Professor A. Niroshan Siriwardena describes effective interventions for adults with chronic insomnia that evade the need for long-term drug treatment
Read this article to learn more about:
- current best practice in the management of people with chronic insomnia in primary care
- assessing people with chronic insomnia
- psychological techniques for chronic insomnia that are more effective than drugs.
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I nsomnia and sleep problems are very common and affect around one-third of the adult population, who often present to primary care.1 Primary care clinicians including GPs, nurses, and community pharmacists, are often at the forefront of care for this important problem, but are inadequately trained to manage patients with insomnia; one US study estimated medical training for sleep problems to be around 2 hours on average—the situation in the UK anecdotally is little better.2 Training often focuses on drug therapy rather than promoting a greater understanding of insomnia, how it affects people, how to assess it, and how to manage it better.3
Fortunately, there is good evidence about how to manage insomnia in adults more effectively, although the evidence needs to be translated better into practice. This article aims to present the evidence and how it might be implemented by GPs, practice nurses, and others including patients themselves.
Population surveys suggest that the epidemiological definition of chronic insomnia, which is difficulty with initiating or maintaining sleep at least 3 nights a week lasting for at least 3 months, applies to around 1 in 10 adults.4 Around one-half of those with chronic insomnia will present to primary care. The term 'secondary insomnia', that is insomnia 'due' to anxiety, depression, pain, and other conditions, is confusing. The problem is that insomnia may not be secondary at all: it may coexist with or even precede conditions like depression. It is therefore better to consider insomnia as comorbid with these conditions, and there is strong evidence that in most cases, treating insomnia as well as the condition with which it is associated will help both insomnia and its comorbidity. The most recent definition of insomnia in the Diagnostic and statistical manual of mental disorders (5th edition) acknowledges the idea of comorbid as opposed to secondary insomnia.4,5
Currently, primary care management of insomnia usually consists of providing patients with a sleep hygiene advice sheet or prescribing drugs such as sedative antihistamines (e.g. promethazine) or low doses of antidepressants (e.g. amitriptyline). These drugs have been shown to be of limited benefit and carry risks of adverse effects;6,7 sleep hygiene by itself does not show evidence of benefit, either.8 The other commonly prescribed options are benzodiazepines or z-drugs (e.g. zaleplon, zolpidem, zopiclone) for which adverse effects outweigh benefits for most, particularly in older patients.9 The side-effects of hypnotics are well known and include daytime sedation, tolerance, addiction (with regular use), withdrawal effects, falls, and road traffic collisions.10 Although there are no NICE guidelines on the management of insomnia itself, the guidance available on hypnotics emphasises that drugs should only be considered after appropriate advice has been given and psychological treatments, which have been shown to be effective and safe, have been considered.11 These non-pharmalogical methods are not available to practitioners in every locality.
Improving management of insomnia—the REST project
There are three things that GPs and other clinicians can do that, in the author's opinion, would improve management of chronic insomnia considerably: firstly, assess patients with insomnia better; secondly, use a simple but proven set of psychological techniques called cognitive behavioural therapy for insomnia (CBT-I); and thirdly (flowing naturally from doing the first two), avoid long-term or repeated prescriptions of hypnotic or other drugs. Cognitive behaviour therapy for insomnia is more effective, safer, and works for longer than drugs.12,13
A team of researchers worked with a group of general practices in the Resources for Effective Sleep (REST) project to show how the above approach might produce a better sleep consultation (see Figure 1, below) and have published their results in peer-reviewed journals, as an online resource, and as an e-learning programme for GPs and primary care staff.14 The REST project was funded by the Health Foundation under their Engaging with Quality in Primary Care scheme to improve care for patients with insomnia. The evidence and learning from this quality improvement project was developed with further support from East Midlands Health Innovation Educational Cluster into an e-learning package for clinicians working in primary care.
