Content of this journal is licensed under a Abstract
Background:
The prevalence of insomnia disorder is high among the general poulation and is a risk factor for many diseases. The rationality of drug use for insomnia in Chinese Medicine Hospital was uncertain. In order to evaluate the use of drugs in the Chinese Medicine Hospital of Longgang, Shenzhen, the authors conducted this cross-sectional research.
Methods:
A retrospective, cross-sectional study was conducted in Shenzhen Hospital of Beijing University of Chinese Medicine (Long Gang), Guangdong Province. Insomnia patients from January 1, 2016, to November 10, 2020, were included in the cross-sectional study. Patients corresponding to International Classification of Sleep Disorders (ISCD-3) Diagnostic Criteria for short-term and chronic insomnia were included. The authors excluded patients with severe mental disease or nervous system dysfunction or who could not correctly describe their symptoms. The characteristics of insomnia patients, survey results of drug use and symptoms of insomnia patients were collected. The authors analyzed the basic information, condition of drug use, and relationship between symptoms and drug use using R software (version 4.0.2) with the arulesViz package.
Results:
A total of 9439 patients were included in the study. The average age of these patients was 45.81 years (SD 13.97 years). Anxiety, dreaminess, dizziness, palpitation, headache, thirst, weakness, chest distress, annoyance, abdominal distension, bad moods, difficulty in falling asleep and bitter taste in the mouth were core symptoms of insomnia. The 10 most commonly used drugs ranged from more to less were estazolam (29.99%), Zaoren anshen capsule (15.50%), oryzanol (14.82%), diazepam (14.51%), flupentixol and melitracen (14.30%), alprazolam (8.12%), zolpidem tartrate (5.29%), vitamin B6 (4.76%), sertraline (4.03%), and clonazepam (2.97%).
Conclusion:
Drugs used for insomnia in the Chinese medicine hospital in Longgang, Shenzhen mainly included benzodiazepines, nonbenzodiazepines, Chinese patent medicines, anti-anxiety drugs, anti-depression drugs, oryzanol, and vitamin B6. The use of oryzanol and vitamin B6 was abused in Chinese medicine hospitals, and the use of Chinese medicine should be evaluated more rigorously. Nonbenzodiazepines should be promoted and more widely understood in the Chinese medicine hospital in Longgang, Shenzhen.
Main Points
Drugs used for insomnia in the Chinese medicine hospital in Longgang, Shenzhen mainly included benzodiazepines, nonbenzodiazepines, Chinese patent medicines, anti-anxiety drugs and anti-depression drugs, oryzanol, and vitamin B6. The overall drug usage conformed to the recommendations of both Chinese and European guidelines. However, there may be cases of overuse concerning certain drugs, such as oryzanol and vitamin B6. The use of Chinese medicine should be evaluated more rigorously.
Introduction
Insomnia is a sleep disorder where people struggle to get off to sleep or to stay asleep. Some individuals have both issues, and others may also have early-morning awakenings, where they are unable to get back to sleep after awakening earlier than desired.1,2 The prevalence of insomnia varied from 6%-19%.3,4 Insomnia could be a risk factor for cardiovascular diseases,5-7 arterial hypertension, myocardial infarction, chronic heart failure,8,9 type 2 diabetes,10 and obesity and hypertension11. Classical benzodiazepines and benzodiazepine receptor agonists (BZRAs, nonbenzodiazepines) are recommended in treating insomnia.2 Antidepressants are also used in clinical practice, although there is less evidence of their efficacy.12 In addition, antipsychotics, antihistamines, herbal medicine, and melatonin are also used as the therapeutic regimen for insomnia with lower evidence.3 Xiaojia Ni17 conducted a meta-analysis on the efficacy of Chinese herbal medicine for insomnia compared to a placebo and found that Chinese medicine outperformed the placebo. However, the quality of the included studies was poor.3
On the other hand, A recent survey indicated that 47% of Chinese residents fall asleep after midnight, and their nighttime sleep duration is generally short, with only 6.75 hours.13 Chinese medicine hospitals are medical institutions that treat patients with both traditional Chinese medicine and western medicine.14 In China, there are about 20% outpatient visits in traditional Chinese medicine hospitals.14 The rationality of drug use for insomnia in Chinese medicine hospitals was uncertain. Previous studies have primarily focused on researching and summarizing the efficacy and evidence-based medical evidence of various traditional Chinese medicine (TCM) treatments for insomnia. However, there has been no research or summary conducted on the rationality of prescriptions in TCM hospitals.15-17 So, a big data analysis on the drug use of insomnia was very necessary to help to evaluate the rationality of drug use in the Chinese medicine hospital. In addition, the authors should evaluate the evidence-based medical evidence on the drug use in the Chinese medicine hospital. In China, to evaluate the condition of usage of drugs in the Chinese medicine hospital in Longgang, Shenzhen, Guangdong Province, the authors carried out this cross-sectional research.
