This study revealed that patients in Saudi Arabia are often prescribed hypnotics for insomnia, do not receive CBT-I as a first-line treatment and are rarely involved in the treatment decision. A majority of patients reported that they were on long-term hypnotics and were not reviewed regularly by their doctors or provided with a plan for discontinuation (Table 3). Among the patients, there was limited knowledge about insomnia and its treatments, and many were only given information about how to use hypnotic medicines when they were prescribed. Even though 44% of patients believed that hypnotics are harmful and would have liked to stop using them, they still believed that hypnotic medicines are the best solution for treating insomnia. While many patients are dependent on their medication and use different methods to get prescriptions, there is considerable resistance among them to using non-pharmacological treatments for insomnia.
One limitation of this study is the mode of sampling, which was a self-completed questionnaire that was administered via the Twitter account of a sleep medicine specialist. The bias of Twitter users who are following a sleep medicine account means that we seem to have captured a highly educated sample and missed others who either have no access to or are not interested in Twitter. The rapid response rate and high number of respondents, however, confirm that this research methodology is a powerful tool and, in spite of the limitations, represents an effective way to gain an initial understanding of patient perspectives that can subsequently be validated over a broader patient population.
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 , even though it is recommended as initial therapy by many clinical guidelines [19–21] and by many experts in Saudi Arabia . 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 non-pharmacological treatment to patients . The current study shows that patients who had not received CBT-I reported that they believed that non-pharmacological treatment is not beneficial. This belief may have contributed to the demand for medical treatment but could conversely reflect a limitation of patient information provided at initial presentation with primary insomnia. It is possible that when patients are offered non-pharmacological intervention, they become more positive about it.
The study revealed that the majority of the participants reported limited knowledge about insomnia and its treatment, and most expressed a desire for more information about both. The study also revealed that most respondents believed that sleep medicines can cause dependence but can be used for long periods. This finding, though apparently contradictory, is not uncommon. As noted by Sirdifield et al. (2013), the belief that sleep medicines are not harmful may be because doctors prescribe the drugs and patients trust their doctor’s professional opinion even if they prescribe them multiple times .
Using antihistamines and over-the-counter herbs for managing primary insomnia, long-term use of hypnotics and lack of regular reviews for patients on long-term prescriptions contradicts most of the available clinical guidelines [19–21]. 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 .
The study also revealed ineffective doctor-patient interaction among sleeping-pill users before and after being prescribed. It was noted that a majority of respondents were given sleep medicine because of the doctor’s ‘executive’ decision and that they had been excluded from discussing their problems with the doctor. It was also noted that most long-term sleep-medicine users were not seeing their doctor regularly nor had they been provided with a plan for medicine discontinuation. These findings are consistent with a previous study showing that patients are not involved in treatment decisions . This might be due to the belief of many Saudi physicians that patients lack knowledge about insomnia and its treatment . What is more, physicians often find it challenging to discuss the risks or side effects of medicines with their patients . This can be a source of dependence on sleep medicines. Indeed, there is a high association between long-term sleeping pill use and addiction [23, 24].
The study shows a high dependence on sleep medicines among respondents. This was evidenced by the various efforts that they had taken to access sleep medicines if the doctor had refused additional prescriptions. The study shows that respondents went to private hospitals, bought medicines from private pharmacies without prescription, went to another doctor at the same hospital, ‘asked someone they know to make (wasta)’ and argued with the doctor to get a prescription—all clear indications of sleeping-pill dependence and misuse [24, 25].
This study also found that a majority of respondents believed that sleep medicines are unsafe and preferred not to continue using them. Most, however, also agreed that sleep medicines are the best solution for treating insomnia. This shows that while the respondents were aware of the medicine’s harmful nature, they believed that sedatives are the only option for them. The study revealed that respondents were not involved in the treatment decision or had discussed the availability of other treatments and that sleep medicines were often the first treatment given for insomnia. This could explain why the majority of respondents would like to stop their medicines. These findings are congruent with other studies that generally show that most sleep medicine users express the desire to stop using them . Forty-one percent of the respondents also understood that some doctors preferred not to prescribe hypnotics, signifying an understanding of their doctor’s awareness of the medicine’s side effects .
The majority of respondents did not prefer non-pharmacological treatments, believing that they confer no benefits. When asked the question in different ways, the majority emphasised that they would not like to go to psychiatric hospitals for counselling therapy and most acknowledged that, if referred for counselling treatment, they would refuse. These findings support the view of many physicians that being referred to psychiatric hospitals for CBT-I carries stigma for Saudi patients and that there is a need for trained psychologists in general hospitals or specialist sleep clinics to provide the service for patients . The only study conducted in Saudi Arabia to investigate stigma among patients with anxiety and depression found that the majority of patients either refused to complete the study or declined to continue when they realised that they would be asked about their mental illness . This explains the extent to which Saudi patients feel stigmatised about their conditions when they are referred to psychiatric hospitals for non-pharmacological treatment.
It was noted that men were more satisfied with their knowledge of insomnia compared to women. Because the study was conducted in a country in which there has been a disparity between men and women in both access to education and the distribution of educational funds , this finding is plausible. A similar finding was also seen with more men than women knowing about other ways to treat insomnia. A recent study by Al-Ahmadi (2011) shows that, in general, access to information is a major challenge women in Saudi Arabia face, even including those in leadership positions . Given that the sample was taken from an educated population with a majority of respondents having a university degree, possibly a result of the sampling method that relied on access to Twitter, this shows that despite the high level of education in respondents, men have better access to information than women.
This study found that women have a higher tendency than men to obtain sleep medicine from private hospitals in the first instance. We propose two reasons for this, based on the fact that 44% of those with a university degree were female. A high level of education has been correlated with high incomes [30, 31] and private hospitals are normally more expensive to access than public hospitals. Additionally, it might be easier for women to access sleep medicine in private hospitals because public hospitals are usually more accountable . For this reason, public hospitals would be more reluctant to issue hypnotics in the first instance compared to private hospitals.
Global issues regarding the use of hypnotics, such as long-term use, misuse, patients not being involved in treatment decisions and patients on long-term use not being reviewed regularly by their doctors or provided with a plan for discontinuation are also common in Saudi Arabia. This study is the first of its kind to explore the knowledge, experiences and perceptions of patients concerning the use of hypnotics for treating insomnia in KSA and provides insight for future work.