A Brief Introduction to the Treatment of Anxiety and Panic Attacks Dr Jonathan Haverkampf MD

A short 15 min talk on anxiety and panic attacks

Antidepressants and Sexual Dysfunction (1)

Sexual side effects of medication can be problematic for patients and, if they occur, often impact their well-being and relationships in significant ways. Common treatment options are switching the psychotropic medication, adding psychotropic or non-psychotropic medication and psychotherapeutic approaches.

Keywords: suicide, treatment, psychotherapy, medication, psychiatry

 

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Antidepressants and Sexual Dysfunction (1) Ch Jonathan Haverkampf

Psychiatric Medication – Weight Gain and the Metabolic Syndrome (1)

About 60% of the excess mortality observed in patients with severe mental illness (SMI), such as schizophrenia, bipolar disorder and major depressive disorder (MDD), is due to physical comorbidities, predominantly cardiovascular diseases. Weight gain and the metabolic syndrome are undesired effects of psychiatric medication, which ultimately can limit the use of a drug. Frequently, the decision whether to continue or switch a drug is not easy to make, and carefully weighing off the benefits and potential problems should be part of an informed treatment strategy.

Keywords: obesity, metabolic syndrome, medication, psychiatry

 

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Psychiatric Medication – Weight Gain and the Metabolic Syndrome (1) Ch Jonathan Haverkampf

Psychiatric Medication and QT Prolongation (1)

Several psychiatric medications can cause a lengthening of the QT interval in the ECG, which in some cases can lead to a potentially lethal situation. Under normal circumstances this condition is quite rare. However, in individuals with complicating preconditions and with certain types of medication, it is advisable to get an ECG and proceed with caution. Some drugs are more likely to cause QT prolongation than others, which should be kept in mind when prescribing psychiatric medication to a patient from a higher risk group.

Keywords: QT interval, QT prolongation, medication, antidepressant, antipsychotic, mood stabilizer

 

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Psychiatric Medication and QT Prolongation (1) Ch Jonathan Haverkampf

A Brief Overview of Psychiatric Medication (4)

Abstract – This article gives a brief overview of the main groups of psychiatric medication.

 

Keywords: medication, psychiatry

 

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A Brief Overview of Psychiatric Medication (4) Ch Jonathan Haverkampf

Depression and Medication (3)

Depression is the medical condition with one of the highest prevalence rates, but also one of the costliest ones in terms of human suffering, missed work hours, higher mortality and the higher incidence of physical illnesses. First-line treatment is usually a combination of medication and psychotherapy. In milder cases, psychotherapy alone may be sufficient, while in very severe cases, psychotherapy may not be possible. Antidepressants from a number of functional families are available, with the serotonin reuptake inhibitors (SSRIs) being the mostly used ones, followed by the serotonin and norepinephrine reuptake inhibitors (SNRIs) and antidepressants from other groups. In cases of treatment resistance, an increase in the dose, or if this is not possible a switch to a different group of antidepressants may be necessary. Rarely is a combination therapy needed. Selection of an antidepressant depends on the specific symptoms, such as insomnia or reduced activity, the patient’s current situation, including pregnancy or a requirement for alertness on the job, and many other factors, including past episodes of depression and the medication history.

Keywords: depression, medication, psychiatry

 

 

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Depression and Medication (3) Ch Jonathan Haverkampf

 


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the website www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. No checks have been made. 

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction and/or publication in any form is prohibited.

Panic Attacks and Medication (2)

Panic attacks can interfere greatly with a patient’s social, professional and personal life. The first-line treatment is usually a combination of psychotherapy and medication. Medication broadly addresses two time horizons. In the short-run, benzodiazepines or benzodiazepine-like drugs reduces anxiety within twenty minutes to an hour, which is too long to treat an acute panic attack biologically, but which gives the patient a greater sense of control over the feelings of anxiety, which can in turn reduce anxiety and panic attacks. In the medium- to long-run, antidepressants with effectiveness on serotonergic pathways reduce or eliminate anxiety and the occurrence of panic attacks in the majority of patients. The group of selective serotonin reuptake inhibitors (SSRIs) is probably the best researched and clinically most widely used family of antidepressants for cases of anxiety and panic attack disorders.