Material and Methods
Study Designs
A retrospective, cross-sectional study was conducted in Shenzhen Hospital of Beijing University of Chinese Medicine (Long Gang), Guangdong Province. Insomnia patients from January 1, 2016, to November 10, 2020, were included in the cross-sectional study. The inclusion criteria: Patients corresponding to the International Classification of Sleep Disorders (ISCD-3) Diagnostic Criteria for short-term and chronic insomnia were included. The exclusion criteria: The authors excluded patients with severe mental disease or nervous system dysfunction or who could not correctly describe their symptoms.
Data Collection and Analysis
The information of patient (including register number, age, sex and diagnosis), medication, medical test results was collected from Shenzhen Hospital of Beijing University of Chinese Medicine Hospital Information System (HIS) by clinical practitioners. The clinical practitioners should be certified Chinese medicine doctors. In China, certified Chinese medicine doctors also have a solid foundation in modern medicine and can use modern medicine expertly. The authors extracted the information of drug use, symptoms of patients using R software (version 4.0.2) from the Hospital Information System (HIS). Data was also analyzed by R software (version 4.0.2). The quantitative data were expressed as mean (SD), and the difference between the 2 groups was calculated by t-test or Wilcoxon test (whether the data were conformed to normal distribution and homogeneity of variance). The authors used the chi-square test to compare the frequency of counting data between groups. Association rules analysis was used to discover strong and directional associations between items and was applied on the previous researches of association of multimorbidity in elderly people18,19 and Chinese medicine compatibility patterns,20 so the authors attempted to use it to find out the relationships with symptoms and the usage of drugs. In visualization of analysis results of association rules, the authors could be an intuitive ability to see the association between drugs and symptoms.21
This study was approved by the ethics committee of Shenzhen Hospital of Beijing university of Chinese Medicine (Long Gang) (Approval No: SZLDH2020LSYM-105, Date: December 18, 2020). Written informed consent was obtained from the participants who agreed to take part in the study. The research was registered in Chinese Clinical Trial Registry, ChiCTR2000040703.
Results
Baseline patient characteristics
A total of 9439 patients were included in the study, with 21 073 times visiting the doctors, among whom 3740 (39.6%) patients were male, and 5699 (60.4%) patients were female. There were 6577 patients (69.7%) and 14 256 (67.7%) times visiting the doctors included in the retrospective cross-sectional study to assess the drug use. The average age of these patients was 45.81 years (SD: 13.97 years). Table 1 shows characteristics of the included 9439 patients (Two patients lacking corresponding information were excluded).
Table 1.
