Antidepressants for insomnia in adults

Background Insomnia disorder is a subjective condition of unsatisfactory sleep (e.g. sleep onset, maintenance, early waking, impairment of daytime functioning). Insomnia disorder impairs quality of life and is associated with an increased risk of physical and mental health problems including anxiety, depression, drug and alcohol abuse, and increased health service use. hypnotic medications (e.g. benzodiazepines and 'Z' drugs) are licensed for sleep promotion, but can induce tolerance and dependence, although many people remain on long-term treatment. Antidepressant use for insomnia is widespread, but none is licensed for insomnia and the evidence for their efficacy is unclear. This use of unlicensed medications may be driven by concern over longer-term use of hypnotics and the limited availability of psychological treatments. Objectives To assess the effectiveness, safety and tolerability of antidepressants for insomnia in adults. Search methods This review incorporated the results of searches to July 2015 conducted on electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 6), MEDLINE (1950 to 2015), Embase (1980 to 2015) and PsycINFO (1806 to 2015). We updated the searches to December 2017, but these results have not yet been incorporated into the review. Selection criteria Randomised controlled trials (RCTs) of adults (aged 18 years or older) with a primary diagnosis of insomnia and all participant types including people with comorbidities. Any antidepressant as monotherapy at any dose whether compared with placebo, other medications for insomnia (e.g. benzodiazepines and 'Z' drugs), a different antidepressant, waiting list control or treatment as usual. Data collection and analysis Two review authors independently assessed trials for eligibility and extracted data using a data extraction form. A third review author resolved disagreements on inclusion or data extraction. Main results The search identified 23 RCTs (2806 participants). Selective serotonin reuptake inhibitors (SSRIs) compared with placebo: three studies (135 participants) compared SSRIs with placebo. Combining results was not possible. Two paroxetine studies showed significant improvements in subjective sleep measures at six (60 participants, P = 0.03) and 12 weeks (27 participants, P < 0.001). There was no difference in the fluoxetine study (low quality evidence). There were either no adverse events or they were not reported (very low quality evidence). Tricyclic antidepressants (TCA) compared with placebo: six studies (812 participants) compared TCA with placebo; five used doxepin and one used trimipramine. We found no studies of amitriptyline. Four studies (518 participants) could be pooled, showing a moderate improvement in subjective sleep quality over placebo (standardised mean difference (SMD) -0.39, 95% confidence interval (CI) -0.56 to -0.21) (moderate quality evidence). Moderate quality evidence suggested that TCAs possibly improved sleep efficiency (mean difference (MD) 6.29 percentage points, 95% CI 3.17 to 9.41; 4 studies; 510 participants) and increased sleep time (MD 22.88 minutes, 95% CI 13.17 to 32.59; 4 studies; 510 participants). There may have been little or no impact on sleep latency (MD -4.27 minutes, 95% CI -9.01 to 0.48; 4 studies; 510 participants). There may have been little or no difference in adverse events between TCAs and placebo (risk ratio (RR) 1.02, 95% CI 0.86 to 1.21; 6 studies; 812 participants) (low quality evidence). 'Other' antidepressants with placebo: eight studies compared other antidepressants with placebo (one used mianserin and seven used trazodone). Three studies (370 participants) of trazodone could be pooled, indicating a moderate improvement in subjective sleep outcomes over placebo (SMD -0.34, 95% CI -0.66 to -0.02). Two studies of trazodone measured polysomnography and found little or no difference in sleep efficiency (MD 1.38 percentage points, 95% CI -2.87 to 5.63; 169 participants) (low quality evidence). There was low quality evidence from two studies of more adverse effects with trazodone than placebo (i.e. morning grogginess, increased dry mouth and thirst). Authors' conclusions We identified relatively few, mostly small studies with short-term follow-up and design limitations. The effects of SSRIs compared with placebo are uncertain with too few studies to draw clear conclusions. There may be a small improvement in sleep quality with short-term use of low-dose doxepin and trazodone compared with placebo. The tolerability and safety of antidepressants for insomnia is uncertain due to limited reporting of adverse events. There was no evidence for amitriptyline (despite common use in clinical practice) or for long-term antidepressant use for insomnia. High-quality trials of antidepressants for insomnia are needed

