Racial Minority Patients Less Likely to Receive Pharmacological Treatment for Insomnia

Patients who are part of racial minority groups are less likely to be prescribed an insomnia medication than White patients after considering sociodemographic and clinical factors, according to a study in Sleep Health.

Study authors also said that more research is needed to decide to what extent patient preferences and physician perceptions impact these prescribing models and look into possible disparities in nonpharmacologic treatment.

This study was conducted because although there has been progress in treatment and further availability of approved medications for insomnia, untreated insomnia still adds up to ample personal and societal cost for patients and payers. Research suggests that racial disparities persist across many medical conditions, but few have looked into possible disparities in insomnia treatment.

First, the study authors wanted to evaluate the connection between race and time to pharmacologic insomnia treatment in a large, multi-institutional cohort.

Previous studies have estimated that 10% to 30% of United States adults have insomnia; and women, older adults, people of lower socioeconomic status, and people with depression or anxiety are especially susceptible. Additionally, insomnia disproportionately impacts racial and ethnic minority groups, with Black and Hispanic people generally describing a higher prevalence of insomnia.

A retrospective analysis of electronic medical records from a regional health information exchange was undertaken. A Cox frailty model was used to study the connection between race and time to an insomnia medication following diagnosis.

A total of 9557 patients were studied. Of those, 7773 (81.3%) patients were White, 1294 (13.5%) Black, 238 (2.5%) fell into the “Other” category, and 252 (2.6%) did not have a race listed.

Around 6.2% of Black patients and 8% of patients in the Other categories got an order for a FDA-approved insomnia medication proceeding diagnosis compared with 13.5% of White patients.

Black patients were significantly less likely to have an order for insomnia medication all time points (adjusted HR [aHR] range, 0.37-0.73), and patients in the Other group were less likely to have an order at 2 (aHR, 0.51, 95% CI, 0.28-0.94), 3 (aHR, 0.33, 95% CI, 0.13-0.79), and 4 (aHR, 0.21, 95% CI, 0.06-0.71) years of follow-up.

Similar results were seen in a sensitivity analysis that included off-label medications.

“Of note, most patients did not receive an FDA-approved insomnia medication after diagnosis, and the median time to an order for an FDA-approved medication was approximately 2.6 years,” said the study authors.

Aligning with previous literature, the results displayed that older patients and those with comorbidities are less likely to be prescribed insomnia medications. However, even when controlling for these factors and others, it was found that White patients are over-represented among those who received a medication order and possessed a shorter time frame between diagnosis and prescription.

Following these results, the study authors surmised that a combination of patient and provider-level characteristics contributed to the contrasting prescribing trends. It’s possible that biases, stereotypes, and/or communication struggles played a role in clinician decisions to prescribe insomnia medications.

To the authors’ knowledge, this is the first study to evaluate racial disparities in the pharmacological treatment of insomnia, but previous research presents evidence of racial and ethnic disparities in prescribing pharmacotherapy for other medical conditions.

Some limitations of this study were that the study authors couldn’t conclude which patients tried cognitive behavioral therapy, which is the recommended initial insomnia treatment. Also, patients were required to have at least 1 health care encounter per year, so results may not be generalizable to patients who use health care less often.

“Additional work is needed to determine the extent that patient preferences and physician perceptions affect prescribing patterns, investigate potential racial differences in physician referrals for [cognitive behavioral therapy for insomnia], and formulate strategies to remove barriers to insomnia treatment for minority patients,” concluded the study authors.

Reference

Holler E, Campbell NL, Boustani M, Dexter P, Miled ZB, Owora A. Racial disparities in the pharmacological treatment of insomnia: a time-to-time event analysis using real-world data. Sleep Health. 2023;9(2):128-135. doi:10.1016/j.sleh.2023.02.002