Different Sexual Characteristics of 9439 Patients with Insomnia
| All | Male | Female | P value | |
|---|---|---|---|---|
| Average age | ||||
| Mean (SD) | 45.81 (±13.97) | 45.28 (±13.92) | 46.16 (±14.00) | .001 (Cohen’s d= 0.063, 95% CI [0.021, 0.104]) |
| Agegroup | ||||
| ≤30 | 1154 (12.23%) | 456 (39.51%) | 698 (60.49%) | <.001 (Cramer’s V = 0.043) |
| 31-45 | 3740 (39.63%) | 1573 (42.06%) | 2167 (57.94%) | |
| 46-60 | 3050 (32.32%) | 1164 (38.16%) | 1886 (61.84%) | |
| >60 | 1493 (15.82%) | 547 (36.64%) | 946 (63.36%) | |
Excluded the patients with no information of age. The difference between different groups was calculated by t-test and r by c (row by column) chi-square test.
Use of Benzodiazepines, Nonbenzodiazepines, Chinese Patent Medicines, Anti-anxiety Drugs, and Anti-depressants and Other Kinds of Medications
Among the total of 21 073 times visiting the doctors, 14 256 times (67.65%) received drug prescription and more than one anti-insomnia drug was administered in 8355 times. For benzodiazepines, estazolam was administered 4276 times (29.99%), alprazolam was administered 1157 times (8.12%), diazepam was administered 2069 times (14.51%), and clonazepam was administered 424 times (2.97%) (Table 2). Among the patients who visited the doctors and were prescribed nonbenzodiazepines, zolpidem tartrate was administered 754 times (5.29%), and eszopiclone was administered 119 times (0.83%) (Table 2). Regarding Chinese patent medicines, Zaoren anshen capsule was administered a total of 2209 times (15.50%), and Shumian capsule was administered 400 times (2.81%) (Table 2). In terms of the use of Chinese medicinal herbs, they were administered a total of 4406 times (30.91%). Flupentixol and melitracen were administered a total of 2038 times (14.30%). Sertraline was administered 575 times (4.03%) (Table 2). As for other medications, oryzanol was administered 2113 times (14.82%), and vitamin B6 was administered 679 times (4.76%) (Table 2).
Table 2.
The Use of Benzodiazepines, Nonbenzodiazepines, Chinese Patent Medicines, Anti-anxiety Drugs, and Anti-depressants and Other Kinds of Medications in Total Patients
| Drugs | Frequency | Percentage |
|---|---|---|
| Use of benzodiazepines | ||
| Estazolam | 4276 | 29.99 |
| Diazepam | 2069 | 14.51 |
| Alprazolam | 1157 | 8.12 |
| Clonazepam | 424 | 2.97 |
| Use of nonbenzodiazepines | ||
| Zolpidem Tartrate | 754 | 5.29 |
| Eszopiclone | 119 | 0.83 |
| Use of Chinese patent medicines | ||
| Zaoren Anshen Capsule | 2209 | 15.50 |
| Shumian Capsule | 400 | 2.81 |
| Use of Chinese medicinal herbs | ||
| Chinese medicinal herbs | 4406 | 30.91 |
| Use of anti-anxiety drugs and anti-depressants | ||
| Flupentixol and Melitracen | 2038 | 14.30 |
| Sertraline | 575 | 4.03 |
| Escitalopram | 120 | 0.84 |
| Other kinds of medications | ||
| Oryzanol | 2113 | 14.82 |
| Vitamin B6 | 679 | 4.76 |
Symptoms Collection
A total of 17 337 visits to doctors were recorded in the electronic medical records (EMRs) system, representing 82.27% of all patient visits. The R software package stringr was used to extract the symptoms and signs information contained in the medical records. The extracted symptoms and signs were sorted in descending order based on their frequency. The top 20 symptoms were selected, and the results are shown in Table 3.
Table 3.
