are noted from childhood, and other causes of their development are excluded.

5. Insomnia in mental disorders. 70% of patients with neurotic mental disorders have problems initiating and maintaining sleep. Often, sleep disturbance is the main “symptomatic” radical, due to which, according to the patient, numerous “vegetative” complaints develop (headache, fatigue, palpitations, blurred vision, etc.) and social activity is limited.

6. Insomnia due to poor sleep hygiene. In this form of insomnia, sleep problems occur as a result of activities leading to increased activation of the nervous system in the periods prior to bedtime. This may be drinking coffee, smoking, physical and mental stress in the evening, or other activities that prevent the initiation and maintenance of sleep (laying down at different times of the day, using bright lights in the bedroom, an uncomfortable environment for sleeping).

7. Behavioral insomnia of childhood. It occurs when children form incorrect associations or attitudes related to sleep (for example, the need to fall asleep only when motion sickness, unwillingness to sleep in their own crib), and when they try to remove or correct them, the child shows active resistance, leading to a reduction in sleep time.

8. Insomnia in somatic diseases. Manifestations of many diseases of the internal organs or the nervous system are accompanied by a violation of night sleep (hungry pain with peptic ulcer, nocturnal, painful neuropathies, etc.).

9. Insomnia associated with taking medications or other substances. The most common insomnia occurs with the abuse of sleeping pills and alcohol. At the same time, the development of an addiction syndrome (the need to increase the dose of the drug to obtain the same clinical effect) and dependence (the development of a withdrawal syndrome when the drug is stopped or its dose is reduced) is noted.

Accompanying illnesses:

1. Syndrome of obstructive sleep apnea.
In 1973, Guilleminault and colleagues described an association between insomnia and obstructive sleep apnea; This phenomenon became known as "obstructive sleep apnea syndrome". The relationship between these two common sleep disorders is complex and not fully understood. There is an increased incidence of respiratory distress in patients with insomnia compared to the general population. The severity of insomnia symptoms is directly related to the severity of apnea, thus determining their comorbidity. Lishtein and colleagues have shown that a significant number of individuals, especially the elderly, have a combination of these two conditions: undiagnosed sleep apnea syndrome and insomnia. Thus, polysomnography can help detect significant breathing problems associated with insomnia.
Women in the peri- and postmenopausal period are more likely to suffer from insomnia compared to women of childbearing age. Hormone replacement therapy (estrogen and progesterone) improves the quality of sleep and has a beneficial effect on the symptoms of obstructive sleep apnea syndrome. Benzodiazepines cause sedation, decreased airway muscle tone, and decreased ventilation, leading to hypoxemia. In this regard, in the presence of the syndrome of obstructive sleep apnea, the appointment of drugs of this group is not recommended. The use of various devices to improve the airway (for example, based on the creation of positive air pressure) also negatively affects the quality of sleep, especially during the adaptation phase.

Insomnia, known in scientific circles as insomnia, can be a symptom of a medical condition, but it often appears on its own. Psychological and physical overstrain, stress, increased excitability of the nervous system and other factors can adversely affect the quality of a night's rest.

Fund types

If the sleep phases are disturbed, a person cannot fall asleep for a long time or he has nightmares, this significantly worsens the quality of life. Sleep deprivation can cause the following problems:

• daytime sleepiness;
• decrease in working capacity;
• increased irritability;
• problems with the work of the cardiovascular system;
• inhibition of reaction, etc.

Insomnia medications will help prevent such consequences. The most effective drugs will be prescribed to you by a somnologist - a doctor who studies and treats sleep disorders. The specialist also looks for the problem that caused the violation, and chooses a way to eliminate it.

The best remedy for insomnia will be different for each patient.. Pharmacists, homeopaths and traditional healers offer various ways to get rid of this problem. The choice falls on one or another drug or technique, depending on what exactly provoked the sleep disorder, how old the patient is, whether he has concomitant acute and chronic diseases, and other factors.