Keywords: panic attack, medication, psychiatry

 

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Panic Attacks and Medication (2) Ch Jonathan Haverkampf

 

 


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. No checks have been made. 

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction and/or publication in any form is prohibited.

Bipolar Disorder and Medication (2)

Bipolar disorder is a condition affecting an individual’s affective states (mood). The different flavors of bipolar disorder have in common that there are alterations in mood between above ‘normal’ (hypomania, mania) and normal or below normal (melancholia, depression). The other important mood disorders are the various types of depression, while mania without episodes of depressions is a rarity. The first line treatment of choice in cases of bipolar disorder is medication. However, in the long run psychotherapy has shown to be successful in making the condition more manageable for individuals suffering from it. This article presents the different types of medication used for bipolar disorder.

Keywords: bipolar disorder, medication, therapy

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Bipolar Disorder and Medication (2)

Shyness

 

Shyness

Dr Jonathan Haverkampf, M.D.

 

The world as one sees it

Shyness itself is not a medical condition. It is a subjective perception, which is triggered by a complex set of emotions. One actually has to see oneself as being shy. If an individual does not perceive oneself as shy, then there is no shyness. This may sound counterintuitive, but even if one is very introverted and prefers to spend all day reading a book, one does not have to experience shyness. It depends on where one sees oneself in a social context. Only if one’s expectations are different from present reality, one may experience negative emotions, which may lead to a sense of shyness.

 

Shyness is not social anxiety

Social anxiety, unlike shyness, is a psychiatric diagnosis and it is present if certain criteria are met.

 

Manifestations of shyness

Shyness means feeling apprehension and discomfort around other people. Quite frequently, there is concern about what other people think about oneself. Minor details of one’s outward appearance, voice or behavior are focused on repeatedly. This constant analyzing of other people’s opinions and thoughts about oneself is often associated with low self-esteem, depressed thoughts, anxiety and setting high standards for oneself. One becomes very self-conscious in the presence of other people rather than being really self-aware. One’s own unrealistic expectations about the outcome of a situation may make it even more difficult. It is quite often the fact that shy people often expect too much rather than two little in social settings. Romantic Hollywood movies with love on first sight or rousing boardroom speeches that completely turn the destiny of a company are not what usually happens in the real world. Most social interactions are much more mundane, which does not make them less important. To see this can be quite liberating to a shy person.

 

Unfamiliar situations

Shyness is most likely to occur during unfamiliar situations, although not always. Unfortunately, situations remain unfamiliar if shy people avoid them. Shyness may fade with time, but avoiding unfamiliar situations. Usually shy individuals want contact to other people and relationships, which makes them struggle against shyness. However, this often makes the problem worse. By focusing on shyness as a problem within oneself self-esteem and self-confidence can further be lowered.

 

Social Skills

Developing social skills may help, but it may not take care of the underlying problems. Especially if there is low self-esteem, there is a risk the newly learned social skills merely cover up a problem further down below. This can have a negative effect on one’s self-esteem and self-confidence in the long-run because deeper down the individual does not believe the image he/she is projecting into the world.

Learning communication skills can be helpful in giving shy individuals more confidence. Behavioral traits in social situations such as smiling, easily producing suitable conversational topics, assuming a relaxed posture and making good eye contact, may not be second nature for a shy person. It may also be worthwhile to explore other communication channels. The internet, for example, has helped shy people become more active in a dating environment. Exchanging a number of messages and photos first, makes the other person less unknown, which helps the shy person be less intimidated and self-conscious.

Communication training can improve the situation as the individual learns to more easily interact with others and receive valuable feedback in return. Focusing on an exploration of one’s values, interests and aspirations can facilitate communication by raising one’s confidence in talking about certain issues. If one sees meaning and value in a topic, it is far easier to converse about it.