Top 20 Symptoms of Insomnia of 9439 Patients
| Symptoms | Frequency | Percentage |
|---|---|---|
| Anxiety | 3803 | 21.94 |
| Dreaminess | 2883 | 16.63 |
| Dizziness | 2063 | 11.90 |
| Palpitation | 1985 | 11.45 |
| Headache | 1867 | 10.77 |
| Upset | 1694 | 9.77 |
| Thirst | 1681 | 9.70 |
| Weakness | 1659 | 9.57 |
| Chest distress | 1538 | 8.87 |
| Annoyance | 1143 | 6.59 |
| Abdominal distension | 1138 | 6.56 |
| Difficulty falling asleep | 1123 | 6.48 |
| Bitter taste | 1108 | 6.39 |
| Bad moods | 978 | 5.64 |
| Constipation | 464 | 2.68 |
| Soreness of waist | 443 | 2.56 |
| Eat less | 365 | 2.11 |
| Lambago | 272 | 1.57 |
| Loose stool | 212 | 1.22 |
| Tinnitus | 189 | 1.09 |
| Short of breath | 148 | 0.85 |
| Dry throat | 134 | 0.77 |
| Irritable | 125 | 0.72 |
| Early awakening | 118 | 0.68 |
| Idrosis | 101 | 0.58 |
According to Table 3, the following symptoms occurred in more than 5% of patient visits: anxiety, dreaminess, dizziness, palpitation, headache, upset, thirst, weakness, chest distress, annoyance, abdominal distension, bad moods, difficulty falling asleep, bitter taste in the mouth, and bad moods.
Multiple Logistic Regression to Examine the Relationship Between Symptoms, Age, Sex, and Drug Use
We carried to multiple logistic regression to explore the relationship between symptoms, age, sex and drug use. First, the authors conducted univariate logistic regression analysis, with the medication used as the dependent variable and symptoms, along with age and gender, as the influencing factors. From this analysis, the authors screened out the factors that had a P-value < .05 and demonstrated a positive correlation. Subsequently, the authors utilized the selected influencing factors to perform multiple logistic regression analysis. The authors further screened the factors that had a P-value < .05 in the multiple logistic regression analysis and calculated their odds ratios. The results are shown in Table 4.
Table 4.
Multiple Logistic Regression to Examine the Relationship Between Drug Use and Symptoms, Age, and Sex
| Drugs | Influencing Factors | OR (95%CI) | P (Wald’s Test) |
|---|---|---|---|
| Estazolam | Dreaminess | 1.66 (1.46, 1.89) | <.001 |
| Irritable | 3.08 (1.85, 5.13) | <.001 | |
| age (cont. var.) | 1.0093 (1.0057, 1.0128) | <.001 | |
| Diazepam | Weakness | 1.5 (1.22, 1.83) | <.001 |
| Anxiety | 8.71 (7.57, 10.01) | <.001 | |
| Eat less | 1.74 (1.29, 2.37) | <.001 | |
| Age (cont. var.) | 0.99 (0.98, 0.99) | <.001 | |
| Alprazolam | Early awakening | 2.88 (1.01, 8.19) | .047 |
| Difficulty falling asleep | 1.88 (1.3, 2.72) | <.001 | |
| Clonazepam | Anxiety | 2.51 (1.56, 4.05) | <.001 |
| Dreaminess | 2.18 (1.51, 3.17) | <.001 | |
| Abdominal distension | 1.79 (1.06, 3.05) | .031 | |
| Thirst | 4.54 (2.64, 7.81) | <.001 | |
| Weakness | 1.78 (1.08, 2.92) | .024 | |
| Bitter taste | 0.24 (0.11, 0.52) | <.001 | |
| Sex: female vs male | 0.5 (0.37, 0.68) | <.001 | |
| Zolpidem Tartrate | Difficulty falling asleep | 3.51 (2.39, 5.16) | <.001 |
| Sex: female vs male | 1.65 (1.3, 2.09) | <.001 | |
| Flupentixol and Melitracen | Bad moods | 1.43 (1.13, 1.83) | .004 |
| Dreaminess | 3.05 (2.62, 3.55) | <.001 | |
| Anxiety | 4.09 (3.52, 4.75) | <.001 | |
| age (cont. var.) | 0.99 (0.98, 1) | <.001 | |
| Sex: female vs male | 1.28 (1.11, 1.48) | <.001 | |
| Sertraline | Bad moods | 16.15 (12.05, 21.65) | <.001 |
| Anxiety | 2.67 (1.97, 3.62) | <.001 | |
| Weakness | 2.16 (1.45, 3.21) | <.001 | |
| Sex: female vs male | 0.72 (0.55, 0.95) | .019 | |
| Age (cont. var.) | 0.96 (0.95, 0.97) | <.001 | |
| Oryzanol | Dreaminess | 1.92 (1.66, 2.22) | <.001 |
| Anxiety | 4.07 (3.57, 4.64) | <.001 | |
| Sex: female vs male | 1.27 (1.12, 1.45) | <.001 | |