Pharmacological remedies for insomnia are divided into the following types:

• Prescription drugs are dispensed only with a prescription from the attending physician;
• over-the-counter synthetic sleep aids;
• herbal preparations for insomnia;
• combined remedies for insomnia, which contain both herbal and chemical components.

Homeopathic preparations for the treatment of insomnia can also be singled out separately. They have practically no side effects, are not addictive, have a minimum of contraindications and are suitable for treatment even for children.

However, these funds do not give results immediately, only after completing a full course, you will see improvements. A separate category is non-drug methods, among which are:

• traditional medicine for sleep;
• acupuncture (acupuncture);
• hypnosis;
• self-hypnosis, etc.

Sleeping pills can only be taken for a certain time, abuse leads to negative reactions and the development of complications.

Herbal sleeping pills

If you have recently been worried about insomnia, it is best to choose herbal medicines. The natural composition is not as dangerous to the body as the chemical one. In addition, the drugs are not addictive, after the end of therapy you will not feel physical or psychological attachment to them. Herbal preparations are dispensed mainly without a prescription. Let's get acquainted with them in more detail.

OTC drugs

You can choose the best medicine for insomnia among drugs that are available without a prescription. They are prescribed for mild or moderate sleep disorders.

Medicines can be natural, synthetic or combination. They have a minimum of contraindications, but before use, you still need to consult a doctor.

Let's take a closer look at what you can drink to get a good night's sleep.

Medicines for this type of insomnia are potent psychotropic drugs. They are released only by prescription, are strictly dosed individually for each patient, give side effects and have a lot of contraindications. They are prescribed to restore the functioning of the central nervous system.

Properly selected therapy with the use of such drugs allows patients to get rid of anxiety and unreasonable fear, restore joy to life, normalize sleep, improve performance and appetite.

The most common tranquilizer drug is Phenazepam. Its active substance,epine, normalizes the functioning of the central nervous system and eliminates the causes that cause insomnia. The tool is very good and effective, but can cause side effects such as nausea, heartburn, fatigue, drowsiness, disorientation in space, dizziness and allergies.

Homeopathy for insomnia

While medicines can cause side effects and have a lot of contraindications, homeopathy can treat insomnia without harm to health. The natural composition makes the preparations completely safe for the body, and the low concentration of active substances eliminates overdose. You can use the following effective sleeping pills to normalize a night's rest:

• improves the quality of sleep;
• eliminates anxiety and aggression;
• accelerates falling asleep;
• fights chronic fatigue;
• improves mood;
• prevents nervous tension.

The effectiveness of the product is provided by its active substances. It was based on gaba alishan - the discovery of the Japanese scientist Tsushida. It stabilizes blood circulation and normalizes the utilization of glucose, strengthens memory, improves sleep, eliminates melancholy and disorders of the nervous system.

Also included is a beaver stream - an antispasmodic and sedative substance that improves tone and mood. Lofant plant extract prevents aging, has bactericidal properties, improves the functioning of the nervous system.

Also, the drug contains a collection of 32 herbs, the action of which is aimed at restoring sleep, normalizing pressure and heart rate, relaxation and relaxation.

These properties of the tool endowed with its natural natural components. The composition includes a beaver stream, which is used to treat nervous disorders and disorders of the cardiovascular system. Alishan gaba is also highly effective - a natural product that strengthens the entire body and improves sleep quality. A collection of 32 herbs provides the patient with complete relaxation and relaxation, lofant extract stabilizes the nervous system, has a bactericidal effect and slows down aging.

It is worth consulting a doctor to find out which traditional medicine medicines will have the desired effect and will not harm your health. The course prescribed by the specialist must be completed to the end, otherwise you will not receive any improvements.

There are various recipes that can be used to normalize a night's rest, we will look at them in more detail.

In conclusion

Official and traditional medicine offers effective drugs to combat insomnia. They may contain plant and chemical components. The most powerful drugs are tranquilizers, they are available only by prescription.

