Comparative efficacy of hypnotics a self-controlled, self-recorded clinical trial in neurotic patients.

Although insomnia due to neurotic illness is one of the commonest of symptoms, reports on the comparative efficacy of hypnotics in man are rare. Werz and Homann (1939) and Cohen and Beecher (1951) made controlled comparative studies but were concerned with the sedative rather than the hypnotic effects of the drugs they used. Meyers, Cook, and Page (1940) investigated the hypnotic action of five drugs and a placebo in chronically ill patients. but did not attempt to compare the hypnotics with one another. A search through the literature of the past 20 years has not revealed any other relevant work. There are a number of probable reasons why the problem has not been studied more. In the first place, there is wide individual variation in the response to a hypnotic drug. If it were also true that an individual's response to one hypnotic bore little relation to his response to another, then there would be no value in attempting to compare the efficacy of different hypnotics in a series of patients. Yet this point is one that does not seem to have been established, and on theoretical grounds we might expect that the comparative efficacy of different hypnotics would remain the same in different individuals provided the cause of the insomnia was the same. In the second place, the conditions necessary for a controlled trial of hypnotics in man are not easily or commonly available, for such a trial requires a series of patients, all suffering from insomnia, under continuous night observation for at least several weeks, and, for preference, sufficiently co-operative and intelligent to give an account of how they slept. These conditions, however, may be fulfilled in hospital wards for the treatment of neurotic patients. In the third place, so many efficacious hypnotics are available that to compare them might seem a work of supererogation. Indeed, in prescribing hypnotics the practitioner suffers an embarras de richesse, and in consequence either tends to confine himself to the use of one or two "favourite" hypnotics or administers a succession of newly-marketed drugs, the comparative efficacy of which has rarely been the subject of a controlled trial. A satisfactory means of comparing the clinical efficacy of hypnotics would have two valuable uses. It would enable new hypnotics to be tested against long-established drugs, and it would permit a comparison of the efficacy of those already in common use. The common hypnotics are usually prescribed in a dosage which experience has shown as that which gives most patients reasonable relief from insomnia and at the same time is associated with a minimum of undesirable side-effects; it has not, however, been clearly established whether there is any significant difference in the efficacy of these drugs when given in their commonly prescribed dosage. If such differences could be established, then, other things being equal, it would be rational to administer the hypnotic which a controlled trial showed to be most effective.