| Age (cont. var.) | 0.98 (0.97, 0.98) | <.001 |
From Table 4, the authors can observe that the use of estazolam was strongly associated with dreaminess and irritability. The use of diazepam was strongly correlated with symptoms such as weakness and anxiety. The use of alprazolam was strongly linked to early awakening and difficulty falling asleep. The use of clonazepam was strongly associated with symptoms including anxiety and dreaminess. The use of zolpidem was strongly related to difficulty falling asleep. The use of Deanxit (flupentixol and melitracen) was strongly correlated with symptoms such as depression, anxiety, and dreaminess. The use of sertraline was strongly linked to symptoms of depression, anxiety, and weakness. The use of oryzanol was strongly associated with symptoms of anxiety and dreaminess. In terms of the relationship between drug use and age or gender, the authors found that gender was a factor influencing the use of several drugs, but only the odds ratios of clonazepam and zolpidem reached a moderate level of association (OR > 1.5 or OR < 0.6).22 Specifically, clonazepam tended to be used more in male patients, while zolpidem tended to be used more in female patients. In terms of age, both sertraline and oryzanol tended to be used more in younger patients.
Reinteraction of Symptoms and Drugs
We selected patient visits where benzodiazepines, nonbenzodiazepines, Chinese patent medicines, oryzanol, vitamin B6, anti-anxiety drugs, and anti-depressants were prescribed, respectively. Subsequently, the authors summarized the occurrences of different symptoms in these visits for each type of medication. The results were as follows (Table 5).
Table 5.
Insomnia Symptoms Corresponding to Different Medications
| Kinds of drugs | Symptoms | Frequency | Percentage |
|---|---|---|---|
| Benzodiazepines | Anxiety | 2310 | 31.35 |
| Dreaminess | 1030 | 13.98 | |
| Palpitation | 611 | 8.29 | |
| Dizziness | 572 | 7.76 | |
| Upset | 527 | 7.15 | |
| Headache | 513 | 6.96 | |
| Weakness | 498 | 6.76 | |
| Chest distress | 482 | 6.54 | |
| Difficulty falling asleep | 408 | 5.54 | |
| Dry throat | 392 | 5.32 | |
| Nonbenzodiazepines | Anxiety | 187 | 21.59 |
| Dreaminess | 105 | 12.12 | |
| Difficulty falling asleep | 95 | 10.97 | |
| Palpitation | 88 | 10.16 | |
| Headache | 84 | 9.70 | |
| Upset | 78 | 9.01 | |
| Dizziness | 78 | 9.01 | |
| Chest distress | 73 | 8.43 | |
| Weakness | 72 | 8.31 | |
| Abdominal distention | 60 | 6.93 | |
| Chinese patent medicines | Dreaminess | 355 | 20.89 |
| Palpitation | 279 | 16.42 | |
| Anxiety | 261 | 15.36 | |
| Dizziness | 205 | 12.07 | |
| Abdominal distention | 195 | 11.48 | |
| Headache | 194 | 11.42 | |
| Chest distress | 174 | 10.24 | |
| Weakness | 156 | 9.18 | |
| Dry throat | 126 | 7.42 | |
| Upset | 120 | 7.06 | |
| Oryzanol or vitamin B6 | Anxiety | 1192 | 52.74 |
| Dreaminess | 728 | 32.21 | |
| Upset | 192 | 8.50 | |
| Headache | 151 | 6.68 | |
| Dizziness | 104 | 4.60 | |
| Bad moods | 103 | 4.56 | |
| Weakness | 97 | 4.29 | |
| Bitter taste | 87 | 3.85 | |
| Dry throat | 75 | 3.32 | |
| Difficulty falling asleep | 74 | 3.27 | |
| Anti-anxiety drugs or anti-depressants | Anxiety | 1466 | 60.06 |
| Dreaminess | 564 | 23.11 | |
| Bad moods | 539 | 22.08 | |
| Upset | 376 | 15.40 | |
| Dizziness | 205 | 8.40 | |
| Difficulty falling asleep | 200 | 8.19 | |
| Headache | 176 | 7.21 | |
| Palpitation | 172 | 7.05 | |
| Weakness | 140 | 5.74 | |
| Dry throat | 103 | 4.22 |
For the patients who received benzodiazepines, nonbenzodiazepines, oryzanol or vitamin B6, and anti-anxiety drugs or anti-depressants, the most common symptom was anxiety. However, for Chinese patent medicines, the most common symptom was dreaminess.
