Current Clinical Practice for the Use of Hypnotics to Manage Primary Insomnia in Adults in a Tertiary Hospital in Saudi Arabia: An Audit Study

Abstract

Despite the risks associated with hypnotics and their recent increased use in Saudi Arabia, there are no specific national guidelines for using these medicines to treat insomnia nor are there any data on how these medicines are currently prescribed. There is the potential, however, that some physicians might be adhering to the United States guidelines. The current audit study was aimed to assess the current practice in treating insomnia with hypnotics in Saudi Arabia, and to evaluate its agreement with the US guidelines. The audit was conducted using data collected between April 2012 and March 2017 at King Fahad Central Hospital (KFCH; Jazan), of patients who were either prescribed benzodiazepines (BZDs) or Z-drugs or diagnosed with insomnia. The audit criteria followed two US guidelines for the management of insomnia in adults. Data included documented diagnosis, use of CBT-I (Cognitive Behavioral Therapy for Insomnia), use of BZDs and Z-drugs including treatment regimen, and whether physicians prescribed anti-histamines for insomnia. The data were analyzed using STATA 14 after transcription to a MS XL file. Of the 504 records reviewed, 379 patients (75%) were prescribed BZDs or Z-drugs; only 182 (48%) of them had clearly documented indications for their use. Three hundred and seven patients (60%) were diagnosed with insomnia; none of them received CBT-I as initial treatment. No patients on long-term use of hypnotics were reviewed by their physicians after they began using the medication. More than 43% of patients were prescribed anti-histamines for insomnia. No records met all (or even six) of the seven criteria. KFCH physicians do not follow US guidelines. Therefore, the Ministry of Health (MOH) should improve its administrative systems including documentation, and instead of using international guidelines that are seldom followed, physicians should be trained in prescribing hypnotics and national guidelines need to be developed.

The use of hypnotics for primary insomnia in Saudi Arabia: a survey of patients’ experiences and perceptions

“…The findings of this study indicate that patients usually receive sleep medication as a first-line treatment rather than non-pharmacological treatment. This finding is consistent with a previous study by our group indicating that patients in Saudi Arabia are not receiving CBT-I [14], even though it is recommended as initial therapy by many clinical guidelines [19][20][21] and by many experts in Saudi Arabia [22]. This might be due to Saudi physicians' lack of knowledge about non-pharmacological treatment modalities for primary insomnia or their not having the time or expertise to deliver nonpharmacological treatment to patients [15].…”

“…These practices mirror the previous findings of a study conducted in a tertiary hospital in Saudi Arabia showing that around 44% of patients were prescribed antihistamines for primary insomnia. For long-term use, most patients had been prescribed hypnotics, but physicians did not review their patients after initiating this medication [14].…”

“…This study used a cross-sectional survey on the Survey Monkey Software platform. The questionnaire was designed based upon the scientific literature and on findings from previous studies conducted by our research group [14,15]. Survey questions were structured in the following six sections:…”

“…Findings from previous research showed that, in a tertiary hospital in Saudi Arabia, prescribing physicians did not follow international guidelines for the management of primary insomnia [14]. Some physicians suggested that Saudi patients lacked knowledge of insomnia and its treatments.…”

Perceptions of physicians in Saudi Arabia on the use of international clinical guidelines for managing primary insomnia

“…In the absence of national Saudi guidelines for treating primary insomnia, previous work has shown that many physicians follow (or at least consult) United States (US) guidelines, which the Saudi Ministry of Health (MOH) considers to be best practice [26, 27]. An audit, however, of medical records of patients who were prescribed benzodiazepines (BZDs) or Z-drugs (from April 2012 to March 2017 in the same institution as the interview study reported here) compared practice with US guidelines and found that physicians did not actually follow US or international guidelines [28]. Imperatively, further research is needed into the factors that guide diagnostic and treatment practices in Saudi Arabia.…”