 

Predisposition for Shyness

There is some evidence for a genetic predisposition for shyness. Some research has indicated that shyness and aggression are related—through long and short forms of the gene DRD4, but this is merely a working hypothesis. Further, it has been suggested that shyness is related to obsessive-compulsive disorder. However, because of the numbers of factors involved and the difficulties in linking a basic cell mechanism to a group of thoughts and behaviors, this remains speculative.

A long form of the serotonin transporter promoter region polymorphism (5-HTTLPR) seems to be somewhat correlated with shyness in grade school children. [1] Interestingly, a connection between this form of the gene and both obsessive-compulsive disorder and autism has been shown in previous studies. [2] The dopamine D4 receptor gene (DRD4) exon III polymorphism, had been the subject of studies in shyness and aggression and “novelty seeking” traits.

 

Medication

Substances from the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs) can be used to treat shyness in individuals who feel inhibited in their daily life because of low self-esteem and psychological symptoms, such as depression or loneliness. They can often be a valued support in combination with psychotherapy. As the individual can better communicate with his or her environment they may no longer be needed after a while. They are generally viewed as non-addictive and can be discontinued relative easily, but to solidify and maintain any positive changes they should be taken for at least a year, and especially in cases of social anxiety longer, if they are well tolerated.

 

Psychotherapy

Psychotherapy can help uncover some of the conflicts and emotions underlying the anxiety and fears in the presence of unknown others. Often there are issues from one’s personal history that add difficulties and fears. If they are dealt with, the shyness can become much less or even disappear. Imagining situations and developing a good communication skill set can go a long way. Ultimately, the explorations of one’s values, interests and aspirations can relieve stress, psychological pressure and help one avoid situations that are more harmful than beneficial, such as unwanted relationship constellations or work situations that lack meaning. (Re)establishing a sense of the inner compass can work miracles in cases of shyness.

According to research, early intervention methods that expose shy children to social interactions involving teamwork, especially team sports, decrease their anxiety in social interactions and increase their self-confidence later on. One possible reason is that a greater set of skills in communicating information, such as emotions and needs, to other people, allows for more variation and better adaptation to different communication situations and environments.

 

Being Oneself

Shyness can seem to be a part of one’s personality. The difference between this and anxiety is fluid. The important question is whether we are really dealing with shyness or heightened sensitivity and insight, which can also be central to creativity. The key is to find out what the person values and finds important and how the individual can lead a more fulfilling and happier life, which frequently resolves the subjective problems with shyness in the process.

 

References

 

[1] Arbelle, Shoshana; Benjamin, Jonathan; Golin, Moshe; Kremer, Ilana; Belmaker, Robert H.; Ebstein, Richard P. (April 2003). “Relation of shyness in grade school children to the genotype for the long form of the serotonin transporter promoter region polymorphism”. American Journal of Psychiatry. 160 (4): 671–676. doi:10.1176/appi.ajp.160.4.671.PMID 12668354.

[2] Brune, CW; Kim, SJ; Salt, J; Leventhal, BL; Lord, C; Cook Jr, EH (2006). “5-HTTLPR Genotype-Specific Phenotype in Children and Adolescents with Autism”. The American Journal of Psychiatry. 163 (12): 2148–56. doi:10.1176/appi.ajp.163.12.2148. PMID 17151167.

 

 

Dr Jonathan Haverkampf, M.D. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

 

Sleep Disorders and Medication

 

 Sleep Disorders and Medication (2)

 

Sleep Disorders and Medication

Dr Jonathan Haverkampf, M.D.

 

Sleep problems affect many people. Especially in our complex and fast paced world remaining thoughts or emotions from the day can occupy us at night. Dealing with stress effectively, such as prioritizing the activities in one’s life in line with one’s values and interests, can improve sleep considerably. The mental health diagnostic manual DSM-IV defines insomnia as difficulty initiating sleep or maintaining sleep.

Several mental health conditions can also cause sleeplessness. Major depression, PTSD, trauma, anxiety, bipolar disorders, psychosis and many more can cause insomnia. Many organic diseases can also cause insomnia, as can sleep apnea and chronic pain syndromes. In some cases, where no other reason can be found, an idiopathic insomnia may itself be a mental health problem.