The arulesViz package was used to draw the correlation diagram of results of association rules analysis, and the results were shown in Figure 1.
Figure 1.
a-d: Association rules analysis of drug use and symptoms. (a) Association rules between benzodiazepines and symptoms. (b) Association rules between anti-anxiety drugs, anti-depressants and symptoms. (c) Association rules between Chinese patent medicines and symptoms. (d) Association rules between oryzanol, vitamin B6 and symptoms. The size of the circle represented the support value, and the color of the circle represented the lift value. For association rules between benzodiazepines and symptoms, the threshold was support value>0.01 and confidence value>0.1. For association rules between Chinese patent medicines, oryzanol and vitamin B6, anti-anxiety drugs, anti-depressants and symptoms, the threshold was support value>0.005 and confidence value>0.05.
The results of association rules analysis showed that patients who were treated with benzodiazepines were associated with anxiety, dreaminess, upset, bitter taste, difficulty falling asleep, chest distress, palpitation, weakness, headache, dizziness, thirst, abdominal distension, which were in accordance with the result in Table 5. Patients who were administered Chinese patent medicines were associated with dizziness, weakness, dreaminess, palpitation, chest distress and headache. Patients who were administered oryzanol or vitamin B6 were associated with headache, anxiety, dreaminess and upset. Patients who were administered anti-anxiety drugs or anti-depression drugs were associated with anxiety, bad mood, upset, dizziness, dreaminess and headache.
Discussion
This study evaluated the drug use in treating patients with insomnia in Longgang, Shenzhen. The information was recorded by the Hospital Information System (HIS) in Shenzhen Hospital of Beijing University of Chinese Medicine (Long Gang).
According to the Chinese and European guidelines on insomnia, benzodiazepines, nonbenzodiazepines, and certain antidepressants are effective for short-term treatment of insomnia, whereas antipsychotic drugs are not recommended for this condition. This aligns with the research results, which showed that benzodiazepines, nonbenzodiazepines, and antidepressants were widely used in Shenzhen Hospital of Beijing University of Chinese Medicine (Long Gang), Guangdong Province.3,23 In this research, the authors found that Chinese patent medicines (18.31%) and Chinese medicinal herbs (30.91%) were widely used in Shenzhen Hospital of Beijing University of Chinese Medicine (Long Gang), which was different to the guidelines. Xiaojia Ni24 conducted a meta-analysis on the efficacy of Chinese medicine on insomnia compared with placebo, and found that the Chinese medicine was better than placebo; however, the quality of included studies was poor.3 In this research, antipsychotics were rarely used. Suzanne M. Bertisch4 did not report the significant efficacy of antipsychotics in a big cross-sectional research of prescription medications for insomnia in America. So, the authors thought the efficacy of Chinese medicine on insomnia and the rationality of drug use in Chinese Medicine Hospital were still should be necessary to be further evaluated.
