Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

Abstract

BackgroundThis review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.MethodsMEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.ResultsA total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.ConclusionsAssuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.Systematic review registrationPROSPERO CRD42017072527.

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“…Our AMSTAR-2 results are consistent with several other published studies which indicate overall critically low or low quality SR/MAs. A review of 64 SR/MAs for pharmacological and non-pharmacological interventions in insomnia found that 40 were rated as low or critically low [68]. A review of 5 SR/MAs for acupuncture in primary dysmenorrhea found all 5 were rated as critically low [69].…”

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

“…Assessing the quality of evidence An algorithm that assigns the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) 32, 47,48 framework level of evidence will be used to grade the certainty of evidence. This algorithm is a new methodological approach to assessing the quality and certainty of evidence in overviews 48 and has been used in recent overviews 49,50 . This approach will assess the quality of the evidence relating to the primary and secondary outcomes included in RCTs in systematic reviews as detailed above.…”

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

“…An overview of systematic reviews (64 systematic reviews, 35 with meta-analysis) confirmed effectiveness across multiple outcomes (including sleep onset latency, total sleep time, wake after sleep onset, sleep quality, sleep satisfaction, sleep efficiency, insomnia severity index scores, fatigue severity, and health related quality of life) based on more than one high or moderate quality review with meta-analysis for zolpidem, suvorexant, doxepin, melatonin, and CBT-i. However, very little data on harms were available (including hangover/morning sedation, accidental injuries, additional healthcare use related to harms of the intervention, delirium related to the intervention, sleep disordered breathing related to the intervention, all-cause mortality related to the intervention, and addiction, dependence, or diversion of medications) 19. Finally, a high quality systematic review (37 RCTs, 2189 participants) on the efficacy of CBT-i for patients with insomnia comorbid with psychiatric and/or medical conditions found 36.0% who received CBT-i were in remission from insomnia compared with 16.9% of those in control or comparison conditions (pooled odds ratio 3.28 (95% CI 2.30 to 4.68); P<0.001) with the longest reported follow-up period of eight months 20…”