For those who do not want to risk their health, homeopathic remedies have been invented, consisting of natural substances.

Before using any method of treating sleep disorders, you should consult a doctor so as not to harm your health.

There are currently three generations of sleep-improving drugs on the pharmaceutical market.

The first generation drugs are barbiturates, paraldehyde, antihistamines, propanediol, chloral hydrate. Hypnotics of the second generation are represented by a wide range of benzodiazepine derivatives - nitrazepam, flunitrazepam, midazolam, flurazepam, triazolam, estazolam, temazepam. third generation- non-benzodiazepine hypnotics - includes relatively new drugs - a cyclopyrrolone derivative (zopiclone) and an imidazopyridine derivative (zolpidem).

Given the variety of sleeping pills and to unify their use, several general principles for their application.

1. It is better to start the treatment of insomnia with herbal sleeping pills. These drugs create the least problems for patients taking them and can be easily discontinued in the future.
2. Use "short-lived" preparations such as zopiclone. These drugs usually rarely cause lethargy and drowsiness during wakefulness.
3. The duration of the use of sleeping pills should not exceed three weeks (optimally - 10-14 days). For such a period, as a rule, addiction and dependence are not formed and there are no problems when the drug is discontinued. This principle is quite difficult to follow, since a significant part of patients prefer to use drugs than painfully endure sleep disorders.
4. Patients of older age groups should be prescribed half (in relation to middle-aged patients) daily dosage of hypnotics, and also take into account their possible interaction with other drugs.
5. Patients receiving long-term hypnotic drugs need to spend "drug holidays", which allows you to reduce the dose of this drug or change it, especially for those patients who use benzodiazepine drugs for a long time. Some help in these cases can be provided by herbal medicine, carried out as part of the "drug holidays".

Benzodiazepines. The first drug in this group, chlordiazepoxide (Librium), has been used since the early 1960s. XX century. To date, about 50 drugs of this series are used. As hypnotics, drugs with the most pronounced hypnotic component are prescribed: brotizolam, midazolam, triazolam (half-life 1-5 hours), nitrazepam, oxazepam, temazepam (half-life 5-15 hours), flunitrazepam, flurazepam (half-life 20-50 h.). Their use is associated with certain problems for patients, such as addiction, dependence, "withdrawal" syndrome, worsening of "sleep apnea" syndrome, memory loss, decreased attention and reaction time, daytime sleepiness. In addition, other complications of benzodiazepine therapy are possible, such as dizziness, ataxia, and dry mouth.

Ethanolamines. Their hypnotic effect is due to the blockade of the effects of histamine, one of the leading mediators of wakefulness. The only hypnotic drug of this group used in Russia is donormil (doxylamine). Effervescent, soluble, divisible tablets of donormil contain an average therapeutic dose of 15 mg. The hypnotic effect is less effective than benzodiazepines. This drug is characterized by a decrease in the time to fall asleep, the incidence of sudden awakenings and a decrease in motor activity during sleep. Among the side effects prevail: dry mouth, constipation, dysuria, fever. Contraindicated in angle-closure glaucoma and prostate adenoma.

Cyclopyrrolones. These include: zopiclone (imovan, somnol, piclodorm, relaxon). The drug is rapidly absorbed from the gastrointestinal tract; its peak plasma concentration is reached after 100 minutes, and the hypnotic threshold is within 30 minutes after taking 7.5 mg. The half-life of zopiclone in adults is 5-6 hours. In the elderly, the accumulation of the drug in the body with prolonged use is minimal. Zopiclone reduces the latent period of sleep, the duration of the first stage, does not significantly change the duration of the second stage, increases the duration of delta sleep and REM sleep, if its duration was reduced before treatment. The optimal therapeutic dose is 7.5 mg; overdoses are relatively safe.

