Professor Niroshan Siriwardena highlights the relevant recommendations for primary care from the British Association of Psychopharmacology guideline on insomnia and sleep disorders
Read this article to learn more about:
- how insomnia is defined and how it should be assessed
- management strategies using cognitive behavioural therapy for insomnia
- restrained use of hypnotics.
Insomnia and sleep disorders are common, with insomnia affecting around 37% of the UK adult population in any given year.1 Insomnia disorder (also termed chronic insomnia) is a common type of sleep disorder presenting in general practice, and affects up to 10% of adults.2 The potential effects of insomnia on patients, the economy, and healthcare services should not be underestimated. Insomnia is associated with:3
- impaired quality of life
- associated health conditions (e.g. obesity,4 type 2 diabetes mellitus, and cardiovascular disease)
- reduced productivity due to work absence and poor performance at work (presenteeism)
- increased healthcare-related costs.
People with sleep problems commonly present to general practice, so it is important for primary care clinicians to be aware of how to assess and manage sleeping issues when they arise. The updated British Association of Psychopharmacology (BAP) guideline on insomnia, parasomnias, and circadian rhythm disorders3 is a timely and helpful read for GPs and other primary care professionals. The guideline authors are leading sleep scientists from a range of relevant disciplines, offering a comprehensive range of expertise. This article explores the key points that primary care professionals should take away from the BAP recommendations.
1. Insomnia should be defined and assessed using validated tools
Better understanding of insomnia has led to a diagnostic definition that is clinically helpful and, critically, appreciates that insomnia is not just a night-time problem but also affects people during the day.2,5,6 Although there are slightly different definitions of insomnia between the International Classification of Diseases (ICD-10),5 International Classification of Sleep Disorders (ICSD3),6 and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),2 the DSM-5 criteria are the most widely used.
The DSM-5 criteria define insomnia as unhappiness with the quality or quantity of sleep, which can include difficulty falling asleep, staying asleep, or waking up early and being unable to get back to sleep (despite ample opportunity to sleep) for at least 3 nights a week, for at least 3 months. The difficulty cannot be better explained by other physical, mental, or sleep-wake disorders and cannot be attributed to substance use or medication. In DSM-5 the distinction between primary and secondary insomnia has been removed and instead insomnia coexisting with other conditions is termed co-morbid. The sleep disturbance must also cause significant distress or impairment in daytime functioning, such as within the individual’s working or personal life, behaviourally, or emotionally.2
In general practice, insomnia should be assessed by first asking simple questions when appropriate. For example: are you having difficulty getting to sleep and/or staying asleep? Do you have this problem most nights? Is it persistent and affecting you during the day?
This assessment can be supported by using simple validated tools such as the nine-item Insomnia Severity Index7 or even simpler, the two-item Sleep Condition Indicator (see Figure 1).8
Thinking about the past month, to what extent has poor sleep …
1. … troubled you in general
Not at all
Thinking about a typical night in the last month …
2. … how many nights a week do you have a problem with your sleep?
[A] Scoring instructions: Add the item scores (top row) to obtain the SCI total (minimum 0, maximum 8). A higher score means better sleep.
Luik A, Machado P, Siriwardena N, Espie C. Screening for insomnia in primary care: using a two-item version of the Sleep Condition Indicator. Br J Gen Pract 2019; 69 (679): 79–80.
Reproduced with permission.
This can be supplemented by asking the patient to keep a sleep diary—a simple written diary for 7–10 days is all that is required. In the meantime, the patient can be provided with advice on sleep hygiene (see below). Although not effective by itself, sleep hygiene does form part of cognitive behavioural therapy for insomnia (CBTi), which is part of first-line treatment.3
2. Screen for other conditions and sleep disorders
It is important to use brief questions to screen for other mental health conditions (e.g. anxiety, depression, psychosis), physical illness (e.g. cancer, arthritis, pain, nocturia), or other specific sleep disorders. These include:3
- obstructive sleep apnoea (OSA) syndrome (e.g. causing snoring or their partner noticing their breathing stopping during sleep)
- restless legs syndrome (e.g. unpleasant, restless feelings in the legs when relaxing in the evening or during the night, relieved by walking or movement)
- narcolepsy (e.g. falling asleep in the daytime without warning, collapsing or extreme muscle weakness triggered by emotion, such as laughing)
- circadian rhythm disorder (e.g. sleeping well but at the wrong times)
- parasomnias (e.g. unusual or unpleasant experiences or behaviours associated with sleep).
