Re: Non-benzodiazepine hypnotics: do they work for insomnia?
I read with interest the article on treatment on insomnia with the non-benzodiazepine hypnotics (the so called ‘Z-drugs’) which focused on the role of non-pharmaceutical treatment such as CBT in supporting treatment (1) given insomnia is common condition.
Aside from the focus of the article there are three significant issues that are commonly seen with management of insomnia in clinical practice:
1. The dependence that patients are increasingly developing with these Z drugs such as zopiclone or zolpidem.
2. The alternatives in treatments for sleep disturbances including insomnia which doesn’t include benzodiazepines or the Z drugs
3. The underlying cause of insomnia or sleep disturbance which would then direct clinicians to using alternative agents.
In an article in the Guardian (2) in August 2012, data from 2011 showed that 15.3 million NHS prescriptions were made for sleep medication. In England there were 5.4m prescriptions for Zopiclone and 2.8m for Temazepam, with an estimated one in 10 of people now taking some form of sleeping tablet regularly. This data suggests that significant proportion patients are taking such sleeping medication long term.
NICE guidelines on treatment on insomnia (3) are clear that Z drugs should be prescribed for a maximum of 4 weeks. However is clear that patients are often prescribed these medications for many months and in some cases years. This is resulting with increasing number of patients dependent on their sleep medication and often taking above recommended BNF doses.
I am a keen advocate not to use either benzodiazepines or Z drugs in the treatment of insomnia routinely as I believe as a clinician I am giving my patients a second problem of ‘iatrogenic’ hypnotic dependence in addition to their initial presenting illness. In the same NICE guidelines (3) figures quoted are of 10–30% of chronic benzodiazepines users are physically dependent on hypnotics with 50% of all users suffer withdrawal symptoms.
So what would the alternatives be?
Before answering that question I would suggest that clinicians spend time investigating the underlying cause of insomnia, which are numerous but include stress, psychiatric disorders, pain or too much caffeine and not being ‘tired’ enough to fall sleep. The treatment for each is significantly different.
Instead of being tempted to prescribe benzodiazepines or Z drugs as first line, clinicians should offer basic sleep hygiene advice focusing on bedtime routines, caffeine intake and ensuring exercise is taken during the day. A very helpful patient leaflet can be found on the RCPsych website (4). Then the reasons for the insomnia should be explored, with a high suspension for depression for those who present with sleep disturbance. Sleep disturbance is well recognised in having a high positive predictive value for depression with 60% of patients with depression presenting first with sleep problems (5).
If the insomnia is due to underlying psychiatric disorder one can treat the anxiety and depressive disorders with an antidepressant such as a SSRI with an adjunct of anti-histamine such as Promethazine to help with sleep. Promethazine (‘Phenergan’) is my first line medication for treating insomnia as it is not addictive and in my clinical practice effective although patients should be warned about driving with the associated drowsiness. Psychological interventions such as CBT or CBT for insomnia should have been considered at this point.
An alternative to treatment with two separate medications would be to use a sedating anti-depressant such as Mirtazapine or Trazadone. Mirtazapine is a highly effective antidepressant and is sedating although it should be noted most sedating at the lower dose of 15mg rather than 30 – 45mg doses. Patients often decline this option due to the increased appetite and weight gain. The other option would be Trazadone which is an effective sedating medication but not considered to be more efficacious than SSRIs in treating depression. In my experience GPs often prescribe low dose amitrypyline to manage insomnia and I would suggest that low dose Trazadone could be used as a suitable alternative.
If patients have more severe insomnia then anti-psychotics can be used, but I suggest that this should be prescribed in secondary care only.
In conclusion although the editorial focused on Z drugs or CBT which are both effective treatments for insomnia, I would ask fellow clinicians to consider the dependence that patients can develop with Z drugs. There are other treatments that can be used including sleep hygiene, anti-histamines, and sedating anti-depressants.
Rapid Response:
Re: Non-benzodiazepine hypnotics: do they work for insomnia?
I read with interest the article on treatment on insomnia with the non-benzodiazepine hypnotics (the so called ‘Z-drugs’) which focused on the role of non-pharmaceutical treatment such as CBT in supporting treatment (1) given insomnia is common condition.