Imidazopyridines. The main representative is zolpidem (ivadal). It differs from the previously mentioned drugs in the least toxicity. Zolpidem is a sleeping pill that does not cause addiction, dependence, and lethargy during the day. Due to the short half-life, it can be used not only at bedtime, but also in the middle of the night in patients who wake up at two to three in the morning. Zolpidem reduces the time to fall asleep and wakefulness within sleep, increases the representation of delta sleep and REM sleep, the most functionally important components of sleep. As a rule, morning awakening after taking the recommended dose of the drug is easy, patients do not show signs of drowsiness, lethargy and fatigue. Zolpidem in its parameters most fully meets all the requirements for sleeping pills.

Melatonin. Melatonin is a hormone produced by the pineal gland, retina and intestines. The biological effects of melatonin are diverse: hypnotic, fever-reducing, anti-cancer, adaptogenic, synchronizing. However, in most cases it is used as a hypnotic, since this substance is maximally synthesized in the dark - its content in human blood plasma at night is 2-4 times higher than during the day. Melaxen is registered in Russia and contains 3 mg of melatonin. Melatonin accelerates falling asleep and normalizes the structure of the sleep/wake cycle.

tryptophan- a natural amino acid that turns into melatonin. Helps to relax and sleep. Found in turkey meat, milk, cheese. It is better absorbed together with vitamin B6 (many in wheat germ, beef liver, bananas, sunflower seeds).

Magnesium- a mineral that is rich in wheat bran, brewer's yeast, almonds, cashews, seaweed. Has a sedative effect. Take 400 mg one hour before bedtime.

Chromium helps with sharp jumps in blood sugar levels, from which a person wakes up in the middle of the night. It is taken at 200-300 mg, preferably together with vitamin C.

The term "sleep disorder - dyssomnia" in the International Classification of Diseases of the 10th revision (ICD-10) is commonly understood as a violation of the quantity, quality or time of sleep, which in turn can lead to daytime sleepiness, difficulty concentrating, memory impairment and state of anxiety.

To describe sleep disorders, a two-component model was created that takes into account both subjective and objective signs of disorders. The authors of this model proceeded from the following assumption: “the clinical picture of clinical “bad” sleep occurs when and only when the somatic disturbance of the rhythm of sleep and wakefulness coincides with the patient’s increased neurotic tendency to complain.” But this model can also be considered dynamically: the initially organically conditioned disruption of the rhythm of the change of sleep and wakefulness can enhance reflection and a tendency to complain. On the other hand, external and internal conflict can cause tension or arousal that negatively affects sleep, and disturbed sleep, in turn, can itself have a negative negative impact on the mental state.

As Yu. A. Aleksandrovsky notes, from the point of view of mental activity, sleep is an extremely important factor, since its deprivation leads to irritability, drowsiness, and difficulties in solving interpersonal and professional problems. Mental exhaustion requires sleep much more often than physical fatigue. However, the ratio of sleep and wakefulness largely depends on the emotional state of a person and his satisfaction with life.

Epidemiological studies conducted abroad indicate that at least 35% (28-45%) of the adult population suffer from sleep disorders (for comparison, according to WHO, patients with diabetes make up 3%, AIDS patients - 3%). The spectrum of these disorders is wide and includes more than 70 nosological entities closely related to pulmonology, neurology, epileptology, cardiology, pediatrics, resuscitation, otolaryngology and dentistry. Persistent insomnia is a risk factor and precursor to depression. Thus, early diagnosis and effective treatment of insomnia can prevent severe depression, often leading to suicide. Chronic insomnia is also associated with an increased risk of car accidents, alcohol and other substance use. Short-term insomnia, lasting only a few days, is often the result of mental stress, an acute illness, or the thoughtless use of various medications for self-medication. Millions of people suffer from disturbed sleep due to social lifestyle factors. People who are divorced, widowed or separated, and those who are poor are more likely to suffer from insomnia. Diagnostic and therapeutic findings depend on whether the symptoms of disturbed sleep are transient or chronic.

At the same time, despite the high relevance of the study of sleep and the impact of sleep disorders on the quality of life, the issues of somnology have not yet received sufficient coverage in educational programs for a wide range of practicing physicians.