When people attend with a symptom of insomnia it is sometimes presented as the main problem, and at other times presents together with a range of other problems. When a patient mentions insomnia they have often had the problem for a considerable period of time, tried a variety of other remedies (including over-the-counter or complementary therapies), discussed the problem with friends or family, sought advice from them and the media, and usually come to the GP as a last resort. Patients often have concerns about 'sleeping tablets' but are not aware of what other treatments are available. They need to be listened to and taken seriously; their health beliefs and previous illness behaviour need to be understood, concerns about medication taken into account, and they need to be given a positive message that effective treatment is available that does not require drugs.3
A detailed assessment of insomnia is easy to do but rarely carried out in primary care. Instead, GPs often focus on looking for comorbidities like anxiety, depression, or other long-term conditions and assessing these instead. Understanding and managing comorbidities is important because they also need assessment and specific treatment (as in the case of anxiety, depression, pain, or sleep apnoea). It is often overlooked that it is just as important to assess the insomnia itself, because assessing and treating insomnia will often lead to improvement, not only in insomnia but also in the comorbid condition and the patient's overall wellbeing. Comorbidities include specific sleep disorders, mental health problems (e.g. anxiety, depression, psychosis), drugs and medications, and physical problems such as sleep apnoea or other long-term conditions.
Specific sleep disorders, including conditions such as restless leg syndrome, are uncommon and often require specialist management. Sleep apnoea is more likely in:
- obese people who snore at night and experience daytime sleepiness
- men whose neck size exceeds 17 inches, and women whose neck size exceeds 16 inches15
- people who score above 10 on the Epworth Sleepiness Scale.16
People with sleep apnoea, or another primary sleep disorder, need referral for sleep studies, either routinely or urgently if it is affecting their job driving or operating machinery, both of which should be stopped pending investigation. Other comorbidities also need assessment and treatment.17
Assessing insomnia gives an understanding of the degree of severity of the insomnia and the pattern of sleep problems, including whether people have difficulty falling asleep (called 'sleep onset latency' [SOL] or 'sleep latency'), waken often ('wake after sleep onset' [WASO]), spend too little time asleep (reduced 'total sleep time' [TST]), or wake unrefreshed (see Box 1, below).18 There are various assessment tools available but the two that GPs found most useful during the REST project were the Insomnia Severity Index to assess severity, and the 2-week Sleep Diary to assess the pattern of insomnia.19
Box 1: Insomnia definition and measures4,18
- Criteria for a diagnosis of insomnia are:
- dissatisfaction with sleep quantity or quality, with one or more of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening
- sleep disturbance causes significant distress or impairment in social, occupational, educational, academic, behavioural, or other important areas of functioning
- sleep difficulty occurs at least 3 nights per week, is present for at least 3 months, and despite adequate opportunity for sleep
- insomnia does not co-occur with another sleep disorder
- insomnia is not explained by co-existing mental disorders or medical conditions
- Sleep effectiveness measures include:
- sleep onset latency (SOL) (over 30 mins)
- wake after sleep onset (WASO) (over 30 mins)
- total sleep time (TST) (less than 6 or more than 9 hours)
- sleep efficiency (SE): time asleep/time in bed (less than 85%)
Insomnia Severity Index
The Insomnia Severity Index (ISI)20 (see Figure 2, below) is a simple seven-question (28-point) rating scale, which can be scored at successive consultations to show progress with treatment. The ISI measures insomnia severity from no clinically significant insomnia (score 0–7), subthreshold insomnia (8–14), clinical insomnia (moderate severity; 15–21) to clinical insomnia (severe; 22–28).
2-week sleep diary
The 2-week sleep diary is another very valuable tool, which also gives a quick visual representation indicating severity, an estimate of the sleep measures, and an idea of possible causes such as work (stress) versus rest days, daytime napping, caffeine, tea, alcohol, exercise, and medication use—see Figure 3, below, for an example of a completed sleep diary, and Box 2, below for a related case study. The sleep diary also provides an estimate of sleep measures SOL, WASO, and TST, and enables a calculation of sleep efficiency. Sleep efficiency (SE) is simply the total sleep time (TST) as a percentage of time in bed (TIB), that is SE = TST/TIB, so if someone spends 10 hours in bed and only sleeps 7 hours, their sleep efficiency is 70%.
