【医脉通】2019+BAP共识声明：失眠异态睡眠以及昼夜节律睡眠障碍的治疗.pdf

https:/doi.org/10.1177/0269881119855343Journal of Psychopharmacology 1 25 The Author(s)2019Article reuse guidelines: Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia,parasomnias and circadian rhythm disorders:An updateSue Wilson1,Kirstie Anderson2,David Baldwin3,Derk-Jan Dijk4,Audrey Espie5,Colin Espie6,Paul Gringras7,Andrew Krystal8,David Nutt1,Hugh Selsick9 and Ann Sharpley10AbstractThis British Association for Psychopharmacology guideline replaces the original version published in 2010,and contains updated information and recommendations.A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field.They were asked to provide a review of the literature and identification of the standard of evidence in their area,with an emphasis on meta-analyses,systematic reviews and randomised controlled trials where available,plus updates on current clinical practice.Each presentation was followed by discussion,aiming to reach consensus where the evidence and/or clinical experience was considered adequate,or otherwise to flag the area as a direction for future research.A draft of the proceedings was circulated to all speakers for comments,which were incorporated into the final statement.KeywordsSleep disorders,insomnia,circadian rhythm disorders,parasomnias,guidelines,evidence-based treatment855343JOP0010.1177/0269881119855343Journal of PsychopharmacologyWilson et al.research-article2019BAP GuidelinesTable of ContentsIntroduction 2Method 2Insomnia 2 Scope of the guidelines 2 Table 1 Levels of evidence 3 Epidemiology of insomnia 3 Table 2 Insomnia:diagnostic criteria 4 Diagnosis of insomnia 4 Figure 1 Diagnosis of insomnia 5 Comorbidity 5 Costs and consequences of insomnia 5 Figure 2 The ideal sleeping pill 6 Recommendation 6 Psychological treatment of insomnia 7 Underpinning principles cognitive behavioural therapy 7 Recommendation 7 Drug treatments for insomnia 7 Underpinning principles-pharmacology 8 Underpinning principles pharmacokinetics 8 Figure 3 treatment of insomnia 9 Tolerance,dependence and withdrawal 9 Pharmacological treatment of insomnia 10 Recommendations 10 Long-term use of sleeping medications 10 Recommendation 11 Using drugs for depression to treat insomnia 11 Recommendations 12 Drugs for psychosis for treatment of insomnia 12 Recommendations 13 Antihistamines(H1 antagonists)13 Recommendations 13Circadian rhythm disorders 13 Diagnosis of circadian rhythm disorders 14 Treating circadian rhythm disorders 14 Recommendations 14Parasomnias 15 Diagnosis of parasomnias 15 Treatment of parasomnias 15Special populations 16 Sleep disorders in women:effects of menopause and pregnancy 16 Menopause 16 Recommendations 16 Pregnancy 16 Recommendations 16 Treatment of insomnia in older adults 17 Recommendation 17 Sleep problems in children 17 Recommendations 18 Sleep disturbance in adults with intellectual disability 18 Assessment 18 Treatment considerations 18 Recommendations 19References 19Appendix 1 25 2 Journal of Psychopharmacology 00(0)IntroductionSleep disorders are common in the general population,and even more so in clinical practice,yet are relatively poorly understood by doctors and other health care practitioners.These British Association for Psychopharmacology(BAP)guidelines address this problem by providing an accessible yet up-to-date and evi-dence-based outline of the major issues,especially those relating to reliable diagnosis and appropriate treatment.We limited our-selves to discussion of sleep problems that are not regarded as being secondary to sleep disordered breathing;National Institute of Clinical Excellence(NICE)guidelines for this are summarised on the NICE website and an updated guideline will be available in 2020;a comprehensive toolkit is available at the British Sleep Society website,http:/www.sleepsociety.org.uk.We also did not consider certain sleep disorders for which sets of guidelines already exist,such as narcolepsy(Billiard et al.,2006)and rest-less legs syndrome(Picchietti et al.,2015).Thus,the main scope of this document is to address insomnia,circadian rhythm disor-ders(CRDs)and the more common parasomnias which are likely to present to primary care physicians and psychiatrists.The BAP is an association of psychiatrists,psychopharma-cologists and preclinical scientists who are interested in the broad field of drugs and the brain.BAP is the largest national organisa-tion of its kind worldwide,and publishes the Journal of Psychopharmacology.The association started publishing con-sensus statements more than two decades ago,and the first BAP guidelines on depression were considered a landmark publication when they appeared in 1993(Montgomery et al.,1993).There are now guidelines for the treatment and management of most of the disorders encountered in psychiatry;all guidelines are avail-able to download from the BAP website(http:/www.bap.org.uk).MethodThis British Association for Psychopharmacology guideline replaces the