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

Guidelines recommend non-pharmacological approaches, including cognitive behavioural therapy, as first line treatment for chronic insomnia in adults (box 1).1-5 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,9 -11 dependency,12 13 and mortality.8 14 Overdose deaths involving benazodiazepines increased in the US from 1135 in 1999 to 8791 in 2015.14

Automated summary

Despite recommendations for non-pharmacological approaches as first line treatment for chronic insomnia in adults, sedatives are still commonly prescribed and associated with serious harm, including cognitive deficits, falls, confusion, and mortality. Overdose deaths involving benzodiazepines have increased significantly in the US from 1999 to 2015.