Background: This 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.
Methods: MEDLINE, 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.
Results: A 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.
Conclusions: Assuming 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 registration: PROSPERO CRD42017072527.
Keywords: Comparative effectiveness; Insomnia; Knowledge synthesis; Overview of reviews; Sleep disorders.
Conflict of interest statement
Dr. Charles Morin is on the advisory board for Phillips, Merck, and Cereve; holds speaking honorariums from Merck, Eisai, and Abbott; provided expert testimony for Cereve; and receives book royalties from Elsevier and Sogides. Dr. Judith Leech has part ownership of two private sleep labs, Somnocor in Gatineau, Quebec, and West Ottawa Sleep Centre in Ottawa, Ontario. All other authors have no known conflicts of interest to declare. Dr. Tricco is an Associate Editor for BMC Systematic Reviews but will not be involved with any decisions related to this paper.
Management of Insomnia Disorder [Internet].Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. Report No.: 15(16)-EHC027-EF. Agency for Healthcare Research and Quality (US). 2015. PMID: 26844312 Free Books & Documents. Review.
Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults.Cochrane Database Syst Rev. 2014 Nov 1;(11):CD011142. doi: 10.1002/14651858.CD011142.pub2. Cochrane Database Syst Rev. 2014. PMID: 25362239 Review.
Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Systematic Review for the U.S. Preventive Services Task Force [Internet].Rockville (MD): Agency for Healthcare Research and Quality (US); 2017 Jul. Report No.: 15-05222-EF-1. Agency for Healthcare Research and Quality (US). 2017. PMID: 29364620 Free Books & Documents. Review.
Second-generation antidepressants for preventing seasonal affective disorder in adults.Cochrane Database Syst Rev. 2015 Nov 8;(11):CD011268. doi: 10.1002/14651858.CD011268.pub2. Cochrane Database Syst Rev. 2015. PMID: 26558418 Updated. Review.
Screening and Interventions for Childhood Overweight [Internet].Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Jul. Agency for Healthcare Research and Quality (US). 2005. PMID: 20722132 Free Books & Documents. Review.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5): American Psychiatric Pub; 2013.
- Morin CM, Jarrin DC. Epidemiology of insomnia: prevalence, course, risk factors, and public health burden. Sleep Med Clin. 2013;8(3):281–297. doi: 10.1016/j.jsmc.2013.05.002. - DOI
- Committee on Sleep Medicine and Research BoHSP . Sleep disorders and sleep deprivation: an unmet public health problem. Washington (DC): National Academies Press; 2006.