original version published in 2010,(Wilson et al 2010)and contains updated information and recommendations.A consensus meeting was held in London in October 2017,attended by recognised experts and advocates in the field.They were asked to provide a review of the literature and identification of the standard of evidence in their area,with an emphasis on meta-analyses,systematic reviews and randomised controlled trials(RCTs)where available,plus updates on current clinical practice.Each presentation was followed by discussion,aiming to reach consensus where the evidence and/or clinical experience was considered adequate,or otherwise to flag the area as a direction for future research.The previous consensus statement was then updated with the new evidence and references.Categories of evidence for causal relationships,observational relationships and strength of recommendations are given in Table 1 and are taken from(Shekelle et al.,1999).The strength of recommendation reflects not only the quality of the evidence,but also the importance of the area under study.For example,it is possible to have methodologically sound(category I)evidence about an area of practice that is clinically irrelevant,or has such a small effect that it is of little practical importance and therefore attracts a lower strength of recommendation.However,more commonly,it has been necessary to extrapolate from the available evidence leading to weaker levels of recommendation(B,C or D)based upon category I evidence statements.The costs of the meeting were defrayed by BAP.All speakers completed conflict of interest statements that are held at the BAP office according to BAP policy.InsomniaScope of the guidelinesOur intention is to provide an updated statement to guide clini-cians who manage patients in primary or secondary medical care.There have been three sets of guidelines for the treatment of insomnia since the previous BAP consensus(Qaseem et al.,2016;Riemann et al.,2017;Sateia et al.,2017).The first set of guidelines concerns adults with insomnia and includes insomnia comorbid with other disorders such as depression;the second set addresses primary insomnia without comorbidity;the third set covers all adults with chronic insomnia disorder.These sets were discussed by the expert group and where appropriate some ele-ments were incorporated in the present consensus.Since the publication of the 2010 BAP guideline,there has been an important shift in thinking about the diagnosis and clas-sification of insomnia.The historical perspective that insomnia could be either primary or secondary,is no longer regarded as valid or evidence-based.Rather,the expanding literature has led the American Psychiatric Association(APA)(Diagnostic and Statistical Manual of Mental Disorders(DSM)-5)and the American Academy of Sleep Medicine(AASM)(International Classification of Sleep Disorders(ICSD)-3)to recommend that chronic insomnia disorder(APA)should be considered as a dis-order in its own right.This means that insomnia disorder should be diagnosed whenever insomnia diagnostic criteria are met,irrespective of any concurrent physical disorder or mental disorder;and,impor-tantly,also irrespective of any other concurrent sleep disorder.It is anticipated that International Classification of Diseases 11th Revision(ICD-11)will reflect the same conclusions when it is presented at the World Health Assembly for adoption by member states in 2019.1Centre for Psychiatry,Imperial College London,London,UK 2Regional Sleep Service,Freeman Hospital,Newcastle Upon Tyne,UK 3 Clinical and Experimental Sciences,University of Southampton,Southampton,UK 4Sleep Research Centre,University of Surrey,Guildford,UK 5Psychology Department,NHS Fife,Dunfermline,UK 6 Nuffield Department of Clinical Neurosciences,University of Oxford,Oxford,UK 7Guys and St Thomas NHS Foundation Trust,London,UK 8 Psychiatry and Behavioral Science,University of California,San Francisco,CA,USA 9Royal London Hospital for Integrated Medicine,London,UK10Department of Psychiatry,University of Oxford,Oxford,UKCorresponding author:Sue Wilson,Centre for Psychiatry,Division of Brain Sciences,Imperial College,Burlington Danes Building,Hammersmith Hospital campus,160 Du Cane Road,London,W12 0NN,UK.Email:sue.wilsonimperial.ac.uk Wilson et al.3The complex relationship between insomnia and psychiat-ric disorders has been the subject of much recent research.It is increasingly recognised that sleep plays a central role in the regulation of emotion and emotion processing(Palmer and Alfano,2017;Tempesta et al.,2018).Therefore,it is not sur-prising to see a bidirectional relationship between insomnia and mental disorder.There is considerable evidence that pre-existing insomnia confers risk for the development of(or relapse into)depression).This makes it all the more important to consider the time-course of how insomnia and other psychi-atric symptoms develop and resolve(Snchez-Ortuo and Edinger,2012).Insomnia often