Treating insomnia: Tablets or CBTi?
For many years insomnia was treated solely with tablets. In more recent times however there has been a move towards Cognitive Behavioural Therapy (CBT) to treat chronic insomnia, and this has proved to be clinically effective in many trials.
There is now access to CBT online through websites such as Sleepio and Sleep Station, both of which have approval from the NHS. There is no data available for the current expenditure on sleeping tablets, but 10 years ago the cost to the NHS was around £50m. The National Institute for Health and Care Excellence now recommends the use of online CBT using apps rather than sleeping tablets (NICE 20/05/2022).
However, the pharmaceutical industry is not going to be defeated easily and is fighting back with a number of new products!
In the old days, global brain suppression used to be the name of the game using barbiturates and benzodiazepine drugs which suppress many brain functions and are not just focused on the sleep wake cycle. More recently there has been a honing of the pharmaco-dynamics and the focus of attention is now either on orexin antagonists or melatonin agonists to promote sleep.
A new meta analysis has just been published in the Lancet online, which used the Cochrane database to identify a number of studies which have looked at modern pharmacology to treat insomnia. The authors managed to pool data on benzodiazepines, benzodiazepine receptor agonists zopiclone, zolpidem, zaleplon and eszopiclone, orexin antgagonists lemborexant, seltorexant, and melatonin receptor agonists ramelteon and melatonin itself.
“Using 154 double-blind randomised trials, we investigated the effects of medications for acute and long-term treatment across the following clinically-relevant primary outcomes: quality of sleep (efficacy), discontinuation due to any cause (acceptability), discontinuation due to any adverse event (tolerability), and presence of at least one adverse event (safety). Considering all the outcomes at different timepoints (ie, acute and long-term treatment), lemborexant and eszopiclone had the best profile in terms of efficacy, acceptability, and tolerability; however, eszopiclone might cause substantial adverse events and safety data on lemborexant were inconclusive. There was insufficient evidence to support the prescription of benzodiazepines and zolpidem in long-term treatment.”
Andrea Cipriani, MD, PhD, Professor of Psychiatry at Oxford University says that for many insomnia medications, there is a "striking" and "appalling" lack of long-term data.
Not all honey and pie with tablets then!
So! Tablets or cognitive behavioural therapy (CBTi) to treat insomnia?
In my own experience when I set up one and ran one of the most comprehensive multidisciplinary face-to-face insomnia clinics in the NHS, many patients referred by GPs had past psychological trauma, some exhibiting frank symptoms of post-traumatic stress disorder (PTSD) missed in primary care, which required treatment by a trained clinical psychologist. There is no doubt that getting to the root cause of inability to initiate or maintain sleep must be the correct principle underlying therapeutics for insomnia, but the biggest issue is accessing that type of service. The NHS is simply not geared up to it and there is not much chance of it becoming so in the near future. There is also resistance amongst GPs to do other than prescribe, although there has been a radical alteration in attitudes in more recent years, and many GPs now refuse to prescribe benzodiazepines or Z-drugs.
At Sussex Sleep Services we have access to several fully qualified clinical psychologists who can undertake work with patients ranging from a straightforward CBTi to treatment for PTSD to get to the root cause of their problem. Furthermore, there is virtually no waiting time. We very rarely use pharmacological interventions, and so far this has stood the test of time with many successfully treated patients.
Reference: https://www.thelancet.com/journals/lancet/issue/vol400no10347/PIIS0140-6736(22)X0029-9