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into a chronic condition

as symptoms will most likely abate once the precipitating factors ( see table 2 ) have resolved . ⁵⁶

Although the RACGP benzodiaz-

external light – dark cycles . ^{7 , 9} Melatonin is associated with less risk of side effects / dependence compared with benzodiazepines and z-drugs ; however , there is limited

to gradually withdraw from these medications . ⁷ A range of withdrawal interventions have been studied , including letters sent from GPs to patients on long-term sedative – hyp-

reduction ), as well as adjunct motivational counselling , family / social support and CBTi to alleviate withdrawal symptoms . ⁶² In some cases , withdrawal will need to occur very

each night for the third week and so on ) rather than the introduction of more medication-free nights ( such as one medication-free night in the first week and two medication-free

epine ( insomnia ) guidelines recom-

efficacy evidence to support mela-

notic medicines advising patients

gradually over several months . It

nights in the second week ). This is

mend CBTi as first-line treatment for insomnia , GPs report very limited access to CBTi referral and treatment options . ^{7 , 57} Consequently , many general practice patients with insomnia are managed with sedative – hypnotics . ^{10 , 11} Benzodiazepines and z-drugs are associated with short-term improvements in sleep ; however , when used for longer periods , they can lead to patterns of dependence ,

tonin in the management of chronic insomnia . ⁷ It has previously been used in the management of circadian rhythm disorders ( eg , delayed sleep – wake phase disorder ) and may be used to overcome jet lag more rapidly .

CBTi and sedative – hypnotic medication

The RACGP recommends that

There is limited efficacy evidence to support melatonin in the management of chronic insomnia .

to consider withdrawal , self-guided tapering information ( pamphlet , booklet ) and GP and / or pharmacist-supervised gradual sedative –

may be better to taper sedative – hypnotic

use through gradual reduction of the nightly dose of medicine that is consumed ( for example , 10mg

because the introduction of medication-free nights too early may result in more abrupt and noticeable withdrawal symptoms and reinforce the perceived need for medication .

CBTi is effective when a patient is taking sedative – hypnotic medicines and , most importantly , facilitates medication withdrawal . ¹² CBTi improves the symptoms of insomnia in the presence of long-term seda-

increasing negative side effects and adverse outcomes . ^{12 , 13 , 58} When used for longer periods of time , the ther-

patients with a history of sedative – hypnotic use are provided support

hypnotic withdrawal programs ( also called tapering program or stepped

each night for the first week , 7.5mg each night for the second week , 5mg

tive – hypnotic use , alleviates withdrawal symptoms and provides

apeutic effects are often replaced

by patterns of tolerance to the original

dose , escalation of frequency

and dose , and symptoms of withdrawal

( rebound insomnia / anxiety

) on nights that medicines are

not consumed . Consequently , the

RACGP recommends that sedative

– hypnotic medicines should be

prescribed for a maximum of four

weeks and only for patients who do

not have access to CBTi or do not

respond to CBTi . ⁷

There has been a recent

increase in the use of antipsychotics

and antidepressants ( such as

quetiapine and mirtazapine ) to

manage the symptoms of insomnia . ^{10 , 25} These medicines are not recommended for the management

of insomnia because of limited

long-term efficacy and safety

6 , 7 , 26 , 27 data .

Suvorexant is an orexin receptor

antagonist . Orexins are neuropeptides

involved in the regulation

of sleep and arousal . Suvorexant

has been available in Australia

since 2016 but is not available on

the PBS . A systematic review of

the efficacy and safety profile of

suvorexant reported small but

statistically significant improvements

in self-reported , and objectively

measured , sleep parameters at three-month follow-up . ⁵⁹ Effect sizes were small at 15mg and 20mg

( the doses available in Australia ).

For example , suvorexant was associated

with a six-minute reduction

in subjective sleep-onset latency

( SOL ), a 16-minute increase in

total sleep time and a five-minute

reduction in overnight wake

time , vs placebo , at three-month

follow-up . Fifty five per cent of

participants treated with suvorexant

showed a clinically significant

reduction in the symptoms of

insomnia ( on the Insomnia Severity

Index questionnaire ) compared

with 42 % of participants in

the placebo group . Higher doses

( 30mg and 40mg , not available in

Australia ) were associated with

greater sleep improvement but an

increased risk of next-day sleepiness . ⁵⁹ Other meta-analyses have

60 , 61 reported similar effect sizes . Suvorexant ( 15mg and 20mg ) did

not increase risk of withdrawal

effects or rebound insomnia on

discontinuation . ⁵⁹

MELATONIN

In Australia , melatonin can now

be purchased as an over-the-counter

medicine by people 55 and

over . Melatonin is an endogenous hormone that influences the synchronicity

of sleep periods with