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INDICATIONS FOR DRUGS

Sleeping medication should be used for not longer than two weeks.
After two weeks the medication is no longer effective for inducing sleep and should be stopped gradually. The only reason for continued use after two weeks is perhaps to prevent the onset of rebound insomnia. Intermittent use of the drug is advisable, skipping the nightly dose after a couple of good night's sleep. Sleeping pills can be used in the following situations, but only if all the non-drug strategies are not working.
All mental illness. This should be treated appropriately by modern medicine. Mental illness still carries a stigma and people are ashamed of it In fact mental illness is an illness of the mind and is not different from physical illness such as diabetes, heart disease, and so on that require constant medication. The fact that drugs and pills which are physical agents can successfully treat mental illness implies that mental illness itself has a physical cause as it requires physical treatment. Hence the old stigma of mental illness that it is the weakling who suffers from mental illness needs to be revised. Mental illness can attack anyone, just like appendicitis does, and no one is immune. Stopping medication does not mean disappearance of mental illness.
Biological clock related insomnia. This is transient insomnia resulting either from jet lag or from shift work. If sleeping pills are required, they should be taken for not more than a few days. People who suffer jet lag can take sleeping pills for the first few nights so as to facilitate the resetting of the biological clock. This applies to shift workers also. After the first few nights, the sleeping pills should be stopped, as the biological clock should be on time with the shift by now. Longer acting pills such as Nitrazepam should be used, as they sustain sleep longer. Very often after arrival at a new destination or after starting a new shift, people feel very sleepy and have no trouble falling asleep, but they may wake up after a few hours and not be able to sleep again. This is because the waking time of their biological clock is early. They need a pill to keep them asleep so as not to wake up prematurely.
Situational insomnia. This is normally stress related and is transient. Sleeping pills can be used if necessary, but should be stopped immediately after the stress is lifted, as addiction is a distinct possibility in some people.
Pain and physical illness. These can disturb sleep, and most sleeping pills prescribed in hospital are to prevent this. Many people who are taking sleeping pills later in life recall that the first time they started taking them was when they were in hospital.
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EPILEPSY AND PREGNANCY

Women with epilepsy are quite often concerned about getting pregnant. There appear to be five reasons for this concern. They wish to know:
if they are likely to hand their epilepsy on to their children;
whether their fits will get worse during pregnancy;
whether it is safe for the baby that the mother should take anticonvulsants drugs during pregnancy;
if there will be any problems in the newborn baby from these drugs;
if they can safely breast feed the baby.
With regard to handing on epilepsy to one’s children – as mentioned earlier, if one parent has epilepsy, the chances of one of the children having epilepsy are no greater than in the population at large. If both parents have epilepsy, it would appear that the risk of a child having epilepsy is about 10 per cent. So in fact the chance of a child inheriting epilepsy, particularly idiopathic epilepsy, is negligible.
As far as seizures during pregnancy are concerned, the situation is not as clear as it might be. There is evidence that for some women, seizure control may deteriorate, while for others there may in fact be no change or even an improvement. A patient told me recently that “she would like to remain pregnant forever” as she had not had a single fit during her pregnancy, compared with six fits in the preceding nine months!
As a general working rule, it is suggested that people who have more than one grand mal fit a month are those who are most likely to have a deterioration in seizure control during pregnancy. The deterioration, if it occurs, is most likely during the first three months of pregnancy. There are a number of theories why this may happen, but none has been proved. It may be of value to check the blood anticonvulsant levels during pregnancy, especially if there is a deterioration in seizure control. The blood levels may fall, necessitating an increase in dosage during the pregnancy.
The main concern for parents is whether the anticonvulsants can harm the unborn baby (foetus). It is known by most people with epilepsy that this is a potential hazard. The effects include physical abnormalities in the baby, a process known as teratogenesis. Abnormalities have been reported in the offspring of mothers on all the commonly used anticonvulsants with the exception of carbamazepine. This is particularly applicable to phenytoin, barbiturates and sodium valproate. Babies born to mothers who have been on carbamazepine have not been shown to have any physical abnormalities, but have a smaller head size than other babies. This has not been shown to be any handicap to the babies who have been followed up for five years.
The risk of abnormalities in the baby is difficult to assess, but it seems to be most common in mothers on polytherapy (receiving numerous drugs), especially if they are on three or more anticonvulsants. The risk in mothers on phenytoin, with or without other medications, appears to be about a 10% chance of the baby showing features of the ‘foetal hydantoin’ syndrome. This syndrome consists of cleft palate, abnormalities of the fingers, possible heart abnormalities and mild mental retardation. Thus, at present, if it is possible, it would seem wise to try to change patients over to carbamazepine before conception. This may not be possible in all patients and, of course, many women will first visit their doctor when already pregnant, at which time there is no purpose in making the change.
Anticonvulsants taken by the mother during pregnancy may have some effects on the baby immediately after birth, as they are transmitted to the baby across the placenta. These include the possibility of a mild bleeding tendency and some drowsiness. In mothers who have been taking barbiturates, the infant may occasionally show features of a withdrawal reaction with irritability, jitteriness and poor sucking. None of these features is [...]

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