Intended for healthcare professionals

Practice Change

Advise non-pharmacological therapy as first line treatment for chronic insomnia

BMJ 2021; 372 doi: (Published 23 March 2021) Cite this as: BMJ 2021;372:n680
  1. Christine Soong, associate professor13,
  2. Lisa Burry, critical care pharmacist and clinician scientist4 5,
  3. Maria Greco, patient and family advisor,
  4. Cara Tannenbaum, professor of medicine and pharmacy6 7
  1. 1Divisions of General Internal Medicine and Hospital Medicine, Sinai Health, Toronto, ON M5G 1X5, Canada
  2. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
  3. 3Centre for Quality and Patient Safety, University of Toronto, ON, Canada
  4. 4Department of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada
  5. 5Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
  6. 6Faculté de Médicine, Institut Universitaire de Gériatrie de Montreal, Montréal, Québec, Canada
  7. 7Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
  1. Correspondence to: C Soong christine.soong{at}

What you need to know

  • Cognitive behavioural therapy is effective first line treatment for chronic insomnia

  • Advise individual or group based cognitive behavioural therapy for insomnia delivered in-person or through internet, telehealth, or smartphone applications to suit your patient’s preferences

  • Identify patients with long term use of sedatives and initiate a discussion about tapering sedatives and substituting with non-pharmacological therapies

Guidelines recommend non-pharmacological approaches, including cognitive behavioural therapy, as first line treatment for chronic insomnia in adults (box 1).12345 Yet, sedatives are commonly prescribed to treat insomnia. Over a quarter of a million people in the UK receive sedatives for more than a year based on estimates from a primary care survey in 2017.6 A drug survey in the UK reported 2.4 million adults had received, and had dispensed, one or more prescriptions for sedatives written in 2017-18.7 In a study of 386 457 US outpatient visits, prescription rates for benzodiazepines doubled from 3.8% (95% confidence interval 3.2% to 4.4%) in 2003 to 7.4% (6.4% to 8.6%) in 2015, including co-prescribing with other sedating medications.8 Sedatives include medications licensed for insomnia—for example, benzodiazepine receptor agonists (such as estazolam, temazepam, eszopiclone, zaleplon, zolpidem), dual orexin receptor antagonists (such as lemborexant, suvorexant), and melatonin receptor agonists (such as ramelteon)—as well as those used off-label (such as quetiapine, trazodone, diphenhydramine). Sedatives are associated with serious harm, including cognitive deficits, falls, confusion, hip fracture,91011 dependency,1213 and mortality.814 Overdose deaths involving benazodiazepines increased in the US from 1135 in 1999 to 8791 in 2015.14

Box 1

Guidelines promoting a non-pharmacological approach to insomnia

  • British Association for Psychopharmacology—“[Cognitve behavioural therapy (CBT)] is an effective treatment for insomnia delivered either individually or in small group format. CBT has been found to be as effective as prescription medications for short-term treatment of chronic insomnia. Moreover, …

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