Abstract
BackgroundThis review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.MethodsMEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.ResultsA total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.ConclusionsAssuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.Systematic review registrationPROSPERO CRD42017072527.
Highlights
This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed
Clinical practice guidelines published in the USA, Canada, and Europe unanimously recommend that nonpharmacological approaches, especially cognitive behavioral therapies, should be the first-line treatment for chronic insomnia and that pharmacological treatment should only be used in acute cases (< 3 months) or as a short-term supplement to nonpharmacological approaches [6,7,8]
Literature search The literature search resulted in 5024 titles and abstracts to be screened after de-duplication, 4499 of which were excluded after level 1 screening for not meeting eligibility criteria (Fig. 1)
Summary
This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed. Insomnia is a common disorder in the general population. The rate of prescription sleep aid use, non-benzodiazepines and off-label use of antidepressants, has risen significantly over the last 20 years [9,10,11], in some cases outpacing the diagnosis of sleep disorders among the general population [10]. A large prospective study of former and current insomnia sufferers found that 70% of patients using a prescription sleep aid continued to do so at 1-year follow-up but did not demonstrate significant improvements in sleep compared to non-users [12]. The use of non-prescription sleep aids is common alongside prescription drugs; up to 60% of sleep aids used by adults with insomnia are non-prescription [12, 13]
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