ARTICLE: Evidence Aside, Drugs First Choice for Insomnia

Source:  Rieu-Werden ML, et al "Underutilization of nonpharmacologic interventions for insomnia by healthcare providers" APA 2010; Abstract NR2-59.

NEW ORLEANS -- Nearly three-quarters of surveyed physicians reported writing prescriptions for sleep medications as their primary course of treatment, Meghan Rieu-Werden, a research assistant at Massachusetts General Hospital, and colleagues reported during a poster session at the American Psychiatric Association meeting.

Many treatment guidelines recommend nonpharmacologic interventions as first-line treatment for insomnia, regardless of the cause or associated medical and psychiatric conditions, according to the researchers. These interventions include cognitive therapy, cognitive behavioral therapy, relaxation therapy, stress reduction therapy, and sleep hygiene education (SHE), all of which have all been shown to be effective monotherapy. Sleep hygiene education is particularly recommended, Rieu-Werden said. It includes going to bed and waking up at the same time every day, limiting the quantity or adjusting the timing of caffeine and alcohol intake, engaging in regular exercise, adjusting the timing of exercise, and implementing relaxation techniques.

Don Hilty, MD, of the University of California Davis, who was not involved in the study, said these elements "should be common sense, but some patients need reminders." To identify practice gaps in the treatment of insomnia, the researchers surveyed 500 healthcare providers who attended a psychopharmacology course -- 40.2% were psychiatrists, 9.4% were nonpsychiatrist physicians, 18.8% were prescribing nurses, and 5% were nonprescribers. It was not possible to identify 26.6% of respondents from the data they provided. All participants answered three open-ended clinical questions based on a case vignette, which described a hypothetical patient presenting with major depressive disorder.

The patient returns for three visits over the next three months. Participants were asked to come up with a diagnosis, provide an initial treatment course, and a treatment for insomnia. Rieu-Werden said the study focused on the treatment of insomnia. They found that the majority of providers listed pharmacologic monotherapy as their first-line intervention (73.19%). These included hypnotic drugs such as eszopiclone (Lunesta) and zolpidem (Ambien). Just 2.22% ordered nonpharmaceutical interventions as their primary treatment. About a quarter used a combination of pharmacologic and nonpharmacologic therapies (24.6%) as first-line treatment. Other nonpharmacologic interventions survey respondents reported using were melatonin and light box therapy as well.

The researchers said that survey respondents may have underutilized the sleep hygiene intervention because the hypothetical patient's insomnia returned while taking antidepressants. Thus, many may have assumed that the medication was the cause of the insomnia, Rieu-Werden said. She added that the results may also have been confounded because participants were attending a psychopharmacology course.

Still, Rieu-Werden and colleagues concluded that the majority of healthcare providers don't use nonpharmacologic interventions as primary therapy in insomnia, despite guideline recommendations. She said healthcare providers would benefit from educational activities that address various treatments for insomnia.

Hilty agreed. "Psychiatrists and primary care physicians need to know more about nonpharmaceutical treatments, or try using medications and other interventions in combination if one is not working," he said.

He also agreed that sleep hygiene generally makes "common sense" as a first-line remedy, but "a more chronic or persistent issue may require cognitive behavioral therapy or cognitive treatment -- something with more impact." Rieu-Werden also said that further research needs to be done to determine what influences diagnostic and treatment choices.