Improving evidence-based practice in the treatment of chronic insomnia: a commentary for Sleep Medicine Reviews on “Chronic hypnotic use: deadly risks, doubtful benefits” (Daniel F. Kripke)

Abstract

The view on chronic hypnotic use by Professor Daniel F. Kripke underscores a scandalous public health issue, namely, the lack of scientific and clinical evidence to support the prevalent clinical practice of chronic sedative hypnotic prescription for patients with chronic insomnia. Not only is there a lack of controlled data to support this practice, there is also reason to think that it may be ultimately harmful to the health and wellbeing of some, if not many, patients, as argued in this review. This state of affairs leads compellingly to the research agenda recommended by Kripke for randomized, placebo-controlled maintenance clinical trials of sedative hypnotics to assess definitively the benefits and risks of these medications in the long-term clinical management of a chronic relapsing condition. Pending the collection of such data, Kripke recommends that maintenance treatment with sedative hypnotics be withdrawn and that cognitive behavioral therapy [1] be offered. While agreeing with Professor Kripke’s research agenda, I believe that it does not go far enough. I also think that there may be a role for support by the pharmaceutical industry, in tandem with federal sponsorship. In my opinion, we definitely need placebo-controlled evaluation of the efficacy of maintenance sedative hypnotic medication for the long-term management of chronic primary insomnia. The data reviewed by Kripke raise the distinct possibility that placebo may be at least as effective, if not more effective, and safer than sleeping pills. Since the highest currency both scientific and ethical between doctor and patient is derived from placebo-controlled evaluation, that standard should be applied to this prevalent clinical practice. However, I also believe that this is too narrow a research agenda and would not adequately inform clinical practice. Patients with chronic insomnia also frequently