3. Treat insomnia disorder in its own right
One of the notable changes since the previous BAP guideline9 has been the recognition that insomnia disorder is an important condition in its own right and should be taken seriously through better identification, assessment, and management.3 It is not enough to think of insomnia as being secondary to other mental and physical health conditions; rather, it is co-morbid and coexists with these other diseases. Insomnia disorder and other conditions (particularly mental health disorders, such as anxiety, depression, and even psychosis) may be preceded, or even caused, by insomnia. Therefore, even if insomnia is co-morbid with other conditions, insomnia needs to be managed in parallel. This may not only improve the person’s insomnia but could also alleviate symptoms of the co-morbid disorder(s) and/or improve quality of life to a greater extent than only treating the co-morbidity itself.3
4. First-line treatment is cognitive behavioural therapy for insomnia
The guideline emphasises that psychological treatment with cognitive behavioural therapy for insomnia (CBTi) should be used first, including stimulus control and sleep restriction therapy.3 CBTi has been shown to be effective in improving sleep, wellbeing, and quality of life,3 whether delivered by psychologists, primary care practitioners (including nurses), or as self-help.10 CBTi is as effective as hypnotic drugs, safe, and the effects last long after treatment stops.11 Unfortunately, although CBTi is relatively simple to learn, understand, and apply, it is not widely available in the UK—even from Increasing Access to Psychological Therapy (IAPT) services. Fortunately, self-help CBTi delivered using booklets, or online digital CBTi (dCBTi) (via computers or smartphones) is also effective, is becoming more widely available, and is covered by the NHS in some areas of the UK.12
Psychological therapies in specific patient groups
In general, psychological therapies are advocated first-line in all patient groups including pregnant women, older adults, children, and people with learning difficulties. In pregnancy, sleep restriction is contraindicated, so sleep hygiene alone is advised in pregnant women whereas CBTi including sleep restriction is advocated in the other groups mentioned above. Melatonin may be useful in jet lag, some circadian rhythm disorders, adults aged 55 years or over, and children with autism or attention deficit hyperactivity disorder (ADHD) when stimulant drugs are not being used.3
What does cognitive behavioural therapy for insomnia involve?
In order for GPs and nurses to recommend CBTi, it is helpful for them to have a basic understanding of the treatment. CBTi consists of five main components: sleep hygiene, sleep education, stimulus control, muscle relaxation, and sleep (time in bed) restriction.13
Sleep hygiene consists of improving regular sleeping habits, for example:
- ensuring a good bedtime routine, with regular sleep and wake times
- ensuring a comfortable bed and the right room temperature, with no noise or light
- avoiding physical activity or eating too much late in the evening.
The onset of sleep is associated with a slight fall in temperature,14 which can be helped by a warm bath or shower (dilating peripheral arteries and stimulating heat loss), whereas exercise tends to raise temperature.
Sleep education is the cognitive component and includes:
- advising on normal healthy sleep duration (this can vary between 6 and 9 hours)
- reducing worry (e.g. by writing a to-do list)
- blocking worrying thoughts (e.g. by simply repeating the word ‘the’ in one’s head).
Stimulus control is about avoiding stimuli before going to or while in bed, such as abstaining from caffeinated drinks, television, and smartphones. Muscle relaxation involves alternate contraction and relaxation working through the different muscle groups in the body. Finally, sleep restriction consists of reducing time in bed to the average sleep time over the previous 10–14 days (using a sleep diary), with a fixed waking time and a later bedtime, with the aim of increasing sleep efficiency (the time asleep divided by the time in bed at night).
5. Use effective hypnotic drugs with a short half-life, second-line, only for short periods
The guideline stresses that drugs should only be used second-line and in the short term.3 The most commonly used hypnotics, benzodiazepines, and Z-drugs (non-benzodiazepines), act on the postsynaptic gamma-aminobutyric acid (GABA) inhibitory receptors, mainly in the hypothalamus, by attaching to sites adjacent to the receptor protein. This interaction changes its conformation to increase the effect of GABA on the receptor through a process termed positive allosteric modulation (PAM).3 If drugs are to be used, agents with short half-lives are preferred to avoid adverse reactions and residual daytime effects.
