A SMART Approach to Evaluating the Benefits of Common Prescription and OTC Medications for Insomnia

Nearly 50% of primary care patients report symptoms of insomnia (e.g., problems initiating and/or maintaining sleep). Such sleep-related difficulties can presage new onset comorbid illness, as well as exacerbate, and be exacerbated by, existing comorbid illnesses. Accordingly, effectively treating insomnia in primary care patients is an untapped means towards the promotion of better public health. Research Question: While cognitive behavioral therapy for insomnia (CBT-I) is considered the first-line treatment, most patients (particularly those in primary care) do not have access to this form of therapy. Instead, the majority of treated patients are using over-the-counter medications (OTCs), including melatonin and diphenhydramine (e.g., Benadryl), or are prescribed hypnotics (most commonly trazodone or zolpidem \[e.g., Ambien\]). Surprisingly, little is known about the absolute or relative effectiveness and safety of these commonly used medications, and of the often used medications, only Ambien is approved/recommended by the FDA and professional medical or sleep medicine societies. There are also limited data on which of these medical strategies has the best risk/benefit profile or is most acceptable to patients. The investigators' recent evaluation of FDA-approved medications for insomnia suggests doxepin, which is less commonly prescribed, has the most optimal risk/benefit profile. Multiple agencies have called for rigorous comparative effectiveness studies addressing these knowledge gaps, including the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), and the Patient-Centered Outcomes Research Institute (PCORI). Moreover, the investigators' feedback from stakeholders shows that the need for such data is not just a professional practice concern, but shared by primary care patients and clinicians. Thus, evidence-based guidance on the management of insomnia with OTC and prescriptive medications is urgently needed. Protocol Synopsis: The investigators propose to conduct a large-scale, double blinded, placebo-controlled sequential multiple assignment randomized trial (SMART) comparing the relative effectiveness and safety of over-the counter medications commonly used by patients to treat their insomnia (i.e., diphenhydramine and melatonin) and prescriptive medications that are either commonly prescribed by clinicians (i.e., zolpidem and trazodone) or less commonly used, but may have a more optimal risk/benefit profile (i.e., doxepin). All conditions will use a nightly dosing strategy and include sleep hygiene education. To better align with current practice, participants who tolerate an initial lower medication dose but do not exhibit a treatment response will increase to a higher dose after 2 weeks. Treatment responders at 1 month will be followed for up to 6 months to understand longer-term maintenance of treatment benefits. The SMART design will re-randomize treatment non-responders at 1 month to an alternative arm (with each successive treatment non-response), providing all participants the opportunity to secure a treatment response with one of the study medications. To maintain blinding, participants will be instructed to take each medication (including placebo) 30 minutes prior to bed and all medications will be manufactured by a central Pharmacy to appear identical. All participants will be further instructed to be in bed for a period of 7-9 hours to both promote safety and potentially increase medication effects on early morning awakening and total sleep time.