The first step is to identify whether there is a sleep problem that requires treatment. People who sleep seven to eight hours usually do not have a problem with lack of sleep. In the case of paradoxical insomnia, although one believes to have a sleep problem, electrophysiological measurements show no sign of a sleep disturbance.

The second step is to identify if there is inadequate sleep hygiene. If there are behaviors that are not conducive to good sleep, they should be addressed first. Some behaviors increase arousal, such as consuming caffeine or nicotine in the evening or at night. Various drugs, legal and illegal, can affect one’s sleep greatly. Intense thoughts or emotions can also disturb one’s sleep, as do day-time naps or significant irregularities in the daily sleep-wake schedule.

Treatment of insomnia should also always include psychotherapy. It can help reduce the worries about and consequences of sleeplessness, and thereby break the vicious cycle of insomnia. Feeling less anxious about the ability to get a goodnight’s sleep often improves one’s sleep. Cognitive therapy, CBT, but also psychodynamic approaches can be helpful.

There are several over-the-counter sleep aids available, often with questionable effectiveness. Nonprescription drugs, such as sedating antihistamines, protein precursors, and a host of other substances can work in individual cases, but they are often not strong enough even in cases of moderate insomnia. L-Tryptophan has been withdrawn from the market after it was linked to outbreaks of eosinophilia. Melatonin may help some individuals, although the placebo should not be underestimated.

Most hypnotics are approved by the U.S. Food and Drug Administration (FDA) only for short-term use. The z-drugs zolpidem (Stilnoct®, Ambien®, Ambien CR®, Intermezzo®, Stilnox® and eszopiclone (Lunesta®), as well as the melatonin-receptor agonist ramelteon (Rozerem®) are exceptions.  The z-drugs are by their function related to the benzodiazepines and are also considered potentially addictive if taken regularly. This means that if they are stopped one’s sleep might be worse for a while. There could also be an additional increase in anxiety and, at least theoretically, panic attacks. Benzodiazepines and z-drugs should not be used while driving a car or operating heavy machinery, and the longer lasting ones can lead to a hangover in the morning and drowsiness during the day.

If the insomnia has lasted for a while and is expected to reoccur for at least a couple of weeks, sleep inducing antidepressants should be considered first choice. Mirtazapine (Remeron®) is often a good option, which in clinical experience is more sleep inducing at lower doses (15mg) than at higher doses (45mg). Second-generation antipsychotics, such as Olanzapine (Zyprexa®) are also used, but it seems there should be some other symptom or reason that justifies their use because of the potentially more serious die-effects. If the insomnia is combined with some types of obsessive thoughts or even Tourette’s syndrome, for example, sleep inducing second-generation antipsychotics may be a logical choice.

Psychotherapeutic treatment of insomnia is discussed in my other articles, but medication as a supportive measure seems warranted in some cases, especially if a modern antidepressant can help the patient maintain a job or a relationship, while using therapy to explore the reasons of the sleep disturbance.

Listed below are some substances that are used to treat insomnia.

We will start with the group of benzodiazepines and then move on to the pharmacologically closely related z-drugs, which should usually be preferred to the former, if they are used at all.

 

Benzodiazepines

The most commonly used class of hypnotics for insomnia are the benzodiazepines. Benzodiazepines are not significantly better for insomnia than antidepressants. [1] While they have an important role in anxiety and panic attacks, especially in the time interval until an antidepressant works, their role in the treatment of insomnia should only occur in niche cases, and only over a short internal. The z-drugs, which also work on the benzodiazepine receptor should be preferred, if at all necessary. In clinical practice, the risk for dependency seems higher if the benzodiazepines are used as sleeping pills than if they are used in acute anxiety attacks.