Nurses´ Experience of Triage Process in the Psychiatric A &amp; E Department for Adults : An empirical study

Title: Nurses´ Experience of Triage Process in the Psychiatric A &amp; E Department for Adults Author: Miljatovic, Milos Department: School of Life Sciences, University of Skövde Course: Degree of Bachelor of Science in Nursing, Thesis in Nursing Care, 15 ECTS Supervisor: - Examiner: Brovall, Maria Pages: 23 Keywords: Triage, Nurse, Psychiatric A &amp; E Department for Adults, Triage scale Background: In the beginning of 21st century some psychiatric A &amp; E departments in Sweden have introduced triage process and psychiatric triage scales. The aim was to meet the growing numbers of patients with mental health problems attending psychiatric A &amp; E departments, in order to shorten waiting and transit times. Aim: The aim of the study was to illustrate nurses´ experiences of triage process in the psychiatric A &amp; E department. Method: Qualitative empirical study was conducted. Results: Three categories were identified: Triage process creates confidence, Obstacles in triage assessment, Possibilities for improved patient care through triage process; and six subcategories: Aid and support in having an assessment tool, Sense of comradeship, Getting possibility to take answer and show the competence, Deficiencies with assessment tool, Sense of inadequateness due to long waiting times to physician, Sense of ambiguity during the triage process. Discussion: Safe triage process is needed to achieve quality care in the psychiatric A &amp; E department, thus it is important that nurses have adequate triage scale, and the results suggest that it is important for nurses to have an adequate triage scale which makes it easier for nurses in nursing care.Bakgrund: Vissa svenska vuxenpsykiatriska akutmottagningar har i början av 2000-taletinfört triageprocess och triageskalor för att kunna möta det ökade vårdbehovet blandpatienter med psykiska problem. Syftet med införandet av triageprocessen var att kortaväntetider och genomlöpstider på mottagningar.Syfte: Syftet med studien var att belysa sjuksköterskors upplevelser av triageprocessen påen vuxenpsykiatrisk akutmottagning.Metod: Som metod valdes kvalitativ empirisk studie.Resultat: Tre kategorier identifierades: triageprocess skapar en trygghet, hinder itriageprocessen, möjligheter till förbättrad omvårdnad genom triageprocessen; och sexsubkategorier: hjälp och stöd genom ett bedömningsinstrument, känsla av kollegialitet, fåmöjlighet att ta ansvar och visa sitt kunnande, brister med bedömningsinstrumentet, känslaav otillräcklighet vid långa väntetider till läkaren, känsla av otydlighet iförbättringsprocessen.Diskussion: En trygg triageprocess behövs för att uppnå god omvårdnad på envuxenpsykiatrisk akutmottagning, och resultatet tyder på att det är viktigt attsjuksköterskor har en adekvat triageskala som underlättar i omvårdnadsarbetet

Healthcare sustainability challenge

Healthcare structures are supposed to protect and improve Public Health, but in the meanwhile they are highly energy-demanding and socially impactful structures, which cause negative side effects on the people’s health and on the environment. Building hospitals able to cope with the definition of Health as complete well-being and which can fit to the future means therefore constructing sustainable structures. Such complex realities work as a whole, single organism, that can be robust and productive only if every single part is healthy. So when it comes to healthcare facilities, sustainability has to be taken into account as both a main requirement and a quality issue, since they must be capable to deliver high standards also in changing circumstances. Starting from these assumptions the Sustainable High Quality Healthcare project is born with the aim of providing a new original insight into such a complex subject. Its goal is to define, through the construction of an innovative assessment system, solutions and strategies towards the realization of sustainable existing operative or in-design hospitals, where sustainability applies to the main macro-areas