A meta-analysis indicated that there was no difference between benzodiazepines and nonbenzodiazepines.25 In this research, the authors found that the usage of benzodiazepines was far more than nonbenzodiazepines and the reason might be related to the fact that benzodiazepines were more acceptable in doctors’ conception in the Chinese medicine hospital in Longgang, Shenzhen.
For oryzanol and vitamin B6, there were about of 14.82% patients were administered oryzanol and about 4.76% patients were administered vitamin B6. In past research, there was no significant evidence indicating that oryzanol could be helpful to insomnia, and it wasn’t recommended in guidelines.25 For vitamin B6, Patrick Lemoine26 found that the combination of melatonin, vitamin B6, and medicinal plants may be beneficial in mild-to-moderate insomnia. However, there was no evidence that vitamin B6 was effective for insomnia when used alone. On the other hand, Agnieszka Marosz27 pointed that the use of vitamin supplements was not always desirable, while being straightforwardly hazardous in certain cases. Cautiously, the authors were of the opinion that the use of oryzanol and vitamin B6 was abused in Chinese medicine hospitals.
As for anti-anxiety drugs and anti-depressants, in this research, Deanxit (flupentixol and melitracen) and sertraline were mostly used in Shenzhen Hospital of Beijing University of Chinese Medicine (LongGang). A research from China also reported the Deanxit (flupentixol and melitracen) was widely used in 20 national hospitals in China. However, there was no precise evidence manifested that Deanxit (flupentixol and melitracen) was effective for insomnia and was not recommended in guidelines.3 For sertraline, there was some evidence indicating that antidepressant pharmacotherapy could relieve the symptoms in patients with comorbid depression and insomnia28 and the efficiency was exactly.3 Alexander Winkler29 made an analysis on antidepression drugs and found that the efficacy of antidepressants was weaker than benzodiazepines and nonbenzodiazepines on insomnia. Other research indicated that adverse effects and withdrawal reactions did not significantly differ between participants receiving antidepressants and those receiving placebo.30 The authors considered that anti-anxiety drugs and anti-depressants should be specifically used in patients with comorbid depression and insomnia.
In the results of the multiple logistic regression analysis, the authors found that the influencing factors of medications were generally correlated with their efficacy. For instance, Deanxit (flupentixol and melitracen) and sertraline were also more related to symptoms such as anxiety and bad moods. Of course, there were also some interesting findings. The use of diazepam was more closely related to anxiety, while alprazolam, estazolam and zolpidem were more associated with sleep issues. Additionally, zolpidem tended to be used more in female patients. The authors believe that there appears to be no particularly inappropriate aspect regarding such outcomes. Previous studies have shown that dosage reduction in women was not supported by available scientific evidence, and may actually result in underdosing and the subsequent risk of inadequately treated insomnia.31
For the drug use of insomnia in Shenzhen Hospital of Beijing University of Chinese Medicine (LongGang), totally 4406(30.91%) comes used Chinese medicinal herbs, which indicated that traditional Chinese medicine would be used very commonly in the Chinese medicine hospital. As is known to all, there were many Chinese medicinal herbs and Chinese patent medicines used in Chinese medicine hospitals in China.14 However, the use of Chinese medicine lacked proper efficacy evaluation and clinical trial or observation with high-level evidence.3 More rigorous, high-quality clinical trials should be carried out to evaluate the exact efficacy of Chinese medicine in specific patients.