Benzodiazepines all bind unselectively to the GABA-A receptor. There is some indication that certain benzodiazepines (hypnotic benzodiazepines) have significantly higher activity at the α1 subunit of the GABA-A receptor compared to other benzodiazepines (for example, triazolam and temazepam have significantly higher activity at the α1 subunit compared to alprazolam and diazepam, making them superior sedative-hypnotics – alprazolam and diazepam, in turn, have higher activity at the α2 subunit compared to triazolam and temazepam, making them superior anxiolytic agents). Modulation of the α1 subunit is associated with sedation, motor impairment, respiratory depression, amnesia, ataxia, and reinforcing behavior (drug-seeking behavior). Modulation of the α2 subunit is associated with anxiolytic activity and disinhibition. For this reason, certain benzodiazepines may be better suited to treat insomnia than others.

  • Triazolam (Halcion®)
  • Temazepam (Restoril®)
  • [Alprazolam (Xanax®)]

and others may be useful as an insomnia medication that stays in the system longer. For instance, they have been effectively used to treat sleep problems such as sleepwalking and night terrors. However, these drugs may cause sleepiness during the day and can also cause tolerance.

Chronic use

With chronic use, the sleep inducing effect of the benzodiazepines often goes away, while the risk of tolerance increases quite quickly if they are used as hypnotics. Chronic users of hypnotic medications have more regular nighttime awakenings than patients suffering from insomnia who are not taking hypnotic medications. [2] Hypnotics should be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible, especially in the elderly. [3] Between 1993 and 2010, the prescribing of benzodiazepines to individuals with sleep disorders has decreased from 24% to 11% in the US, coinciding with the first release of nonbenzodiazepines. [4]

Common Side Effects

The benzodiazepine and nonbenzodiazepine hypnotic medications have a number of side-effects such as day time fatigue, changes in reaction time potentially leading to motor vehicle crashes and other accidents, cognitive impairments and falls and fractures. Elderly people are more sensitive to these side-effects. [5]

Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short term but in the longer-term benzodiazepines can lead to tolerance, physical dependence, benzodiazepine withdrawal syndrome upon discontinuation, and long-term worsening of sleep, especially after consistent usage over long periods of time. Benzodiazepines, while inducing unconsciousness, actually worsen sleep as—like alcohol—they promote light sleep while decreasing time spent in deep sleep. [6] A further problem is, with regular use of short-acting sleep aids for insomnia, daytime rebound anxiety can emerge. [7]

Although there is little evidence for benefit of benzodiazepines in insomnia compared to other treatments and evidence of major harm, prescriptions have continued to increase. [8] This is likely due to their addictive nature, both due to misuse and because—through their rapid action, tolerance and withdrawal—they can “trick” insomniacs into thinking they are helping with sleep. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the long-term use of benzodiazepines and is recommended whenever possible. [9]

 

Z-Drugs

  • Zolpidem (Ambien®, Intermezzo®)

They often work quite well, but some patients wake up in the middle of the night. Zolpidem is now available in an extended release version, Ambien CR®. This helps prolong the effect of the medication. The FDA has approved a prescription oral spray called Zolpimist®, which contains zolpidem, for the short-term treatment of insomnia brought on by difficulty falling asleep.

  • Eszopiclone (Lunesta®)

Studies show people sleep an average of seven to eight hours. Because of the risk of impairment, the next day, the FDA recommends the starting dose of Lunesta® be no more than 1 mg.

  • Zaleplon (Sonata®)

Zaleplon stays active in the body for the shortest amount of time. That means patients can try to fall asleep on their own. Then, if they are still not asleep at 2 a.m., they can take it without feeling drowsy in the morning. However, if one tends to wake during the night, this might not be the best choice.

 

Melatonin-receptor agonist

  • Ramelteon (Rozerem®)

This is a sleep medication that works differently than the others. It works by targeting the sleep-wake cycle, not by depressing the central nervous system. It is prescribed for people who have difficulty falling asleep. Rozerem® can be prescribed for long-term use, and the drug has so far shown no evidence of abuse or dependence.

 

Antidepressants

  • Mirtazapine (Remeron®)
  • Doxepine (Silenor®)

This tricyclic antidepressant is approved for use in people who have trouble staying asleep. Silenor® may help with sleep maintenance by blocking histamine receptors. Dosage is based on health, age, and response to therapy. Caution is required with all the tricyclic antidepressants as they can prolong the QT interval and have a number of other potentially severe side-effects.

