Sleep Medication Recommendations Clinicians and Patients May Not Have Expected from the Sleep Academy
Recently, the American Academy of Sleep Medicine reviewed the evidence from randomized controlled trials to give clinicians a guide to prescribing medications for chronic insomnia in adults. They defined chronic insomnia as more than 3 months of insomnia with 3 or more episodes a week.
One recommendation was for CBT-I (cognitive behavior therapy for insomnia) as a first line treatment with low risk to the patient for chronic insomnia. The academy recognizes that not everyone will be able to benefit from CBT-I due to issues such as motivation, and access to CBT-I (there are online programs-see our resource page).
Surprisingly, commonly prescribed over the counter sleep medications such as Benadryl, melatonin and prescription medication trazodone were deemed to be not recommended due to a lack of evidence, whereas medications such as sedating non-benzodiazepines like Ambien, and benzodiazepines (restoril) were felt to be more evidence based and were recommended.
An important point in interpreting the recommendations is that the evidence was weak due to limitations in the amount and quality of research studies. Thus, the medications deemed to not be recommended were not exhaustively studied and cannot be considered obsolete to the medications that were. For example, there was a lack of evidence to support Benadryl, which clinically can help individuals, but lacks the amount of research evidence that the academy was looking for. Many of the melatonin trails looked at 2 mg does, a low dose that many people start at and end up requiring more, and there were not enough studies to perform a complete analysis of the evidence. Trazodone, a prescription medication for insomnia and depression, was not recommended, but a meta-analysis (comparison of many studies yielding strong conclusions) was not possible due to lack of evidence. The benzodiazepine/non-benzodiazepine medications had more evidence, it was generally still deemed weak due to industry bias for studies and imprecision of data. Other sleep medications not in the benzodiazepine/non-benzodiazepine classes were included in the study.
The take home points from the study were that there are medications that can promote sleep but the evidence in general is not strong due to limits of the research available and that adding cognitive behavior therapy for insomnia is a useful intervention that should be utilized in chronic insomnia.
© Neevon Esmaili 2017
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349.
Neevon Esmaili, MD
Child Adolescent, & Adult Psychiatrist
Dual Board Certified
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