Box 2: Case study
Greg is a 25-year-old student who has had 3 months of poor sleep on most days. His insomnia was triggered by the stress of exams the previous summer. At the initial consultation he had severe insomnia (ISI score of 22) (see Figure 2, above) There were no symptoms of comorbid insomnia. He had previously been given several short courses of hypnotic drugs, which had not been very effective and which he was keen not to continue taking. After he had described his symptoms and his previous treatments, the importance of careful assessment was discussed, a sleep diary was provided, and it was explained to him how to complete this.
When Greg returned 2 weeks later, the sleep diary (Figure 3, above) confirmed severe insomnia with mean total sleep time of 5.3 hours a day. He had a very variable wake time, high caffeine and alcohol intake, little exercise, and poor sleep with severely delayed sleep onset latency and night-time waking. At this consultation he was advised on sleep hygiene and the importance of a regular sleep schedule, with a fixed wake time. He was also advised about stimulus control, including avoiding caffeine after midday, moderating his alcohol consumption, and increasing exercise. Among other stimulus control measures, he was advised to avoid daytime naps and to perform muscle relaxation. He was invited to re-consult in 2 weeks, having completed another sleep diary.
At follow-up, the ISI had improved to 18 and the sleep diary showed an average of 6 hours’ sleep each night. A sleep restriction programme was advised, limiting sleep to 6 hours with a regular wake time of 7am and bedtime of 1am. His sleep and quality of life continued to improve over the next 4 weeks, when he had a final review.
ISI=Insomnia Severity Index
At an initial consultation it is quick, simple, and vital to explain the importance of sleep assessment to aid insomnia treatment, to complete an ISI, and to show the patient how to complete a sleep diary. The patient can be provided with some initial advice and asked to return in 14 days with a completed sleep diary.
At the follow-up consultation, the sleep diary is reviewed. It is then possible to advise on measures collectively termed 'cognitive behavioural therapy for insomnia' (CBT-I).
Cognitive behavioural therapy for insomnia
Cognitive behavioural therapy for insomnia consists of five simple techniques that can be explained at a consultation or delivered through online self-help programmes.21 It is sometimes available through community psychology services (e.g. Increasing access to psychological therapy, or IAPT) but is only rarely accessible in the UK. The five elements of CBT-I include:22
- sleep education (cognitive)
- behavioural techniques, including:
- sleep hygiene
- stimulus control
- muscle relaxation
- sleep restriction.
Sleep education provides information about normal and abnormal sleep and simple techniques to prevent people lying awake in bed worrying about their sleep or other life problems. Normal sleep is around 6–8 hours. Some people have an unrealistic expectation of sleep and spend longer in bed when they really do not need to. One patient came back to see the author for their second consultation and their sleep diary showed that they spent 12 hours in bed, of which they slept for 8 hours. I simply advised the patient to spend only 8 hours in bed and her sleep miraculously improved—her sleep efficiency increased from 66% (8 hours/12 hours) to 100% (8 hours/8 hours)! Some insomniacs give sleep enormous importance, blame many unrelated problems on lack of sleep, or feel that the following day will be a disaster if they don’t sleep well ('catastrophise'); these thoughts need to be addressed so that expectations are realistic and the importance of sleep is not over-emphasised.
Simple techniques can be used to reduce staying awake worrying. Advise patients to write a to-do list for the next day. Thoughts can blocked by asking some to repeat the word, 'the, the, the' in their head—it is impossible to think about anything else while doing this. Counting sheep is much less effective for a variety of reasons. People who sleep well don’t make an effort to sleep, they just fall asleep. Keeping relaxed is vital.23
Sleep hygiene, although not effective alone, is effective as part of CBT-I. It involves setting healthy sleep routines and bedtime behaviours:23,24
- advise patients to wake at the same time each day, and if possible to go to bed at the same time. 'Lying in' at the weekends is a sure-fire way to disrupt sleep–wake routines.
- sleep onset is often triggered by a slight fall in body temperature, so having a warm bath or shower about an hour before going to bed is often helpful because of the drop in temperature following this
- exercise during the day promotes sleep but exercise late in the evening can be stimulating and so is best avoided.
