Review analyzes supply situation and identifies potential for improvement

A publication published in 2023 by Ellis et al. highlights the clinical management of chronic insomnia in Central Europe. In Switzerland, around one in ten adults suffers from chronic insomnia, which is roughly the European average. Contrary to the guideline recommendations, benzodiazepines and benzodiazepine receptor agonists are often used for more than just a short time. The review concludes that there is room for improvement in this and other aspects.

In adults, chronic insomnia is diagnosed when sleep disturbances have persisted for at least 3 months and have a significant impact on daytime activity [1,19]. In Switzerland, 11% meet the diagnostic criteria for chronic insomnia, according to Sentinella** data published in 2020 [2]. The diagnostic workup should include a careful assessment of the patient’s medical and sleep history, including information on triggers, circadian factors and sleep-wake rhythm. There is a reciprocal relationship between sleep and general health. Daytime sleepiness and difficulty concentrating are associated with cognitive impairment and mood swings and can impair social and occupational performance [3,4]. And recently, healthy sleep has been added as one of the pillars of cardiovascular health [5].

** The Sentinella reporting system is used to collect epidemiological data and to monitor common communicable and other acute diseases in family medicine. www.bag.admin.ch/bag/de/home/krankheiten/infektionskrankheiten-bekaempfen/meldesysteme-infektionskrankheiten/sentinella-meldesystem.html

Ideally, the treatment of chronic insomnia should primarily aim to improve the quality and duration of sleep as well as daytime form [6]. Cognitive behavioral therapy for insomnia (CBT-i: Cognitive Behavioral Therapy for Isomnia) is considered first-line treatment according to European guidelines [7]. CBT-i is a multimodal intervention aimed at modifying dysfunctional thoughts, feelings and behaviors [8]. Pharmacological treatment options recommended in second-line include a variety of different agents ranging from older treatments such as benzodiazepines and benzodiazepine receptor agonists to melatonin and the recently approved orexin receptor antagonist daridorexant [9,10]. Other synthetic or herbal substances are also used, in some cases off-label. For example, valerian extracts or preparations made from a combination of valerian with other medicinal plant extracts can be used for mild sleep disorders.

What does the reality of treatment look like?

A 2018 survey of Swiss GPs found that in patients with chronic insomnia without comorbidities, only 8% of GPs recommended CBT-i as a first-line treatment; 87% recommended sleep hygiene, 65% phytopharmaceuticals, 49% antidepressants and 18% benzodiazepine receptor agonists [11]. Knowledge of CBT-i was rather low among GPs: 19% said they knew nothing about it and 46% very little [11].

In Germany, a cross-sectional study conducted in 2012-2014 among adults over the age of 50 found that benzodiazepines or benzodiazepine receptor agonists were mainly prescribed for sleep disorders [12]. Most patients considered their use to be vital. However, long-term use of these substances was significantly associated with unemployment (OR: 2.9, 95% CI: 1.2-7.1) [12].

In France, psychiatric care is provided in the health and social care departments [13]. In 2015, 5.6% of the French population took benzodiazepines for sleep problems [20]. A 2015 study of patients in GP surgeries and pharmacies found that around 15% of them were prescribed CBT-i, but that 69% of GP prescriptions were for benzodiazepines [14].

In Italy, a large epidemiologic survey of 738 general practitioners published in 2004 found that 18% of patients with chronic insomnia were treated pharmacotherapeutically, with the benzodiazepine lorazepam (23%) and the benzodiazepine analog zolpidem (15%) among the most commonly prescribed medications [15]. A similar survey conducted in 2017-2018 showed that half of patients over the age of 50 (55.3%) suffered from sleep disorders, of which 45.6% were mainly treated with benzodiazepines [16].

As a conclusion of their review, Ellis et al. state that the most common measures for chronic insomnia across Europe, apart from sleep hygiene and over-the-counter medication, are the prescription of long-term pharmacotherapy, with benzodiazepines, z-drugs and benzodiazepine receptor analogs being among the most commonly prescribed medications [17,19]. However, the long-term use of benzodiazepines, z-drugs and benzodiazepine receptor analogs represents a discrepancy with the guideline recommendations [7,19].

Literature:

ICD-10; www.icd-code.de,(last accessed 03.09.2024)
Maire M, et al: Prevalence and management of chronic insomnia in Swiss primary care: Cross-sectional data from the “Sentinella” practice-based research network. J Sleep Res 2020; 29(5): e13121
American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Americal Academy of Sleep Medicine; Darient, IL, USA: 2014.
Sateia MJ: International classification of sleep disorders-third edition: Highlights and modifications. Chest 2014; 146: 1387-1394.
Lloyd-Jones DM, et al: Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association. Circulation 2022; 146: e18-e43.
Schutte-Rodin S, et al: Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. J Clin Sleep Med 2008; 04: 487-504.
Riemann D, et al: European guideline for the diagnosis and treatment of insomnia. J Sleep Res 2017; 26: 675-700.
Baglioni C, et al: The European Academy for Cognitive Behavioral Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment. J Sleep Res 2020; 29: e12967.
Brandt J, Leong C: Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs R D 2017; 17: 493-507.
Quviviq-Daridorexant. EPAR Product Information. EMEA/H/C/005634—N/0003 EMA/187589/2022. European Medicines Agency.
Linder S, et al: Treating insomnia in Swiss primary care practices: A survey study based on case vignettes. J Sleep Res 2021; 30:e13169.
Mokhar A, et al: Potentially inappropriate use of benzodiazepines and z-drugs in the older population-analysis of associations between long-term use and patient-related factors. Peer J 2018; 6:e4614.
European Observatory on Health Systems and Policies France: Health System Review 2015. Health Systems in Transition, Volume 17 No. 3.
Driot D, et al: Non-drug and drug alternatives to benzodiazepines for insomnia in primary care: Study among GPs and pharmacies in a Southwest region of France. Therapy 2019; 74: 537-546.
Terzano MG, et al: Studio Morfeo: Insomnia in primary care, a survey conducted on the Italian population. Sleep Med 2004; 5: 67-75.
Proserpio P, et al: Insomnia in primary care: A survey conducted on Italian patients older than 50 years-results from the “Sonno e Salute” study. Neurol Sci 2022; 43: 6487-6494.
17 Ferini-Strambi L, et al: Insomnia disorder: Clinical and research challenges for the 21st century. Eur J Neurol 2021; 28: 2156-2167.
Hayward RA, Jordan KP, Croft P: The relationship of primary health care use with persistence of insomnia: A prospective cohort study. BMC Fam Pract 2012; 13: 8.
Ellis J, et al: Chronic Insomnia Disorder across Europe: Expert Opinion on Challenges and Opportunities to Improve Care. Healthcare (Basel) 2023 Feb 28; 11(5):716.
Chapoutot M, et al: Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. Int J Environ Res Public Health 2021; 18: 10222.