Treatment duration and discontinuation with CBTi
Hypnotic drugs are generally licensed for short-term use (usually 2–4 weeks) only, due to the risk of developing tolerance, addiction, and adverse events (including falls and road traffic collisions).15 There is limited evidence from one randomised controlled trial for use, in adults aged 55 years or over, of prolonged-release melatonin.16 There is no evidence for the use of antidepressants (unless also to treat depression), antihistamines (apart from doxepin which is not available in the UK), or psychotropic agents, because of potential harms and lack of benefit.1
If it is decided to discontinue hypnotics, these should be tapered down slowly. Introducing CBTi during tapering improves sleep outcomes.1
6. Know when to refer to a sleep specialist or clinic
If OSA syndrome, a circadian rhythm disorder, restless legs syndrome, or a parasomnia is suspected, the BAP guideline recommends that the patient is referred for specialist assessment and treatment.1
Further information about primary care management of insomnia can be found at the REST Project website (www.restproject.org.uk), where there is also a multimedia e-learning programme (elearning.restproject.org.uk/) for primary care clinicians to learn more about primary care for insomnia and access the resources described in this article.
Professor Niroshan Siriwardena
Professor of Primary and Prehospital Health Care, Community and Health Research Unit, University of Lincoln
Implementation actions for STPs and ICSs
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
Insomnia is a common problem but rarely catered for adequately by current NHS provision.
- Explore the possibility of providing a web-based facility to provide support for GPs and patients, with simple programmes to facilitate self-help:
- embed in this facility sleep assessment tools for people to use directly; these tools could also help to assess the severity of sleep problems so that people needing medical assessment can be identified
- Ensure that specialist services are available for GPs to refer to for more specialist problems and conditions, e.g. sleep apnoea
- Consider contracting with commercial online providers that can provide a subscription-based sleep assessment and self-help services.
STP=sustainability and transformation partnership; ICS=integrated care system
- Morphy H, Dunn K, Lewis M et al. Epidemiology of insomnia: a longitudinal study in a UK population. Sleep 2007; 30 (3): 274–280.
- Reynolds C, O’Hara R, Morin C et al. Sleep-wake disorders. In: Schultz S, Kuhl E, editors. Diagnostic and statistical manual of mental disorders, fifth edition—DSM-5. Arlington: American Psychiatric Association, 2013.
- Wilson S, Anderson K, Baldwin D et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol 2019; 33 (8): 923–947.
- Blank M, Zhang J, Lamers F et al. Health correlates of insomnia symptoms and comorbid mental disorders in a nationally representative sample of US adolescents. Sleep 2015; 38 (2): 197–204.
- World Health Organization. International statistical classification of diseases and related health problems—10th revision (ICD-10). 2016. icd.who.int/browse10/2016/en (accessed 18 December 2019).
- American Academy of Sleep Medicine. International classification of sleep disorders, third edition. Darien: AASM, 2014.
- Bastien C, Vallières A, Morin C. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2001; 2 (4): 297–307.
- Luik A, Machado P, Siriwardena N, Espie C. Screening for insomnia in primary care: using a two-item version of the Sleep Condition Indicator. Br J Gen Pract 2019; 69 (679): 79–80.
- Wilson S, Nutt D, Alford C et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol 2010; 24 (11): 1577–1601.
- Davidson J, Dickson C, Han H. Cognitive behavioural treatment for insomnia in primary care: a systematic review of sleep outcomes. Br J Gen Pract 2019; 69 (686): e657–e664.
- 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.
- Sleepio website. www.sleepio.com (accessed 20 December 2019).
- Belanger L, LeBlanc M, Morin C. Cognitive behavioral therapy for insomnia in older adults. Cogn Behav Pract 2012; 19 (1): 101–115.
- Walker, Matthew P. Caffeine, jet lag, and melatonin—losing and gaining control of your sleep rhythm. In: Welch S, Belden K, editors. Why we sleep: unlocking the power of sleep and dreams. New York: Scribner, 2017: 13–37.
- NICE. Insomnia. Clinical Knowledge Summary. Available at: cks.nice.org.uk/insomnia
- Lemoine P, Nir T, Laudon M, Zisapel N. Prolonged-release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects. J Sleep Res 2007; 16 (4): 372–380.