Stimulus control is about reducing unwanted stimuli when in bed or beforehand. Caffeine (in coffee, tea, cola, etc.) should be avoided within 6 hours of going to bed.17 Alcohol should be limited because it causes rebound insomnia after initial sedation so people often wake in the early hours (WASO), even after a moderate binge. Nicotine in cigarettes is also a stimulant and best avoided.
It is surprising how often people watch television, play games on mobile devices, use the phone, listen to the radio, or even eat in bed. All these need to be avoided if someone has insomnia—bed should be restricted to sleeping (and sex).23
Muscle relaxation consists of gently and alternately contracting and relaxing muscle groups starting in one foot, going upwards to leg, thigh, abdominal, chest, arm, head, and down the other side of the body. Combining muscle relaxation with thought-blocking effectively reduces SOL.23
The final technique used in CBT-I is sleep restriction. Paradoxically, this consists of asking people with insomnia to spend less time sleeping, which is often very effective for improving sleep quality and sleep efficiency. The total sleep time is calculated from the sleep diary. The patient is asked what time they would like to wake up each day. A 'sleep window' for an individual patient is then calculated from the time they normally sleep over 24 hours including naps, and adding 45 minutes to create an individual ideal. They are advised that they will only be allowed to sleep for this length of time. The minimum sleep window is 6 hours. For example, if the sleep window is 6 hours and the patient wishes to wake at 7am they are advised to stay awake until 1am, then go to bed and set the alarm for 7am. Over the next 1–2 weeks, the quality of sleep will improve. Every 1–2 weeks the bedtime is moved back 15 minutes until the patient is sleeping 7–8 hours each night.
Many patients are concerned about sleeping tablets (hypnotics)3 and GPs are also ambivalent about their use.25 Gradual withdrawal is possible for most patients already on hypnotics and the use of psychological support and treatments (CBT-I) together with tapering off medication has been shown to improve sleep and quality of life.26,27
Primary care for chronic insomnia can be improved by adopting a problem-focused approach, responding positively to the patient's need for help, and understanding health beliefs and illness experience. The problem of insomnia needs to be taken seriously: careful assessment of insomnia and comorbidities should be carried out using tools such as the ISI and a sleep diary. Patients will benefit from advice tailored to their sleep problem using CBT-I, which consists of sleep advice and cognitive techniques, sleep hygiene, stimulus control, muscle relaxation, and sleep restriction. Hypnotic drugs can be tailed off gradually or used intermittently.
Barriers to implementing these interventions include training and time; however, through the REST project we have shown that training is relatively straightforward and can be done online,3 and the time required to assess and deliver effective treatments could be offset as a result of a reduction in the number of consultations for repeat prescriptions or to discuss the adverse effects of drugs.
- currently receive little training in treating insomnia
- need to respond positively to people with insomnia and understand their health beliefs and experience
- assess and treat insomnia as well as comorbidities
- People with insomnia need a thorough assessment using validated assessment tools
- Drugs commonly prescribed for chronic insomnia are less effective than proven psychological therapies, collectively known as 'cognitive behavioural therapy for insomnia' (CBT-I)
- Drug side-effects can outweigh benefits, particularly in older people
- Cognitive behaviour therapy includes:
- sleep education
- sleep hygiene
- stimulus control
- muscle relaxation
- sleep restriction
- Hypnotic drugs can be withdrawn gradually or used intermittently alongside psychological support and treatments.
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- Chronic insomnia:
- is a common problem but is rarely assessed adequately in primary care
- can usually be effectively managed without medication; CBT-I is particularly helpful
- Commissioners should consider making psychological services available to provide CBT-I for people with chronic insomnia, even in the absence of significant depression or anxiety:
- these services could be provided by local IAPT teams but the national specifications will need to be locally adjusted to allow treatment for insomnia
- NHS Choices has some useful tips on its site to help patients manage their own insomnia; practices could signpost patients to these via their own websites.28
CBT-I=cognitive behaviour therapy for insomnia; IAPT=increasing access to psychological therapy
- Morphy H, Dunn K, Lewis M et al. Epidemiology of insomnia: a longitudinal study in a UK population. Sleep 2007; 30 (3): 274–280.