In addition, the authors thought the nonbenzodiazepines had some advantages over benzodiazepines and should be promoted in Chinese medicine hospitals. Compared to traditional benzodiazepines, non-benzodiazepines may have less disruptive sleep stages, have lesser effects on next day psychomotor performance and be more safe,32-34 although this conclusion could be controversial.35
Compared with other results on drug use of insomnia, Barry Krakow36 carried a retrospective chart review on 137 consecutive patients who nightly used prescription medication for sleep for at least 6 months in America, found that benzodiazepines (n=40, 29.20%), nonbenzodiazepines (n=57, 41.61%) and antidepressants(n=38, 27.74%) were widely used. Compared with the study Barry Krakow carried, the authors found that the percentage of usage of nonbenzodiazepines and antidepressants was much less in Shenzhen, China (41.61% vs 6.12%, 27.74% vs 19.17%). The percentage of usage of benzodiazepines was much more in Shenzhen, China (29.20% vs 55.59%). Guodong Lou37 found that benzodiazepines (53.99%) were the most common type of medicine for insomnia in a western medicine hospital, Zhejiang Province, China. The result was approximate to this finding in Shenzhen, China. However, the percentage of drug use of nonbenzodiazepines was 31.34% in a western medicine hospital, Zhejiang, China. The authors thought that maybe the usage of traditional Chinese medicine crowded out the usage of nonbenzodiazepines in Chinese medicine hospitals. Another study in Japan38 included 261,167 patients in Japanese hospitals. They found the most prescribed drugs were benzodiazepines (59.7%) and nonbenzodiazepines (36.8%). The result was approximate to a western medicine hospital, Zhejiang Province, China. In general, compared with hospitals in other countries or western medicine hospitals in China, the use of nonbenzodiazepines maybe was insufficient in Chinese medicine hospitals in Shenzhen, China.
Limitations of the study
For the deficiencies of this research, foremost, the data of research was from the HIS, and some clinicians would omit or miswrite some information during the busy work, the data could have some biases and some incompleteness. P. W. Handayani39 pointed out that the HIS still needs to be refined in terms of providing optimal health services in developing countries, and there was considerable dissatisfaction with the quality of the existing HIS among doctors. In addition, the patient’s information in HIS of the Chinese medicine hospital, Longgang, Shenzhen, contained only sex and age, and no other important information was recorded. Therefore, as a cross-sectional study, the information collection was inadequate. In the HIS, there are also some patients (30.3%) and some visits (32.7%) do not be recorded completely in the system. It may have some impact on the results. However, as remaining data was large enough (6577 patients (69.7%) and 14256 (67.7%) visits), the authors believed that the results would have high reliability and the loss data could not influence the result crucially.
In conclusion, the drugs used for insomnia in the Chinese medicine hospital in Longgang, Shenzhen mainly included benzodiazepines, nonbenzodiazepines, Chinese patent medicines, anti-anxiety drugs and anti-depression drugs, oryzanol and vitamin B6. Oryzanol and vitamin B6 were abused in the Chinese medicine hospital, and the usage of Chinese medicinal herbs and Chinese patent medicines should be evaluated more rigorously. The nonbenzodiazepines should be promoted and broader understood in the Chinese medicine hospital in Longgang, Shenzhen.
Funding Statement
Funding: This work was funded by Hangzhou Special Sci-Tech Program to Support Biomedicine and Health Industry Development (No. 2021WJCY248) and Zhejiang TCM Sci-Tech Program (No. 2024ZF116). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Footnotes
Ethics Committee Approval: This study was approved by the Ethic committee of Shenzhen Hospital of Beijing university of Chinese Medicine (Long Gang) (Approval No: SZLDH2020LSYM-105, Date: December 18, 2020).
Informed Consent: Written informed consent was obtained the participants who agreed to take part in the study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – L.Z., Z.H.; Design – L.Z., Z.H.; Supervision – L.Z., Z.H.; Resources – J.L., Z.W., D.T., R.X.; Materials – J.L., Z.W., D.T.; Data Collection and/or Processing – J.L., Z.W., D.T., R.X.; Analysis and/or Interpretation – J.L., Z.W., D.T., R.X.; Literature Search – J.L.; Writing – J.L.; Critical Review – L.Z., Z.H.
Declaration of Interests: The authors have no conflict of interest to declare.
Data Availability Statement:
The data that support the findings of this study are available on request from the corresponding author.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.