Aside from the focus of the article there are three significant issues that are commonly seen with management of insomnia in clinical practice:
1. The dependence that patients are increasingly developing with these Z drugs such as zopiclone or zolpidem.
2. The alternatives in treatments for sleep disturbances including insomnia which doesn’t include benzodiazepines or the Z drugs
3. The underlying cause of insomnia or sleep disturbance which would then direct clinicians to using alternative agents.
In an article in the Guardian (2) in August 2012, data from 2011 showed that 15.3 million NHS prescriptions were made for sleep medication. In England there were 5.4m prescriptions for Zopiclone and 2.8m for Temazepam, with an estimated one in 10 of people now taking some form of sleeping tablet regularly. This data suggests that significant proportion patients are taking such sleeping medication long term.
NICE guidelines on treatment on insomnia (3) are clear that Z drugs should be prescribed for a maximum of 4 weeks. However is clear that patients are often prescribed these medications for many months and in some cases years. This is resulting with increasing number of patients dependent on their sleep medication and often taking above recommended BNF doses.
I am a keen advocate not to use either benzodiazepines or Z drugs in the treatment of insomnia routinely as I believe as a clinician I am giving my patients a second problem of ‘iatrogenic’ hypnotic dependence in addition to their initial presenting illness. In the same NICE guidelines (3) figures quoted are of 10–30% of chronic benzodiazepines users are physically dependent on hypnotics with 50% of all users suffer withdrawal symptoms.
So what would the alternatives be?
Before answering that question I would suggest that clinicians spend time investigating the underlying cause of insomnia, which are numerous but include stress, psychiatric disorders, pain or too much caffeine and not being ‘tired’ enough to fall sleep. The treatment for each is significantly different.
Instead of being tempted to prescribe benzodiazepines or Z drugs as first line, clinicians should offer basic sleep hygiene advice focusing on bedtime routines, caffeine intake and ensuring exercise is taken during the day. A very helpful patient leaflet can be found on the RCPsych website (4). Then the reasons for the insomnia should be explored, with a high suspension for depression for those who present with sleep disturbance. Sleep disturbance is well recognised in having a high positive predictive value for depression with 60% of patients with depression presenting first with sleep problems (5).
If the insomnia is due to underlying psychiatric disorder one can treat the anxiety and depressive disorders with an antidepressant such as a SSRI with an adjunct of anti-histamine such as Promethazine to help with sleep. Promethazine (‘Phenergan’) is my first line medication for treating insomnia as it is not addictive and in my clinical practice effective although patients should be warned about driving with the associated drowsiness. Psychological interventions such as CBT or CBT for insomnia should have been considered at this point.
An alternative to treatment with two separate medications would be to use a sedating anti-depressant such as Mirtazapine or Trazadone. Mirtazapine is a highly effective antidepressant and is sedating although it should be noted most sedating at the lower dose of 15mg rather than 30 – 45mg doses. Patients often decline this option due to the increased appetite and weight gain. The other option would be Trazadone which is an effective sedating medication but not considered to be more efficacious than SSRIs in treating depression. In my experience GPs often prescribe low dose amitrypyline to manage insomnia and I would suggest that low dose Trazadone could be used as a suitable alternative.
If patients have more severe insomnia then anti-psychotics can be used, but I suggest that this should be prescribed in secondary care only.
In conclusion although the editorial focused on Z drugs or CBT which are both effective treatments for insomnia, I would ask fellow clinicians to consider the dependence that patients can develop with Z drugs. There are other treatments that can be used including sleep hygiene, anti-histamines, and sedating anti-depressants.
References:
1. Cunnington D. Non-benzodiazepine hypnotics: do they work for insomnia?. BMJ 2013;346:e8699
2. http://www.guardian.co.uk/lifeandstyle/2012/aug/20/sleeping-pills-britai...
3. NICE Guidelines (2004) TA 77 Insomnia – newer hypnotic drugs TA77 http://www.nice.org.uk/ta77
4. Sleeping well http://www.rcpsych.ac.uk/expertadvice/problems/sleepproblems/sleepingwel...
5. Gerber PD., Barrett JE., Barrett JA., et al. The relationship of presenting physical complaints to depressive symptoms in primary care patients. J Gen Intern Med. 1992;7:170–173
Competing interests: I have received speaker fees and travel expenses from Pfizer for treatment of anxiety and depression in primary care.