- Rosen R, Rosekind M, Rosevear C et al. Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep 1993; 16 (3): 249–254.
- Dyas J, Apekey T, Tilling M et al. Patients' and clinicians' experiences of consultations in primary care for sleep problems and insomnia: a focus group study. Br J Gen Pract 2010; DOI: 10.3399/bjgp10X484183.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edn). Arlington, Virginia: 2013.
- Macedo P, Neves G, Poyares D, Gomes M. Insomnia current diagnosis: an appraisal. Rev Bras Neurol 2015; 51 (3): 62–68.
- Culpepper L and Wingertzahn M. Over-the-counter agents for the treatment of occasional disturbed sleep or transient insomnia: a systematic review of efficacy and safety. Prim Care Companion CNS Disord 2015; 17 (6): 10.4088/PCC.15r01798 .
- Vande Griend J, Anderson S. Histamine-1 receptor antagonism for treatment of insomnia. J Am Pharm Assoc 2012; 52: e210–219.
- Posner D, Gehrman P. Sleep Hygiene. In: Perlis M, Aloia M, Kuhn B, editors. BSM treatment protocols for insomnia. Oxford: Elsevier, 2011: 31–43.
- Glass J, Lanctôt K, Herrmann N et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005; 331: 1169.
- Siriwardena A, Qureshi M, Dyas J et al. Magic bullets for insomnia? Patients' use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care. Br J Gen Pract 2008; 58: 417–422.
- NICE. Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. Technology Appraisal Guidance 77. NICE, 2004. Available at: www.nice.org.uk/guidance/ta77
- Mitchell M, Gehrman P, Perlis M, Umscheid C. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract 2012; 13: 40.
- Trauer J, Qian M, Doyle J et al. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med 2015; 163: 191–204.
- The Resources for Effective Sleep Treatment (REST) Project website. Assessment and management of insomnia—e-learning package. Available from: elearning.restproject.org.uk (accessed 11 November 2016).
- Miller J, Berger A. Screening and assessment for obstructive sleep apnea in primary care. Sleep Med Rev 2016; 29: 41–51.
- Johns M. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep 1991; 14 (6): 540–545.
- NICE. Clinical Knowledge Summaries. Insomnia. NICE, 2015. Available at: cks.nice.org.uk/insomnia (accessed 22 November 2016).
- Insomnia medicine website. Assessment and diagnosis: diagnosis. www.insomnia-medicine.com/assessment-and-diagnosis/diagnosis.html (accessed 7 December 2016).
- Siriwardena A, Apekey T, Tilling M et al. Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial. BMC Fam Pract 2009; 10: 9.
- Bastient C, Vallieres A, Morin C. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2001; 2: 297–307
- Wolski A. 6 online options for insomnia therapy. Sleep Review website, 11 December 2014. Available at: www.sleepreviewmag.com/2014/12/online-options-insomnia-therapy (accessed 1 December 2016).
- Belanger L, LeBlanc M, Morin C. Cognitive behavioral therapy for insomnia in older adults. Cognitive and Behavioral Practice 2012; 19 (1): 101–115.
- Morin C, Espie C. Insomnia: a clinical guide to assessment and treatment. New York: Springer, 2004.
- Falloon K, Elley C, Fernando A III et al. Simplified sleep restriction for insomnia in general practice: a randomised controlled trial. Br J Gen Pract 2015; DOI: 10.3399/bjgp15X686137.
- Sirdifield C, Anthierens S, Creupelandt H et al. General practitioners' experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis. BMC Fam Pract 2013; 14: 191.
- Voshaar R, Couvée J, van Balkom A et al. Strategies for discontinuing long-term benzodiazepine use: meta-analysis. Br J Psychiatry 2006; 189: 213–220.
- Morin C, Beaulieu-Bonneau S, Bélanger L et al. Cognitive-behavior therapy singly and combined with medication for persistent insomnia: Impact on psychological and daytime functioning. Behav Res Ther 2016; 87: 109–116.
- NHS Choices website. Insomnia. www.nhs.uk/conditions/insomnia/Pages/introduction.aspxG