starts with a specific problem,for example a stressful life event such as the loss of a job or change to a more demanding one;or through something that changes sleep patterns,such as the birth of a child or starting shift work.In some people this acute insomnia persists into a chronic state.Factors involved in the persistence of insomnia are not fully established,but include anxiety about sleep,maladaptive sleep habits and the possibility of an underlying vulnerability in sleep-regulating mechanisms.Persistence of the precipitating stressor can also contribute.Some cases of insomnia are pre-cipitated by,or co-morbid with,other psychiatric disorders especially anxiety and depression,or by physical illness such as cancer or arthritis.The nature of sleep changes with age.Older age is associated with poorer objectively-measured sleep with shorter sleep time,diminished sleep efficiency,and more arousals.These changes may be more marked in men than women according to a very large study of elderly people living at home in the USA(Sleep Heart Health Study;Unruh et al.,2008).In the same study,the association of subjective report of poor sleep with older age was stronger in women.The higher prevalence of chronic health con-ditions,including sleep apnoea,in older adults did not explain changes of sleep parameters with aging and age-sex differences in these relationships.There is now greater consensus about how long insomnia should have been present before it merits intervention.Chronic insomnia is regarded as established after three months of persis-tent poor sleep.There is also general agreement that when insom-nia causes significant personal distress or marked impairment then some form of treatment is appropriate.The cause of insom-nia may be known or not,and knowledge of causation is not nec-essary for a diagnosis.Epidemiology of insomniaStudies of prevalence of insomnia in the general population indi-cate that one third of adults in Western countries experience dif-ficulty with sleep initiation or maintenance at least once a week(LeBlanc et al.,2009;Leger and Poursain,2005;Sateia et al.,2000),and 615%are thought to meet the criteria of insomnia in that they report sleep disturbance as well as significant daytime dysfunction(LeBlanc et al.,2009;Sivertsen et al.,2009).One-year incidence rates have been reported to be 30.7%for insomnia symptoms and 7.4%for insomnia syndrome.These rates decreased to 28.8%and 3.9%for those without a prior lifetime episode of insomnia(LeBlanc et al.,2009).There is much evi-dence that insomnia can be a long-term disorder.In one large UK study,about three-quarters of patients reported symptoms lasting at least a year(Morphy et al.,2007)and,in a population-based three-year longitudinal study,46%of subjects who had insomnia at baseline still had it at the three-year time point.The course of insomnia was more likely to be persistent in those with more severe insomnia at baseline and in women and older adults(Morin et al.,2009).Two studies have described an increase of insomnia over time:in the UK,insomnia diagnosis increased from 3.1%to 5.8%(National Psychiatric Morbidity Surveys 19932007;Calem et al.,2012);and in Norway,insomnia diag-nosis increased from 11.9%to 15.5%between two surveys in 20002010(Pallesen et al.,2014).Table 1.Levels of evidence.Category of evidence:Ia evidence for meta-analysis of randomised controlled trials.Ib evidence from at least one randomised controlled trial.IIa evidence from at least one controlled study without randomisation.IIb evidence from at least one other type of quasi-experimental study.III evidence from non-experimental descriptive studies,such as comparative studies,correlation studies,and case-control studies.IV evidence from expert committee reports or opinions or clinical experience of respected authorities,or both.Strength of recommendation:A directly based on category I evidence.B directly based on category II evidence or extrapolated recommendation from category I evidence.C directly based on category III evidence or extrapolated recommendation from category I or II evidence.D directly based on category IV evidence or extrapolated recommendation from category I,II or III evidence.What is known about prevalence of insomnia:Estimates of prevalence of insomnia vary according to the definition used(Ia).Prevalence of symptoms varies with age,with increase of nocturnal awakenings but decrease in complaints of non-restorative sleep as people age(Ib).Prevalence is between 1.52 times higher in women than in men(Ia).Insomnia is a long-term disorder;many people have had insomnia for more than two years(Ib).Approximately half of all diagnosed insomnia is comorbid with a psychiatric disorder(Ib).What is not known:What is the prevalence of distress about sleep?What is the significance of duration of symptoms on distress?4 Journal of Psychopharmacology 00(0)There is a higher incidence of insomnia in women,and the incidence increases in men and w