Diagnosis of sleep disorders should precede treatment.

Modern classification of sleep disorders includes insomnia, hypersomnia and parasomnia. The term "insomnia" has a subjective connotation, while the term "insomnia" is scientifically based. "Insomnia" is defined as a state of difficulty in initiating and maintaining sleep, often in combination with daytime weakness, weakness, decreased performance and drowsiness. "Insomnia" is a painful symptom and requires a medical approach to diagnosis and treatment. This approach, first of all, requires the differential diagnosis of these disorders. The causes of insomnia are diverse: 1) psychophysiological

reactions to stressful influences; 2) neurotic disorders; 3) endogenous mental illnesses; 4) somatic diseases; 5) abuse of psychotropic drugs and alcohol; 6) endocrine - metabolic diseases; 7) organic diseases of the brain; 8) syndromes that occur during sleep (sleep apnea syndrome, movement disorders in sleep); 9) pain phenomena; 10) changes in time zones; 11) constitutionally determined shortening of night sleep.

The clinical phenomenology of insomnia includes presomnic, intrasomnic, and postsomnic disorders.

Presomnic disorders are problems with falling asleep. With the long-term existence of presomnic disorders, obsessive-compulsive symptoms are formed in the form of “going to bed rituals”, “fear of bed”, “fear of not being able to fall asleep”. A polysomnographic study of these patients noted a significant increase in the time to fall asleep, frequent transitions from stages I and II of the first sleep to wakefulness.

Intrasomnic disorders include frequent nocturnal awakenings, after which the patient cannot fall asleep for a long time, and a feeling of "shallow" and "shallow" sleep. The polysomnographic correlates of these sensations are a significant representation of the superficial stages of sleep (I, II FMS - phases of slow sleep), frequent awakenings, long periods of wakefulness within sleep, reduction of delta sleep, and an increase in motor activity during sleep.

Postsomnic disorders are early awakenings (beyond the division of people into "owls" and "larks") and disorders that occur shortly after awakening. This group includes poor health immediately after sleep and the phenomenon of "sleep intoxication", when active wakefulness comes slowly. With these disorders, patients are dissatisfied with the night spent and characterize their sleep as

"non-restorative". They experience a feeling of "brokenness" and reduced performance. Postsomnic disorder can also be attributed to imperative daytime sleepiness, which occurs in 56% of patients.

The algorithm of the diagnostic process and the choice of therapy consists of the following elements

A) Differential diagnosis and identification of the causes of insomnia.

First, the leading symptom of sleep disorders is determined - insomnia, excessive sleepiness or restless behavior during sleep. The possible causes of sleep disturbances should then be considered, which include: comorbid conditions or their treatment; the use of substances such as caffeine, nicotine or alcohol; mental disorders (states of depression, anxiety or fear); acute or chronic stress; violation of daily rhythms; sleep apnea (accompanied by snoring or obesity); nocturnal myoclonus. Depression requires special attention, which requires the appointment of antidepressants. In most depressed patients, sleep disorders are manifested by the following features: 1) sleep disturbance and interrupted sleep with early

awakening; 2) decrease in the depth of sleep (slow waves, stages 3 and 4), primarily in the first sleep cycle; 3) shortened first non-REM sleep period (stages 2-4), which leads to premature entry into the first REM sleep phase (shortened REM latency); 4) uniform distribution of REM - sleep in all phases of sleep.

B) Accounting for the effects of drugs that cause insomnia.

When identifying the causes of insomnia, internists should be aware that some drugs commonly prescribed by general practitioners (not psychiatrists) cause sleep disturbances. The following groups of drugs that contribute to the occurrence of sleep disorders are distinguished:

1) antihypertensive drugs;

2) stimulants of the central nervous system;

3) anticancer drugs;

4) beta - blockers;

5) hormones;

6) oral contraceptives;

7) thyroid preparations;

8) anticholinergics;

9) sympathomimetic agents;

10) bronchodilators;

11) decongestants;

12) commercially available cough and cold preparations.