  • Trazodone (Desyrel®)

 

Antipsychotics

Certain antipsychotic drugs like Olanzapin (Zyprexa®) also have a sedative effect and they are sometimes used in slow doses as sleep medication. However, because of the rare but potentially severe side-effects of neuroleptics, even in the second generation, they should not be used as sleep medication without any other rational for using them.

 

Over-the-Counter Sleep Aids

Most of these sleeping pills are antihistamines. They generally work well but can cause some drowsiness the next day. They are generally considered safe enough to be sold without a prescription. However, if combined with other drugs that also contain antihistamines, like cold or allergy medications, one could inadvertently take too much.

 

Sleep medication can have a number of side-effects. In 2007, the FDA issued warnings for prescription sleep drugs, alerting patients that they can cause rare allergic reactions and complex sleep-related behaviors, including “sleep driving.” Medication should in the case of a sleeping disorder always be the last option. Better sleep hygiene and psychotherapy/counselling should come long before it and be the first choice. No sleeping pill can take away worries about the job or one’s relationship or correct for drinking coffee in the evening or sleeping next to one’s laptop.

 

References

[1]   Buscemi, N.; Vandermeer, B.; Friesen, C.; Bialy, L.; Tubman, M.; Ospina, M.; Klassen, T. P.; Witmans, M. (2007). “The Efficacy and Safety of Drug Treatments for Chronic Insomnia in Adults: A Meta-analysis of RCTs”. Journal of General Internal Medicine. 22 (9): 1335–1350. doi:10.1007/s11606-007-0251-z. PMC 2219774Freely accessible. PMID 17619935.

[2]   Ohayon, M. M.; Caulet, M. (1995). “Insomnia and psychotropic drug consumption”. Progress in neuro-psychopharmacology & biological psychiatry. 19 (3): 421–431. doi:10.1016/0278-5846(94)00023-B. PMID 7624493.

[3]   “What’s wrong with prescribing hypnotics?”. Drug and therapeutics bulletin. 42 (12): 89–93. 2004. doi:10.1136/dtb.2004.421289. PMID 15587763.

[4]   Kaufmann, Christopher N.; Spira, Adam P.; Alexander, G. Caleb; Rutkow, Lainie; Mojtabai, Ramin (2015). “Trends in prescribing of sedative-hypnotic medications in the USA: 1993–2010”. Pharmacoepidemiology and Drug Safety. 25: 637–45. doi:10.1002/pds.3951. ISSN 1099-1557. PMID 26711081.

[5]   Glass, J.; Lanctôt, K. L.; Herrmann, N.; Sproule, B. A.; Busto, U. E. (2005). “Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits”. BMJ. 331 (7526): 1169. doi:10.1136/bmj.38623.768588.47. PMC 1285093Freely accessible. PMID 16284208.

[6]   Tsoi, W. F. (1991). “Insomnia: Drug treatment”. Annals of the Academy of Medicine, Singapore. 20 (2): 269–272. PMID 1679317.

[7]   Montplaisir, J. (2000). “Treatment of primary insomnia”. Canadian Medical Association Journal. 163 (4): 389–391. PMC 80369Freely accessible. PMID 10976252.

[8]   Carlstedt, Roland A. (13 December 2009). Handbook of Integrative Clinical Psychology, Psychiatry, and Behavioral Medicine: Perspectives, Practices, and Research. Springer. pp. 128–130. ISBN 0-8261-1094-0.

[9]   Authier, N.; Boucher, A.; Lamaison, D.; Llorca, P. M.; Descotes, J.; Eschalier, A. (2009). “Second Meeting of the French CEIP (Centres d’Évaluation et d’Information sur la Pharmacodépendance). Part II: Benzodiazepine Withdrawal”. Thérapie. 64 (6): 365–370. doi:10.2515/therapie/2009051. PMID 20025839.

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.