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1、慢性失眠及安眠藥物的使用,財團法人佛教慈濟綜合醫院精神醫學部 佛教慈濟大學精神科林喬祥醫師,個案描述一,28歲的王先生，唸專科時期開始就有經常睡不好，經常得要躺超過一個小時才能入睡，遇到有考試壓力或者和朋友之間有些爭執時就更不好睡，就算睡著了，一有聲響很容易就醒過來，又得躺好一陣子才能再入睡。學校畢業後因為家庭經濟因素開始工作，睡眠狀況還是不理想。王先生曾經在一般開業醫師診所處方過安眠藥，效果還不錯。但是他很擔心常用會成癮，總是盡量不用安眠藥，有時一整個星期都沒有一天睡得好。他聽別人說什麼方法可以治失眠，都會去試，但是效果都不好。到後來每天一天黑就覺得要找一點上床準備睡覺，但是又覺得害怕、怕那
2、一天又會睡不好或睡不著。長期下來，白天不但會常頭暈，而且越來越沒耐性，常常提不起勁來，感覺自己快要垮了，近半年來已經把休假請光，還請了不少病假，最近才由朋友介紹到精神科看門診。,個案描述二,36歲的陳女士離婚後因為背負卡債及家庭經濟重擔，有入睡困難和睡眠中斷的睡眠障礙已有4、5年。剛開始看精神科時，吃1、2顆安眠鎮靜藥物就可以睡上幾個小時，但是總覺得睡不夠，半夜一醒過來就再吃2顆，有時已經塞了7、8顆安眠藥還是睡不好。後來藥不夠時她就到另一家醫院的精神科開藥。雖然有醫師建議她應該要嘗試其他改善睡眠的方法，並且控制使用安眠藥，但是她就是擔心不吃睡不著，雖然她也知道其實吃了也不一定睡得好，有時候就
3、乾脆把安眠藥配著啤酒吃，最近喝酒的量也漸漸多起來。,問題討論,問題一： 慢性失眠應用藥物治療治療前應有的評估及處置？ 問題二：安眠藥到底是持續用好還是盡量不要用？ 問題三：安眠藥的療效究竟如何？,Insomnia Has Several Definitions,NHLBI. Am Fam Physician. 1999;59 (abstract).,Difficulty falling asleep,Next-day consequences,Difficulty staying asleep,Non-refreshing sleep,Early morning awakenings,+,Gi
4、ven adequate opportunity to sleep,Chronic Insomnia: Definition,Chronic insomnia vs. Acute insomnia Acute insomnia may occur in anyone at one time or another Varied definitions for chronic insomnia Durations ranging from 30 days 6 months Chronic insomnia is often associated with a wide range of adver
5、se conditions including: Mood disturbances Difficulties with concentration and memory Some cardiovascular, pulmonary, and gastrointestinal disorders,NIH Statement. Sleep. 2005;28:1049-1057.,Insomnia is the most common sleep complaint across all stages of adulthood, and for millions, the problem is c
6、hronic Insomnia can be a symptom of other disorders, like depression, or it can be a primary disorder in itself,The Majority of Insomniacs is Chronically Ill,Mild insomnia,Severe insomnia,Insomnia (DSM-III-R),Elderly, difficulty falling asleep,Elderly, disturbed sleep continuity,%,%,%,%,%,Mean 68%,%
7、 Isomniacs with Persistence of Complaints in Two-Years Follow-Up in Primary Care Surveys,Ganguli et al. 1996; Hohagen et al. 1993; Katz and McHorney 1998,Chronic Insomnia: Epidemiology,Prevalence,30% of general population complains of sleep disruption 10% has daytime functional impairment,Natural Hi
8、story,Few studies describe the course and duration of insomnia,Incidence,Very little is known about chronic insomnias incidence Only a few studies have examined incidence,Risk Factors,Higher prevalence of insomnia in: Women (especially postmenopausal) Divorced, separated, widowed adults Psychiatric
9、and physical illnesses,Other risk factors include cigarette smoking, alcohol, coffee consumption, and numerous prescription drugs,NIH Statement. Sleep. 2005;28:1049-1057.,Chronic Insomnia: Consequences,Some evidence suggests a relationship between chronic insomnia and impaired memory, cognitive func
10、tioning, and depressed mood,Consequences,Associated with high health care utilization Direct and Indirect Costs: estimated in the tens of billions of dollars annually,Quality of Life,Reduces quality of life Hinders social functioning Related to impaired work performance,NIH Statement. Sleep. 2005;28
11、:1049-1057.,Comorbidities,Seldom appears without one or more other disorders Common comorbidities: depression, generalized anxiety, substance abuse, attention deficit, and a variety of physical problems,Public Health Burden,Difficult to evaluate because literature is not developed Focus is on popula
12、tions rather than people,Comorbid Psychiatric Disorders With Insomnia,*P.001 compared with those with no sleep complaint. P.05 compared with those with no sleep complaint. Ford DE et al. JAMA. 1989;262:1479-1484.,Percentage,*,*,*,*,Medical Conditions Associated With Insomnia,*P.001; P.05. P.01. CHF
13、= congestive heart failure; COPD = chronic obstructive pulmonary disease. Katz DA et al. Arch Intern Med. 1998;158:1099-1107.,*,*,Adjusted Odds Ratio,Impact of Sleep Difficulties on Daily Functioning,Rating Ability as Poor (%),Doghramji PP. J Clin Psychiatry. 2001;62(suppl 10):18-26.,Greater Impaire
14、d Function,Impact of Insomnia on Physical and Emotional Health and Social Functioning,*Scale ranges from 0 to 100, with higher scores reflecting greater quality of life. Adapted from Zammit GK et al. Sleep 1999;22(suppl 2):S379-S385.,SF-36 Subscales*,* P0.0001,Greater Interference,Impact of Insomnia
15、 in the Workplace,Daytime functioning and loss of productivity Two to three times as many days of poor productivity and concentration in individuals with insomnia as in good sleepers Absenteeism Severe insomniacs were absent from work twice as often as good sleepers Work accidents Seven times higher
16、 rate of work accidents in insomniacs than in good sleepers,Metlaine A, et al. Industrial Health. 2005;43:1119.,Therapeutic Goals in Treating Insomnia,Sleep Onset,Sleep Maintenance,Number of awakenings Duration of awakenings,Time to fall asleep,Sleep Duration,Total sleep time,Alertness Functioning Vitality,Next-Day Functioning,Initial Screening Nature of complaint Daytime consequences Frequency Duration,Precipitating events Exacerbating factors Sleep-wak