B) Behavioral therapy for insomnia.

Treatment of insomnia should begin with hygiene measures aimed at changing behavior. Patients should be taught to go to bed only when they feel sleepy, to use the bedroom only for sleeping and intimate life, and not for reading, watching TV, eating or working. If patients cannot fall asleep within 15 to 20 minutes of being in bed, they should get out of bed and move to another room. At this time, it is not recommended to watch TV, and you should read in low light. Patients should only go back to bed when they feel like sleeping. The goal is to restore the psychological connection between the bedroom and sleep, not between the bedroom and insomnia. In case of sleep disorders, even a short nap during the daytime should be avoided. Another useful behavioral intervention that has been shown to be effective is limiting bedtime to only actual sleep time.

D) Drug therapy for insomnia.

Rational pharmacotherapy of insomnia, especially chronic insomnia, in adult or elderly patients is characterized by five main principles:

1) use of the lowest effective doses;

2) the use of a hopping regimen of reception (two to three times a week);

3) prescribing a medicine for short-term use (i.e., regular use for no more than three to four weeks);

4) stopping the use of drugs gradually;

5) make sure that insomnia does not recur after stopping the medication.

The awareness of the attending physician about the properties of certain hypnotic drugs contributes to the correct choice of the hypnotic drug. Preferred drugs are those that do not disrupt sleep patterns, selectively target insomnia symptoms, have a short half-life, and do not cause behavioral toxicity and dependence due to euphoric effects. When prescribing therapy, one should take into account previous experience in the treatment and self-treatment of patients with insomnia. Most often in the anamnesis of patients suffering from insomnia, doctors can identify self-medication with alcohol and over-the-counter drugs. Alcohol and antihistamines, commonly taken as sleep aids, have only a minimal effect on sleep and, if continued, interfere with sleep quality and cause behavioral toxicity. Herbal medicines generally do not have direct hypnotic properties, but rather sedatives, and are difficult to dose and predict aftereffects.

Many drugs used as hypnotics of the 1st and 2nd generations have become a thing of the past and are no longer used in practice. Based on data obtained by American researchers in the study of the effectiveness of therapy in adult patients (9114 people) suffering from insomnia. The most effective sleep aids are benzodiazepines, zopiclone, zolpidem, antidepressants, and melatonin. However, each of the selected groups of drugs has its own indications. Benzodiazepines have ataractic, sedative and hypnotic effects. However, due to the euphoric and relaxing effect, their use is fraught with drug dependence. In addition, many of them cause behavioral toxicity due to the accumulation of metabolites. Antidepressants have an undeniable advantage in the treatment of insomnia associated with depression. Doctors' concern about possible dependence on benzodiazepines and zolpidem and their side effects, along with the need for control, has led in recent years, according to American researchers, to a 30% decrease in the prescription of benzodiazepines and a 100% increase in the use of antidepressants as hypnotics. Serotonin-specific antidepressants such as trazodone and paroxetine relieve sleep disturbances and have fewer side effects than tricyclic antidepressants. It is possible that the use of safe serotonergic antidepressants for the treatment can reduce the burden of chronic insomnia and prevent depression that is dangerous in relation to suicide. Currently, antidepressants are used for the treatment of chronic insomnia at lower doses than for the treatment of depression and anxiety. Melatonin as a hypnotic agent has not yet been sufficiently studied and is preferable for insomnia associated with circadian rhythm disturbances. Zopiclone and zolpidem, which are similar in their psychopharmacological properties, are the third generation drugs of modern hypnotics. A more studied and approved drug in Ukraine is zopiclone, represented by a number of generic drugs. A high quality drug is zopiclone manufactured by the Latvian company "Grindex" with the trade name "Somnol".

