In-person or electronically delivered melatonin antagonists to treat chronic insomnia: Where are we going? How long can the drug be used?

Fortunately for Miranda and millions of others with chronic insomnia, new treatments are arriving. A class of pharmaceuticals that uses a different brain pathway than the ones currently used to induce sleep is a promising development, and new drugs that use cannabis as a sleep aid are also showing potential. Soon, those struggling with sleep could have a range of new options available to help.

Researchers hope to learn more about the causes and treatments of insomnia in the coming years, so they can recommend personalized therapies. She says that these are the frontiers people are working at.

Uptake among physicians has been slow so far, Krystal says. But once practitioners catch on, he adds, “I can imagine a world where you have digital care as your first stop, and if that’s not successful, you see a therapist.”

There are digital platforms being developed by the Department of Veterans Affairs, and the Cleveland Clinic in Ohio. SleepioRx, for example, is a 90-day digital programme that has been evaluated in more than two dozen clinical trials and has showed efficacy as high as 76%. This includes making people fall asleep faster, getting them to sleep better and making them feel better the next day. Big Health in San Francisco received FDA clearance to develop the programme. A 2024 meta-analysis of 15 studies that compare in-person and electronically delivered CBT-I concluded that the two approaches were equally effective12.

The search for more effective insomnia treatments continues even in other places. Some research groups are experimenting with different receptors that they hope could lead to new classes of drugs. One of the brain’s two melatonin antagonists, Mtt2, has been found by a clinical psychiatrist and research neuroscientist at a Canadian university. We want to find an alternative mechanism without any addiction liability that would be suitable for children and elderly people. A molecule that the team developed that binds to MT2 increased the time that rats spent in deep sleep by 30%11. Gobbi aims to launch clinical trials in the next two to three years.

As for cannabidiol (CBD) and THC — the most well-known cannabinoids — the prospects for efficacy against insomnia are doubtful, at least for the doses used in trials so far. The small studies have failed to show a benefit to sleep from taking the drug. In an experiment, it was shown that participants in the study who were given 10 or 200 milligrams of THC and CB can sleep for 25 minutes less than those who received a placebo. There are no significant improvements in the company- sponsored trials of low-dose CBD for insomnia. He says it has been one failure after another.

Other drugs that target the orexin system are in the clinical pipeline. The US pharmaceutical firm Johnson & Johnson is working on a product for people who have both major depression and insomnia. Around 70% of people with depression have insomnia, so having a medication that treats both of those disorders “has the potential to fill an important gap”, says Krystal, who has consulted for Johnson & Johnson on the drug. In a phase III trial6, participants who took the drug experienced meaningful improvement in both sleep and depressive symptoms, with an antidepressant effect that seemed to be independent of the participants getting better sleep. One of the things that might cause Seltorexant to have an antidepressants effect is it’s designed to block one of the two types of theorexreceptor, according to Krystal.

The main drawback to DORA drugs, Buysse says, is not medical but financial: their high cost keeps them out of reach of many people who could benefit from them. Patients will have to go through trials of other drugs before they can be prescribed one of these drugs, Buysse says. Only a few countries have DORA drugs available.

Miranda has experience with many of these products. melatonin, which is available without a prescription in the United States, was prescribed to her by her doctor when she was a child. It helped her fall asleep but she couldn’t sleep. During her teenage years, different neurologists prescribed off-label antidepressants and other mood medications, including trazodone and mirtazapine. But they came with what she calls “torturous” side effects: she felt constantly anxious and exhausted during the day, and her memory became “incredibly foggy”.

CBT-I doesn’t work for everyone. Miranda has tried it and has received conventional talking therapy for over a decade, with limited success. She says it only helps so much.

The Infuriating, Costly Road to a Good Night’s Sleep: Insurance Coverage Requires Extra Funds to Pay for Belsomra

12% of adults in the US are diagnosed with chronic insomnia, which is when you can’t sleep for more than three nights a week for a long period of time. According to research, the worldwide figure is 10– 30%. It also causes a vicious cycle with other conditions, such as chronic pain, depression and anxiety.

I was hopeful that my health-insurance company would eventually agree to cover Belsomra. The initial rejection note from the company included a list of eight cheap generic Z-drugs that needed to be tried first, because they have a risk of dependency. My PA and I worked through the list of prescriptions in an effort to make a case that none of them were suitable. In late March, the insurance company agreed to pay for Belsomra over the next year. My drugstore confirmed that $150 is normal for this medication and that I am still required to pay it even with that coverage. Until a generic DORA drug is available, this particular sleep solution will only be available for people with enough extra income to pay for it.

It shouldn’t be like this. Insurance companies that are focused on ringing out as much profit as possible from clients who are already paying excessive premiums are not calling the shots on what care their patients need. However, until the system changes, millions of people will continue to take the same tortuous path that I have been forced onto, and resort to medications that might have harmful long-term effects while the most advanced therapies remain tantalizingly out of financial reach.

Source: The infuriating, expensive road to a good night’s sleep

A doctor’s assistant discusses the COVID-19 pandemic and how to get help: A case study on buspirone, an anti-anxiety medication

I never had issues with sleep until the COVID-19 pandemic. A couple of months into lockdown in 2020, I found myself unable to fall or stay asleep. The longer I stayed in bed, the more I was worried about not sleeping. This vicious cycle left me exhausted. After a few months, I became depressed. It was time to get professional help.

A licensed medical professional called a physician’s assistant is a primary-care provider who is sympathetic, but isn’t actually a doctor. She listened to my problems and asked me questions about my life. She agreed at the end of the appointment that I should try the antidepressant bupropion. I was still having trouble sleeping, however, and my night-time anxiety spiked following the election. “Sadly, we are getting a lot of these messages,” my PA said when I told her about this. We added buspirone, an anti-anxiety medication, to my daily regimen. I was able to sleep better. But buspirone left me feeling deflated, numb and unmotivated during the day. A month was suggested by my PA if I didn’t develop serious depression thoughts.

It took almost three weeks for me to receive the prescription, and my insurance would not cover it. There are no generic DORA drugs. It was going to cost me 500 dollars a day for 30 tablets of Belsomra. But, I was desperate to get some sleep and my pharmacist was able to find a coupon that knocked $150 off the bill. I sucked it up and paid.