Zopiclone (Somnol) belongs to a new class of psychotropic drugs (hypnotics) - derivatives of cyclopyrrolone. Its mechanism of action is associated with the gamma-aminobutyric acid (GABA-A) receptor complex. Zopiclone modulates the effect of GABA on the GABA - A complex through the benzodiazepine receptor, enhancing the activity of the cellular pump for pumping chloride ions into the cell. Although zopiclone is a non-selective benzodiazepine receptor agonist, its binding site is different from that of benzodiazepines. Unlike benzodiazepines, zopiclone exhibits a certain selectivity for the cerebral cortex, cerebellum, and hippocampus. The clinical profile of zopiclone can be described as exclusively hypnotic and tranquilizing. Zopiclone is distinguished by very low toxicity: LD50 is 2000-3000 times higher than the therapeutic dose. In the established single dose of 7.5 mg / day, zopiclone does not have a cumulative effect, but for people over the age of 65 and patients with liver and kidney damage, it is recommended to use a half dose (1/2 tablet) of the drug.

Comparative dynamic electroencephalographic (EEG) studies of the effectiveness of benzodiazepine (phenazepam) and zopiclone showed that after the completion of a course of treatment with phenazepam, there was an increase in 5- and 9-activity, an increase in the power of the α-band in the central and occipital regions, and smoothing of zonal differences. In 50% of patients, the a-rhythm slowed down by 1 Hz. These changes are due to increased synchronizing influences from the mid-stem structures of the brain, which clinically correlated with a decrease in the level of wakefulness. In patients treated with zopiclone, the dynamics of EEG parameters was of a completely different nature: a decrease in the spectral power of the 5- and 9-bands, a decrease in a-activity in the occipital regions were recorded. Strengthening of the disorganizing effects on the a-band may be due to the desynchronizing (activating) effect on the cerebral cortex from the stem formations, which increased the level of daytime wakefulness while improving the quality of night sleep.

Zopiclone (Somnol) has the following set of qualities: 1) provides a quick fall asleep when taking the minimum dose; 2) does not require increasing the dose to achieve the desired effect; 3) selectively binds to the receptor and causes only a hypnotic effect; 4) induces sleep close to physiological in structure and duration; 5) does not cause an aftereffect (in the morning, vigor is quickly restored, memory, reaction speed and cognitive functions do not worsen); 6) non-toxic, does not interact with other drugs and their metabolites; 7) does not cause addiction, overdose and drug dependence.

Thus, zopiclone (Somnol) approaches in its properties to the "ideal hypnotic" and has a therapeutic effect on all types of insomnia - short-term, episodic and chronic.

The duration of short-term insomnia is usually from 1 to 3 weeks. The etiological factors of short-term insomnia can be (in order of their importance): 1) life difficulties; 2) psychological stress; 3) various somatic diseases; 4) snoring; 5) excessive motor activity during sleep. In the treatment of short-term insomnia with zopiclone for 10 days, both the subjective assessment and the objective somographic structure of sleep improved in all treated patients.

Episodic insomnia is most often a consequence of the emotional stress of everyday life, emergencies, desynchronosis, the reaction of the individual to a somatic disease (nosogeny). Episodic insomnia is often associated with long flights. Moreover, it is shown that the influence of desynchronosis during long flights occurs more often when moving from east to west than from north to south. Studies by French scientists have shown that with sleep disorders due to desynchronosis, the use of zopiclone (7.5 mg) has a positive effect on adaptation to life in a new time zone.

The treatment of chronic insomnia is more difficult, since its causes are multiple, and these patients have a combined somatic and mental pathology. The use of zopiclone in chronic insomnia in combination with the main pathogenetic therapy is very effective.

Thus, timely diagnosis and treatment of sleep disorders in general medical (non-psychiatric) practice indicates the qualifications of a family doctor. Knowledge of somnology is an obligatory subject of undergraduate and postgraduate training of physicians. Modern treatment of insomnia is impossible without knowledge of third-generation hypnotics, among which one of the leading places is occupied by zopiclone (Somnol).